Pyoderma Gangrenosum of the Hand: A Case Series and Literature Review of Clinical Presentation and Management

Purpose

To perform a retrospective review on pyoderma gangrenosum (PG) involving the hands. We hypothesize that this rare disease is frequently misdiagnosed and appropriate treatment delayed.

Methods

A retrospective chart review between 1995 and 2015 was carried out at two large academic medical institutions. 8 patients were identified to have biopsy proven PG involving the hand. Our case series represents the largest to date. Clinical data were collected which include patient demographics, location of lesion, past medical history, smoking, and clinical management. Also, an extensive literature review of clinical case reports was carried out by searching “pyoderma grangrenosum” and “hand” using various databases limited to English language (MEDLINE, EMBASE, and PubMED), followed by screening reference lists of these database search results. Relevant clinical data were then collected.

Results

Our case series was comprised of 6 females and 2 males with ages ranging from 35 to 62. All patients were initially diagnosed as having hand infections, and had received a combination of antibiotics, incision and drainage, and/or surgical debridement. Only one patient’s wound culture showed bacterial growth.  One patient had an unusual presentation of PG involving all four extremities with a history of ulcerative colitis. Two patients’ wounds involved the dorsum of the left hand only. Interestingly, the remaining five patients demonstrated PG exclusively to the index fingers. Once steroid was administered, either intralesional or systemic, all patients’ lesions showed clinical improvement of wound healing.

Our literature search revealed a further 23 clinical cases[1,2,3]. Five patients demonstrated PG involving the index finger exclusively. 15 patients experienced extensive hand involvement. The affected sites for remaining three patients were: index/long fingers (right hand), index (right hand) and ring/small (left hand), and long (left hand). All 23 cases were initially misdiagnosed as infection, similar to our case series.

The management of PG is multimodal, which includes local and systemic anti-inflammatory measures, hyperbaric oxygen, negative pressure wound therapy, and skin grafting. Surgical debridement has a limited role[1,4,5].  

Conclusions

PG of the hand is a rare condition commonly misdiagnosed as infection. A delayed diagnosis or mismanagement may prolong patient suffering and worsen morbidity. An interesting finding was that the index finger seemed to be the most commonly involved digit. It could be due to its great independence that it is prone to minor trauma.