Postoperative Pyoderma Gangrenosum After Breast Surgery: A Single-Centre Retrospective Study

Abstract

Pyoderma gangrenosum (PG) is a rare neutrophilic dermatosis sometimes induced by trauma, including surgical procedures, through a process known as pathergy [1]. Breast surgery accounts for roughly 25% of postoperative PG (PSPG) cases [1]. Identifying factors associated with developing PSPG is critical for facilitating early recognition and timely intervention [2, 3]. In this study, we analysed the characteristics of patients who developed PSPG after breast surgery at our academic medical centre.

Institutional review board was obtained to review the medical records of patients evaluated at Atrium Health Wake Forest Baptist's dermatology clinic between 2010 and 2024 who were diagnosed with PG after breast surgery. A 2:1 randomized control cohort of patients who underwent similar procedures and did not develop PG was utilized for comparison. Parameters analysed included demographics, comorbid conditions, surgical procedures and characteristics, risk factors and postoperative complications. Statistical significance between the PSPG and control cohort was compared.

The PSPG (n = 11) and control cohort (n = 22) had similar demographic characteristics (Table 1). Associated medical conditions included previous episodes of PG (9% PSPG vs. 0% control, p = 0.33), prior malignancy (55% PSPG vs. 100% control, p = 0.002), and inflammatory arthritis (55% PSPG vs. 18% control, p = 0.05). Patients also had inflammatory skin disorders (36% PSPG vs. 5% control, p = 0.033). Only eczema and psoriasis were identified. No patients in either cohort had a history of leukaemia, lymphoma, or inflammatory bowel disease (Table 1). Patients more frequently developed PSPG following breast reconstruction (55% vs. 5%, p = 0.0025) and reduction (45% vs. 5%, p = 0.0096) compared to the control cohort (Table 1). No differences in suture type were observed between the cohorts (Table 1). The average time between surgery and the onset of PG symptoms was 3.91 months. Seven patients (64%) developed symptoms within 90 days of surgery.

Classic surgical risk factors were higher for PSPG patients compared to the control cohort (Table 1). Body mass index (BMI) was greater for PSPG patients (33.6 kg/m²) compared to the control group (26.6 kg/m², p = 0.0063). The PSPG cohort had more current or former smokers (63% vs. 41%, p = 0.28), diabetics (36% vs. 18%, p = 0.39) and a longer duration of surgical procedure (323 min vs. 226 min, p = 0.21), although these characteristics were not statistically significant. Mean estimated blood loss (EBL) was comparable for both groups.

Initial versus successful treatments for PSPG patients were also evaluated (Table 2). Most patients were initially treated with systemic antibiotics (73%) and debridement (45%, Table 2) for an average duration of 9.6 months before starting therapy with systemic immunosuppressants. All patients had improvement in PG following the initiation of an average of 39.5 mg daily of prednisone.

PSPG is a rare but serious complication of breast surgery [4]. Pertinent patient features that may be related to the pathogenesis of PG included higher BMI, inflammatory skin conditions and inflammatory arthritis [4, 5]. Most cases of PSPG occurred after breast reconstruction surgeries highlighting the potential role of surgical trauma in triggering pathergy [1, 5]. This study had a small sample size and retrospective design that limit the generalizability of the findings. However, it calls attention to the complexity of PSPG as a rare postoperative complication and identified clinical and surgical factors that predispose patients to this condition. These findings emphasize the need for increased awareness to improve recognition, prevention and management of PG in patients undergoing breast surgery.

Substantial contributions to conception and design, or acquisition of data, or analysis and interpretation of data: Shirley Parraga, Jonathan Greenzaid, Matthew Hrin, Wasim Haidari, Kyle Robinson and Lindsay Strowd. Drafting the article or revising it critically for important intellectual content: Shirley Parraga, Jonathan Greenzaid, Matthew Hrin, Wasim Haidari, Kyle Robinson and Lindsay Strowd. Final approval of the version to be published: Shirley Parraga, Jonathan Greenzaid, Matthew Hrin, Wasim Haidari, Kyle Robinson and Lindsay Strowd. Collection of data: Shirley Parraga, Jonathan Greenzaid and Matthew Hrin. General supervision of the research group: Kyle Robinson and Lindsay Strowd.

Dr. Strowd has received research, speaking and/or consulting support from Pfizer, Novartis, Galderma and Sanofi. The other authors do not have any conflicts of interest to disclose.

The patients in this manuscript have given written informed consent to publication of their case details. Reviewed and approved by Wake Forest University Health Sciences, IRB#00109357.