From the Guidelines
Inflammatory bowel disease (IBD) is commonly associated with several skin lesions, including pyoderma gangrenosum, erythema nodosum, Sweet's syndrome, and aphthous stomatitis, with the most frequent being erythema nodosum. These cutaneous manifestations often parallel intestinal disease activity, with flares of skin lesions occurring during bowel inflammation.
Skin Lesions Associated with IBD
- Pyoderma gangrenosum: painful, rapidly enlarging ulcers with undermined borders, which can be debilitating and requires rapid healing as the therapeutic goal 1
- Erythema nodosum: painful, red or violet, raised nodules typically on the extensor surfaces of the lower extremities, especially the shins, with diagnosis made on clinical grounds and treatment based on the underlying IBD 1
- Sweet's syndrome: painful erythematous plaques, characterized by tender, red inflammatory nodules or papules, usually affecting the upper limbs, face or neck, with a strong predilection for women and patients with colonic involvement and other extraintestinal manifestations 1
- Aphthous stomatitis: painful oral ulcers
Treatment of Skin Lesions in IBD
Treatment primarily focuses on controlling the underlying IBD with medications such as:
- Corticosteroids
- Immunomodulators like azathioprine or methotrexate
- Biologics such as anti-TNF agents (infliximab, adalimumab) 1 Specific skin-directed therapies may include:
- Topical or intralesional steroids for localized lesions
- Topical calcineurin inhibitors (pimecrolimus or tacrolimus) for pyoderma gangrenosum, but specialist advice is recommended 1 Infliximab should be considered if a rapid response to corticosteroids cannot be achieved, especially in patients with pyoderma gangrenosum 1. Daily wound care should be performed in collaboration with a wound-care specialist.
From the Research
Skin Lesions Associated with Inflammatory Bowel Disease
The skin lesions seen with inflammatory bowel disease (IBD) can be classified into several categories, including:
- Specific manifestations, which have the same histological features as the underlying IBD 2, 3
- Reactive disorders, such as erythema nodosum, pyoderma gangrenosum, and Sweet's syndrome 2, 4, 5, 6
- Associated manifestations, including psoriasis and epidermolysis bullosa acquisita 4, 3
- Treatment-induced manifestations, such as paradoxical reactions and cutaneous infections 6, 3
Common Skin Lesions
Some of the most common skin lesions associated with IBD include:
- Erythema nodosum, which is a common cause of tender red nodules on the shins 2, 4, 5, 6
- Pyoderma gangrenosum, a severe and painful ulcerating disease 2, 4, 5, 6
- Sweet's syndrome, a condition characterized by fever, leukocytosis, and tender erythematous skin lesions 2, 4, 6
Management of Skin Lesions
The management of skin lesions in patients with IBD should be individualized and directed at treating the underlying IBD as well as the specific dermatologic condition 4, 5. Treatment options may include:
- Topical and systemic steroids 2, 5
- Anti-tumor necrosis factor (TNF) agents, which can be effective in managing both IBD and associated skin lesions 2, 6
- Moist wound management and systemic corticosteroids or cyclosporine for pyoderma gangrenosum 5
- Leg elevation, NSAIDs, and potassium iodide for erythema nodosum 5