From the Guidelines
Cutaneous findings in Crohn's disease should be managed with immunosuppression as the mainstay of treatment, with infliximab being a viable option for patients who do not respond rapidly to corticosteroids, as evidenced by a multicentre, randomised, placebo-controlled trial showing a significant improvement in patients treated with infliximab compared to placebo 1. The cutaneous manifestations of Crohn's disease can be diagnosed on clinical grounds, based on their characteristic features and the exclusion of other specific skin disorders, with biopsy being helpful in atypical cases 1. Some of the common cutaneous findings in Crohn's disease include:
- Pyoderma gangrenosum, which appears as rapidly evolving painful ulcers with undermined violaceous borders, often on the legs
- Erythema nodosum, which presents as painful, red, tender nodules typically on the shins and lower extremities
- Metastatic Crohn's disease, which involves granulomatous lesions histologically identical to intestinal Crohn's that can appear anywhere on the skin
- Oral aphthous ulcers, perianal skin tags, fistulas, and abscesses
- Sweet's syndrome (acute febrile neutrophilic dermatosis), which presents with painful erythematous plaques and is associated with disease flares Treatment of these cutaneous findings typically involves managing the underlying Crohn's disease with immunosuppressants, biologics like TNF-alpha inhibitors, or other targeted therapies, which often improves both intestinal and cutaneous symptoms simultaneously 1. Topical treatments may be used for localized lesions, while systemic therapies are necessary for widespread or severe skin involvement, with infliximab being a viable option for patients who do not respond rapidly to corticosteroids, as shown in the study 1.
From the Research
Cutaneous Findings in Crohn's Disease
- Cutaneous manifestations of Crohn's disease can be diverse and include perianal, peristomal, and perifistular ulceration, as well as granulomatous cutaneous inflammation separate from gastrointestinal tract openings (metastatic Crohn's disease) 2.
- Metastatic Crohn's disease is a rare but challenging dermatologic manifestation of Crohn's disease, characterized by the presence of non-caseating granulomas at skin sites separated from and non-contiguous to the gastrointestinal tract 3.
- Cutaneous findings may precede, develop concurrently with, or follow gastrointestinal involvement, and a detailed history and thorough physical examination including a full-skin exam may help to exclude other dermatoses 4.
- The skin manifestations associated with Crohn's disease can be classified into four categories according to their pathophysiology: specific, reactive, associated, and induced by treatment 5.
Clinical Characteristics and Treatment Options
- Metastatic Crohn's disease can present with versatile clinical features, including abscesses, fistulas, or hidradenitis suppurativa-like features, and its occurrence can predate the initial diagnosis of Crohn's disease 3.
- Treatment options for metastatic Crohn's disease remain challenging and often unsatisfactory, with a lack of randomized controlled studies and varying responses to reported therapeutic methods 4, 3.
- Biologics have shown promise in the treatment of metastatic Crohn's disease, even in refractory cases 4.
- Other cutaneous manifestations of Crohn's disease, such as pyoderma gangrenosum, erythema nodosum, and psoriasis, may require different treatment approaches 5.
Diagnosis and Differential Diagnoses
- A biopsy is required for a definitive diagnosis of metastatic Crohn's disease 4.
- Cutaneous metastatic Crohn's disease should be distinguished from contiguous cutaneous manifestations of Crohn's disease, which present at perianal or peristomal sites with direct extension from the intestine to the adjacent skin 3.
- Differential diagnoses for metastatic Crohn's disease include other granulomatous diseases, such as sarcoidosis, and other inflammatory skin conditions 3.