The Neutrophilic Dermatoses

David Farhi, MD; Daniel Wallach, MD


Dermatology Nursing. 2008;20(4):274-282. 

In This Article


In most cases, diagnosis suspicion relies on clinical expertise, and the skin biopsy helps in ruling out differential diagnoses (see Table 3 ). In SS, a blood cell count may show elevated circulating neutrophils, though this feature is neither constant, nor specific. A nonspecific biologic inflammatory syndrome (e.g., elevated erythrocytes sedimentation rate and C-reactive protein) is frequent.

Differential diagnosis chiefly addresses the problem of ruling out a bacterial infection. This might rely on cutaneous and blood samples. Cutaneous swabbing should ideally be obtained from pus drained from a freshly broken pustule. Since the saprophyte flora might constitute a confusing factor when interpreting the microbiological results (e.g., if a Staphylococcus epidermidis is detected), the breaking of the pustules is better done after adequate cleaning of the surrounding skin. It is of note that even doing this, the saprophyte flora often remains detectable and may mislead the diagnosis. Blood samples for culture are best done during fever peaks and/or chills, which improve their sensibility. Overall, negative bacterial work-up constitutes a strong argument in favor of the diagnosis of neutrophilic dermatosis.

Investigations of use for the screening of associated systemic diseases are summarized in Table 3 . The key idea is that in the absence of extracutaneous symptoms, there is no indication for aggressive investigation.

Treatments options are summarized in Table 4 . Some basic laboratory investigations are useful for the screening of absolute or relative treatment contraindications.

Oral steroids are used in severe cases at initial mean daily doses of 0.5 to 1 mg/kg. In some chronic ND, dapsone may be used, either alone (mostly in SPD, EED, and IgA pemphigus) or as a steroid-sparing agent. The initial dose is usually 100 mg daily, eventually adapted to effectiveness and tolerance. The most severe case may be treated by immunosuppressive agents, such as cyclosporine or azathioprine, or biologics such as infliximab.

The nurse can play a significant role in the topical care (see Table 5 ) and also by contributing to the education of the patient on the main features of the disease (see Table 6 ). A key feature of PG should be ex plained by the nurse to the patient: the pathergy. This term expresses the fact that a skin trauma — even mild — may initiate or extend ulcerations in PG. In terms of nursing care, the consequence is an absolute contraindication for aggressive wound care or debridement, even when fibrin covers the surface of the ulceration. For the same reason, the patient should be taught to avoid circumstances where a trauma can occur (e.g., certain sport activities).


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