cutaneous ulceration in crohn's disease · into the right groin. aseparate ulcer at the base...

Gut, 1970, 11, 18-26

Cutaneous ulceration in Crohn's disease

J. C. MOUNTAIN1From St Mark's Hospital, London

SUMMARY This paper describes in detail seven cases of extensive perineal ulceration seen in 207cases of Crohn's disease at St Mark's Hospital in the last eight years. Four of these cases alsohad cutaneous ulceration elsewhere. Suggestions are made for the management of furthercases of this rare condition.

Extensive cutaneous ulceration in Crohn's diseaseis a rare complication which has become clinicallyapparent in the last few years.

It is well known that anal lesions are commonmanifestations, occurring in approximately 25%of ileal and 80% of large intestinal Crohn'sdisease, and they may precede the abdominalcondition by many years (Lockhart-Mummeryand Morson, 1964). The clinical features andpathology of these anal lesions have beendescribed in detail in previous reports from thishospital (Morson and Lockhart-Mummery, 1959;Gray, Lockhart-Mummery, and Morson, 1965).

It has been mentioned that gross perinealulceration occasionally occurs, leading to exten-sive destruction of the anal sphincters and sur-rounding tissue but it has never been describedin detail, except for three isolated cases reportedto the Royal Society of Medicine, includingcase 4 of our own series (Hunter-Craig 1961;Scott, 1961; Parks, Morson, and Pegum, 1965).Cutaneous ulceration, other than in the perineal

region, does not appear to be well documentedin the literature, although it was mentioned byMcCallum and Kinmont in 1968, in a review ofthedermatological manifestation of Crohn's disease.In reviewing the 207 cases of Crohn's diseaseseen in the last eight years at St Mark's Hospital,seven cases of extensive perineal ulceration werePresent address: Royal Victoria Hospital,Boscombe,Bournemoutb

found and four of these had cutaneous ulcerationelsewhere. They are now presented as they alldemonstrate different features of this condition.

Case Histories

CASE 1V.K., a girl aged 14, was referred to St Mark'sHospital in June 1961 with gross perineal ulcera-tion. There was a history of perineal soreness in1957 when 10 years of age, which settled with localcaladryl and saline baths. In 1959 she developedgross oedema and inflammation of the labia andan anal fistula. A biopsy was performed whichshowed chronic low-grade inflammatory changesbut no tubercles or caseation; however, the patientwas given a two-month course of streptomycinand Inah without benefit.

Sigmoidoscopy in October 1959 revealed mul-tiple granular nodules in the rectum but a bariumenema was reported as normal. Treatment withsystemic prednisolone was begun and continuedfor 18 months. This resulted in improvement buthealing was incomplete. A further biopsy in theanal region in 1961 showed multinucleated giantcells of the tuberculous type and it was consideredthatthelesion was a tuberculide of the tuberculoussarcoid group.

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When she was admitted to St Mark's Hospitalin June 1961 there was extensive ulceration of theperineal skin. The previous histological sectionswere reviewed by Dr Morson and he consideredthe changes to be consistent with a diagnosis ofCrohn's disease. A defunctioning ileostomy with-out resection of the colon was performed. Theappendix, which was removed during this opera-tion, showed non-caseatinggiant cell and epitheli-oid cell systems supporting the diagnosis ofCrohn's disease. The anal ulceration initiallyimproved but eventually relapsed.

In August 1963 a synchronous combinedexcision of the rectum and lower sigmoid colonwas performed and the defunctioning ileostomyclosed. Thereafter the perineal wound healed wellbut the skin around the colostomy becamedesquamated and subsequently ulcerated (Fig. 1).By July 1965 gross ulceration was present aroundthe colostomy and a biopsy confirmed the pre-sence of Crohn's disease. A barium enema showednarrowing with fissuring of the last few centi-

Fig. 1 Paracolostomy ulceration in case 1.

metres of the colon consistent with a recurrenceof the disease in this segment.

In August 1965 the remainder of the colon wasexcised and a permanent ileostomy established.Histology of the excised specimen showedCrohn's disease of the distal colon with earlylesions in the ileo-caecal region, the right colon,and the transverse colon.The postoperative course was satisfactory and

the ulcerated area on the abdomen healed rapidlywith the aid of skin grafts. She was last seen inJuly 1968 when she was very well with no ulcera-tion of the perineum or abdominal wall.

CASE 2A.S., a man aged 54, was referred to St Mark'sHospital in August 1963. There was a history ofa rectal discharge developing in July 1961 whichcontinued until a complicated fistula was laidopen in October 1962.

Postoperatively the wound showed no signsof healing and his general condition remainedvery poor, with general malaise and continuousrectal discharge. Sigmoidoscopy in February1963 showed inflammation of the lower rectalmucosa and a biopsy revealed non-specificinflammation. As his general condition did notimprove an ileostomy was performed in April1963 after which he made good progress forabout two months only to relapse again withmalaise, perineal discharge, and fluid ileostomyactions.The only other relevant history was a traumatic

rupture ofthe bulbous urethra 25 years previously.On examination he was in poor general condi-

tion, being anaemic and obviously having lostconsiderable weight. A loop ileostomy appearedsatisfactory but there was gross undercuttingJlceration of the perineum extending onto bothsides of the scrotum anteriorly, into the ischio-rectal fossae laterally, and as far as the sacrumposteriorly. It was impossible to determine thesite of the anus on initial examination as thisalso was ulcerated.A chest radiograph was normal, a barium

enema was impossible. Culture of pus from theperineum revealed no tubercule bacilli. He wasexamined under an anaesthetic. Sigmoidoscopyto 14 cm revealed an ulcerated oedematous rectalmucosa with complete desctruction of the analcanal and loss of the anal sphincter. Biopsy ofthe anal canal region confirmed Crohn's diseasethough rectal biopsy showed non-specific inflam-matory changes only.

In September 1963 a proctocolectomy, butpreserving the old ileostomy, was performed. Atoperation the whole colon was involved withCrohn's disease and this was confirmed on histo-logical examination of the specimen. Post-operative progress was extremely stormy and theperineal wound showed few signs of healing.Three months after the initial operation hesuddenly developed an acute abdomen which atlaparotomy proved to be due to a spontaneousrupture of the spleen and splenectomy wasperformed. Afterwards his progress was satis-factory and he was discharged one month laterthough the perineum remained unhealed.

In July 1965 the ulceration had again extendedand he was admitted and the wound curetted.Histology of the curettings confirmed the diag-nosis of Crohn's disease. No form of local dress-ing appeared to produce any improvement in theulceration and the wound was again curetted inMarch 1966.

In July 1966 he developed a spontaneousperineal urinary fistula through the bulbousurethra which was confirmed by urethrogram.Synalar N cream was applied to the perineum atthis time with no effect and in November 1966he was started on oral prednisone which wascontinued until July 1967.

In November 1967 he was admitted again for3*

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reassessment with persistent perineal ulcerationand urinary fistula. As neither condition wascausing him any concern and he was generallyvery well no operative treatment was advisedbut he was started on bacitracin insufflationsto the wound.He has not attended for follow up since this

admission.

CASE 3L.W., a man aged 33, was admitted to St Mark'sHospital in September 1963 with an unhealedperineal wound. There was a history of a perinealabscess being laid open in 1958 after which hedeveloped diarrhoea severe enough to warranttreatment with steroids. The diarrhoea recurredin 1959 but responded to a period of medicaltreatment in hospital.

In February 1960 he developed an ischio-rectal abscess and associated fistula which waslaid open but diarrhoea returned on decreasingthe oral steroids.A colectomy and ileostomy was performed in

September 1961 and this was followed by asynchronous combined excision of the rectum inMay 1962.On admission to St Mark's Hospital there was

Fig. 2 Metastatic ulceration at the base of thepenis, in case 3.

some ulceration of the angles of the mouth andface creases and he had a typical moon face due tosteroid therapy. Abdominal examination revealedulceration and excoriation of the skin around theileostomy but otherwise there was no abnormality.There was, however, gross ulceration of the peri-neum extending round the root of the scrotuminto the right groin. A separate ulcer at the baseof the penis with a subcutaneous fistula to thecoronal region was also present (Fig. 2).He was examined under an anaesthetic and a

biopsy of the perineum taken. This showedsarcoid foci typical of Crohn's disease and latera biopsy was taken of the para-ileostomyulceration and this again confirmed Crohn'sdisease. A Mantoux test (1-1,000) was positivebut no acid alcohol-fast bacilli were found in thecurettings and guinea-pig inoculation wasnegative.

Repeated curettage was performed in the nextfour months and a variety of local applicationswere tried, including potassium permanganatedressings and Savlon dressings and also varioustypes of steroid lotions. The oral steroids werealso gradually tailed off.The para-ileostomy ulceration and ulcer at the

base of the penis soon healed but the perinealwound was rather slow in healing. He waseventually discharged in February 1964. He wasre-admitted in July 1964 and March 1965 whenthe perineal wound was again curetted. When hewas last seen in the Outpatient Department inOctober 1968 the perineal wound was healed exceptfor a small sinus.

CASE 4M.Y., a woman aged 70, was transferred to StMark's Hospital with an unhealed perinealwound in October 1963.

In 1959 she developed diarrhoea with blood andmucus which was diagnosed as being due toulcerative colitis and responded to a period ofbed rest in hospital and oral steroids. Afterdischarge from hospital her condition againdeteriorated and she eventually had a totalcolectomy and ileostomy performed in 1961.Pathological examination of the specimen con-firmed the diagnosis of Crohn's disease.

Subsequent progress was satisfactory except fora discharging fistulous track in the paraumbilicalregion, until December 1962 when she developedacute intestinal obstruction which subsided con-servatively. As she was also passing large quanti-ties of blood from the rectum a synchronouscombined excision was performed in January1963. The immediate postoperative progress wassatisfactory but the perineal wound remainedunhealed.On admission to St Mark's Hospital the peri-

neal ulceration extended into the fourchette oneither side of the labia majora and into thegroins, and a biopsy showed the typical sarcoid

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reaction of Crohn's disease. Right submammary'intertrigo' and eczema of both legs were notedat this time but were not biopsied.A chest radiograph showed no evidence ofactive

disease and a Mantoux test was negative to1 in 10,000 but positive to 1 in 1,000.

Initially only local treatment, including steroidapplications, was given but after one month theperineal wounds were curetted and a skin graftwas applied. This did not take and she wastherefore put on prednisone, 40 mg daily, withfairly rapid improvement. She was eventuallydischarged in January 1964 when the prednisonehad been reduced to 15 mg daily.As soon as she returned home the condition

relapsed so the prednisone dosage was againincreased with some improvement but it haddeteriorated again by May 1964 so she was re-admitted. Fresh biopsies confirmed the diagnosisof Crohn's disease. After further local treatmentshe was discharged in June only to be admittedagain in September. The perineal ulceration hadnow extended on both sides of the labia majorafurther into the groins and there was a largeulcer 76-2 mm x 12.7 mm (3 in. x c in.) andin the right submammary region. A biopsy ofthis ulcer showed 'chronic inflammation with aflorid sarcoid reaction consistent with Crohn'sdisease'. Further investigations to exclude tuber-culosis again proved negative and examinationof the ileostomy showed a normal mucosa to10 cm.Though she was anaemic with a haemoglobin

Fig. 3 Metastatic ulceration in the submammaryregion in case 4.

of 64% it was decided to treat her with cytotoxicagents. After an initial blood transfusion she wasstarted on 6 mercaptopurine 100 mg, tds, whichwas gradually reduced to 25 mg tds. As there wasno improvement on this regime she was also putback on prednisone, 20 mg daily, in October1964 and she gradually improved, with completehealing of the right submammary lesion over thenext four weeks. In January 1965 the 6 mercapto-purine was replaced by Imuran, 150 mg daily, andthis was eventually stopped in March 1965.Over the first six months of 1965 there was very

little improvement in the perineal and groinwounds despite intermittent curettage and a greatvariety of local dressings. In March 1965 theright groin wound was excised and closed byprimary suture but this broke down within twoweeks.She was eventually discharged in May 1965,

and has been followed up regularly as an out-patient since then, and, though her general healthhas remained quite good, the ulceration persistsdespite all form of treatment.

CASE 5J.D., a man aged 67, was transferred to St Mark'sHospital in November 1966 from a sanatoriumwhere he was being treated as a case of analtuberculosis. He had been previously diagnosedelsewhere as a case of 'ulcerative colitis' in 1958and of 'diverticulitis' in 1960. He remainedrelatively well until 1965 when he developed ananal fistula which failed to heal in spite of treat-ment. In that year he had a left iliac colostomy andsubsequently a right transverse colostomy as theformer was unsatisfactory but the fistula stilldid not heal. In June 1966 a biopsy from theedge of the fistula was reported as tuberculousgranulation tissue and the patient was thereforetransferred to the sanatorium and treated withantituberculous drugs for four months withouteffect.On admission to St Mark's Hospital the

patient's general condition was very poor, as hehad lost over 4j stone in weight. A Devine typetransverse colostomy was functioning normallybut there was a purulent discharge from the leftiliac loop colostomy. There was gross ulceration ofthe perianal region and perineum extending for-wards to involve the scrotum and both groins(Figs 4 and 5) and exposing the hamstrings andpelvic floor muscles. A blind sinus was also notedon the dorsum of the penis along which a probecould be passed for over 1 inch (25-4 mm).A barium enema via the colostomies showed thedistal part of the transverse colon, the splenicflexure, the descending and the sigmoid colon tobe grossly irregular, with narrowing and ulcera-tion consistent with Crohn's disease, and this was.confirmed on sigmoidoscopy. A barium meal andfollow through showed no lesion in the smallbowel.

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Fig. 4 Perinealulceration extending intothe groins in case 5 (left).

Fig. 5 Perineal ulcerationextending into the groinsin case S (right).

Fig. 6 Typical follicular lesions under the perinealskin in case 5 x 20. Fig. 7 Typical sarcoid granuloma in case 5 X 400.

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Fig. 8 Eleven months after proctocolectomy incase 5.

The patient's general condition improved onintensive supportive therapy and a total procto-colectomy was performed in December 1966.Pathological examination of the excised specimenconfirmed Crohn's disease of the colon, rectum,anal canal, and perianal region (Figs 6 and 7).The postoperative course was complicated by a

left lower lobe collapse, urinary infection, andan abdominal wound abscess but subsequentlyhis progress was steady and the perineal wound,which was initially enormous, gradually closedafter the use of local potassium permanganatedressings and oral zinc sulphate, 200 mg tds.The perineal wound was regularly reviewedunder general anaesthesia and intermittent curet-tage was performed over the next five months.He was eventually discharged in May 1967 whenthe perineal wound was still 76-2 mm (3 in.) deepand dressings were continued by the districtnurse.

His general condition continued to improveand he was readmitted in November 1967 whenthe perineal wound was curetted. At this timethe left groin was completely healed and the rightgroin was almost healed but there was still a deepperineal cavity (Fig. 8). Histology of the curettingshowed no sarcoid reaction.

In December 1968 he had gained over 4 stonein weight since his operation and although therewas slight residual perineal ulceration it was notcausing him any incapacity.

In November 1969 he developed a spontaneousurinary fistula which was demonstrated by ureth-rogram to be from the posterior urethra at theanterior part of the unhealed perineal wound.No treatment has been suggested as he is conti-nent and therefore it does not cause him muchinconvenience.

CASE 6R.L., a man aged 46, was transferred to St Mark'sHospital with multiple ulcers and sinuses anteriorto the anus extending into both groins in January1967. In 1956-57 he had developed a high horse-shoe fistula which had healed after multipleoperations. There had been no further symptomsuntil July 1966 when he developed the ulcerationand fistulae spontaneously. Sigmoidoscopy and abarium enema were completely normal. A pro-visional diagnosis of hidradenitis suppurativawith recurrent low fistula was made and the peri-anal skin was excised and primary skin graftingwas performed in January 1967.

Histological sections taken from all parts of theexcised specimen showed deep, penetrating andfissure-like ulcers surrounded by chronic inflam-matory granulation tissue. There were numerouscollections of epithelioid cells and giant cells,mainly of the Langhans type, in the form of asarcoid reaction suggestive of a diagnosis ofCrohn's disease. Postoperatively the skin graftdid not take but the wound granulated well andhealed slowly using Betnovate cream dressings.He was discharged in February 1967 and contin-ued to dress the wound himself at home.By August 1967 the wound had almost healed

but in January 1968 the anal Crohn's diseaserelapsed and he developed a recurrent posteriorhorseshoe fistula and also a low anterior fistulaassociated with a new area of ulceration. He wasreadmitted and the anterior fistula was partiallylaid open to allow drainage of the wound butsubsequently the ulceration extended anteriorlyonto both sides of thescrotum. Excision ofrectumwas suggested to the patient at this time but herefused as he was able to manage the dressingsof the extensive wound very well indeed and hewas extremely fit and active.The anal condition, however, continued to

deteriorate so that by November 1968 the ulcera-tion had extended both anteriorly and posteriorly.An abdomino-perineal excision was then per-formed and histology confirmed Crohn's diseaseconfined to the anal region. He was dischargedafter six weeks when the perineum was notcompletely healed. He was last seen in March1969 when healing was almost complete.

CASE 7E.C., a woman aged 65, was transferred to StMark's Hospital in July 1967 with extensivecutaneous ulceration of the perineum, bothgroins, and in a transverse lower abdominal

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skin crease. There was a previous history ofdrainage of an ischio-rectal abscess in June 1958followed by laying open of a fistula-in-ano inFebruary 1960. After this operation she continuedto pass pus from the rectum and a barium enemawas reported as showing diverticulitis and ulcera-tive colitis. The symptoms subsided after a courseof crystamycin.She was readmitted in June 1960 with colicky

abdominal pain and diarrhoea and passage ofpus per rectum. The abdomen was tender overthe colon and was distended. The fistula-in-anowas still discharging pus. A transverse colostomywas performed for subacute intestinal obstructionand an inflammatory sigmoid mass was noted.

In November 1960 the descending and sigmoidcolon were resected with a clinical diagnosis ofulcerative colitis but the pathological reportdescribed patchy ulceration of the mucosa withmultinucleated giant cells, probably of a foreignbody type, near the ulcer bases and scattered fociofepithe)ioid cells, without caseation.The patholo-gist considered these features suggestive of tuber-culosis but if this were disproved he thought themost likely diagnosis would be sarcoid ofthecolon;in fact this was certainly Crohn's disease. AMantoux test was then performed and was posi-tive. Though no definite diagnosis had so farbeen made she was started on streptomycinand Pasinah.

In February 1961 she was readmitted and a rec-tal stricture demonstrated from 5 to 10 cm,with a red, haemorrhagic, thickened, oedematousmucosa. There was extensive superficial ulcerationat the anus in the right lateral quadrant and thiswas excised. Histology of the specimen wasreported as tuberculous granulation tissue. Subse-quent progress was poor and eventually anabdomino-perineal excision of the rectum was

performed for persistent rectal stricture andpurulent discharge in February 1962. Histologyagain was reported as showing 'tuberculosis'.

After this operation progress was very satis-factory with increase of 3 stone in weight duringthe following year. Superficial ulceration of theperineum, groins, and transverse abdominalskin folds, however, still persisted. In December1966 she was readmitted and the ulcerationbiopsied. This showed features consistent withCrohn's disease of the skin. In February 1967the ulcerated areas were excised and primarysuture was performed but these broke downwithin two weeks.On admission to St Mark's Hospital there was

linear deep ulceration in both groins, being moreextensive on the right side and extending intothe perineum. There was also a small area ofseparate ulceration on the lower abdominal wall.The ulceration was biopsied and curetted andhistology confirmed the presence of giant cellsand epithelioid cells consistent with a diagnosisof Crohn's disease. Repeated curettage twiceweekly was performed under a general anaesthetic

and lotio rubra dressings were applied. She wasalso given oral zinc sulphate, 200 mg tds, andthis regime resulted in rapid healing of the woundsso that it was possible for her to be dischargedfrom hospital after three weeks.

Discussion

Cutaneous ulceration in Crohn's disease is notrestricted to any one age group or sex. There werefour men and three women and the age of ourpatients at the time of onset of the ulcerationranged from 10 to 69 years, with a mean age of48 years; three of the patients were over 60 yearsof age.

Macroscopically the ulceration has florid granu-lation tissue and there is marked destruction ofthe surrounding tissues. The skin edge is oedema-tous and there is a typical dusky cyanosis of thesurrounding skin (Lockhart-Mummery, 1965).Though the ulceration is usually associated

with severe Crohn's disease of the gastro-intestinal tract thecondition has to be differentiatedfrom tuberculosis by demonstrating the typicalsarcoid granulomatous reaction in the absenceof central caseation in a biopsy of the ulceration,together with a normal chest radiograph and anegative Mantoux test to a dilution 1 in 100. If theMantoux test is positive, and no tubercle bacillihave been demonstrated in the granulation tissuea guinea-pig is inoculated with fresh tissue fromthe ulcerated area. If this inoculation is negativeit may have to be repeated. It is interesting thatthree of our patients (cases 1, 5. and 7) wereinitially considered to be suffering from tuber-culosis but the diagnosis was later changed onreview of the histological sections and clinicalpicture and when healing had not occurred withantituberculous therapy.The cutaneous ulceration occurs in three

different sites: (1) perineal ulceration, (2) para-stomal ulceration, and (3) 'metastatic' ulceration.

1 PERINEAL ULCERATION

This is the commonest site and in all our patientswas the initial site of the disease. It may extendwidely in the perineum, into the groins, and evenas far as the anterior abdominal wall.

UlcerationCase Sex Age 'Metastatic'No. (Yr.) Perineal Parastomal

1 F 10 + +2 M 53 +3 M 32 + + +4 F 69 + - +5 M 66 + -

6 M 45 + - -7 F 60 + - +

Table I Types of cutaneous ulceration in Crohn'sdisease

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Marshak, Lindner, and Janowitz (1966)observed that large intestinal Crohn's diseaseonly appeared to extend after surgical interference.It is therefore interesting that in this small seriesthe perineal ulceration tended to become extensiveafter some form of anal surgery; thus in three ofour patients it began after an abdomino-perinealexcision for rectal and anal disease and in twoothers after anal fistulae had been laid open.In our other two patients, however, the ulcerationbegan without any recent anal surgery, and it isinteresting to note that these were the only twocases where associated rectal disease was notinitially present. Case 1, however, eventuallyhad an abdomino-perineal excision for the analcanal and perineal ulceration and she developedsevere Crohn's disease in the proximal colon twoyears later which required a total colectomy andileostomy.Case 6 has also recently had an abdomino-

perineal excision but as yet has not developeddisease of the proximal bowel.The cutaneous ulceration appears to be just

as liable as the ulceration in the gastrointestinaltract to erode into the surrounding structures.This is demonstrated by cases 2 and 5 wherespontaneous perineal urinary fistula developedthree years after proctocolectomy and it stillpersists. Case 2 had a traumatic rupture of thebulbous urethra 25 years previously and presum-ably therefore this area of the urethra was fibroticand weakened but there was no similar historyin case 5.

2 PARASTOMAL ULCERATIONOccasionally ulceration occurs on the anteriorabdominal wall in continuity with an ileostomy orcolostomy. It is usually associated with recurrentdisease of the adjacent bowel and is typicallydemonstrated by case 1 where the cutaneousulceration healed rapidly soon after the diseasedbowel had been excised by total colectomy andileostomy.Case 3 probably developed para-ileostomy

ulceration but it is interesting that in this patientileal disease has never been demonstrated and thisulceration healed quickly with conservative meas-ures. It should therefore probably be consideredto be a second area of 'metastatic' ulcerationsimilar to the ulcer at the base of the penis.

3 METASTATIC ULCERATIONThis appears to be a very rare condition, and,other than a previous report of case 4, we haveonly found this condition mentioned byMcCallum and Kinmont (1968) when they statedthat they had seen two cases of submammaryulceration but did not give any clinical details.

Ulceration is described as being metastaticwhen it is completely remote from the gastro-intestinal tract and is, and always has been,

separated from other areas of ulceration by normalintact skin. Three examples of this have beenseen in this series. In case 3 there was an area ofdiscrete ulceration on the anterior surface at thebase of the penis. The para-ileostomy ulcerationin this patient should also probably be con-sidered to be metastatic. In case 4 there wassubmammary ulceration, and in case 7 there wasan area of ulceration in a transverse crease on thelower abdominal wall.

In all these three cases it is interesting that theulceration occurred in sites where there was closeapposition of two skin surfaces and where thesurfaces tended to become rather moist. Inaddition cases 4 and 7 were rather obese women,the type of person in whom intertrigo and similarskin lesions tend to occur. In all three cases, how-ever, the typical sarcoid granulomatous reactionhas been demonstrated on biopsy of the lesions.So far no explanation can be given for this inter-esting complication of Crohn's disease.

TREATMENTIt is difficult to discuss treatment of this rarecondition due to the small number of cases andthe variation in the extent of the ulceration butseveral basic principles have evolved during thecare of these patients.The first stage in treatment is usually the

removal of the adjacent bowel if it is involved inthe disease as the ulceration will never heal whenthe bowel is still present no matter what localtreatment is employed. This statement may appearto contradict the earlier observation that usuallyanal surgical interference initially caused theulceration to extend, but it is interesting that theonly patient in the serieswho refused an abdomino-perineal excision of rectum still had extensiveulceration of the perineum until he eventuallyagreed to surgery whereas in nearly all the otherpatients ulceration has gradually healed.A simple diversion ileostomy had been per-

formed in case 1 and a transverse colostomyin two patients (cases 5 and 7) but this did notresult in any improvement in the ulceration.This confirms thefindings ofJones, Lennard-Jones,and Lockhart-Mummery (1966) and it is thereforenot a procedure which is recommended in thetreatment of this condition.

Three attempts at excision and primarysuture were made (cases 4, 6, and 7) but on eachoccasion the wounds broke down after about oneweek and this form of treatment should probablybe abandoned.

Systemic steroids were given in four of theseven cases and though some improvement in theulceration had been noted while the treatmentwas continued healing has not been completeand relapse has always occurred when the dosagewas decreased.

Cytotoxic agents were used in case 4 followingreports that their use sometimes resulted in a

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remission in ulcerative colitis (Bean, 1966, Bowen,Irons, Rhodes, and Kirsner, 1966) but there wasno definite beneficial effect resulting from thistherapy.

Various local applications to the ulcerationwere used, including Milton solution, potassiumpermanganate solution, lotio rubra, and varioustypes of steroid lotions but there has been noevidence that one type of treatment is superiorto the others.

Since Pories, Henzel, Rob, and Strain (1967)showed that oral zinc sulphate improved thehealing rate of open pilonidal sinus wounds by30% we have used this drug in the dosage of200 mg tds. So far two patients (cases 5 and 7)have been treated with this drug and the rapidhealing may in some degree be due to this drug.

In my opinion more importantly, however, isrepeated curettage. This is usually performed aboutevery 10 days but may be done up to twice weeklywith good effect. This is well illustrated by case 7as she was transferred to St Mark's Hospitalfive and a half years after an abdomino-perinealresection still with gross ulceration of the peri-neum and groins. She was treated with a regimeof oral zinc sulphate and repeated curettage andthe wounds were almost healed within threeweeks.

I wish to thank the consultant staff of St Marks'Hospital for permission to study their patients andalso to publish this paper. This work was performedwhilst receiving a grant from the St Mark's HospitalResearch fund.

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Bowen, G. E., Irons, G. V., Jr., Rhodes, J. B., and Kirsner, J. B.(1966). Early experiences with Azathioprine in ulcerativecolitis. J. Amer. med. Ass., 195, 460464.

Gray, B. K., Lockhart-Mummery, H. E., and Morson, B. C. (1965).Crohn's disease of the anal region. Gut, 6, 515-524.

Hunter-Craig, C. J. (1961). Granuloma of the groins and perineumsecondary to chronic proctocolitis. Proc. roy. Soc. Med.,54, 1019.

Jones, J. H., Lennard-Jones, J. E., and Lockhart-Mummery, H. E.(1966). Experience in the treatment of Crohn's disease ofthe large intestine. Gut, 7, 448-452.

Lockhart-Mummery, H. E. (1965). Pathological lesions of theanal region associated with Crohn's disease. Dis. Colonand Rect., 8, 399-401.and Morson, B. C. (1964). Crohn's disease of the largeintestine. Gut, 5, 493-509.

McCallum, D. I., and Kinmont, P. D. C. (1968). Dermatologicalmanifestations of Crohn's disease. Brit. J. Derm., 80, 1-8.

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cutaneous ulceration in crohn's disease · into the right groin. aseparate ulcer at the base...

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