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To the Editor:

We report a case of a female, 21 years old, with a diagnosis of Crohn's disease (CD) since age 14. She began with extensive perineal disease without evidence of intestinal involvement, with progressive improvement with conventional treatments. There was recurrence after 2 years, beginning use of infliximab with partial improvement, but there was a need for sigmoid colostomy for patient comfort, resulting in almost complete improvement. The patient during this time remained on infliximab. After 3 months she showed paracolostomy hernia, prolapsed colostomy, and parastomy dermatitis (Figures 1 and 2). Colonoscopy was performed which showed active disease in the descending colon. Left hemicolectomy was performed with primary anastomosis and loop ileostomy, because perineal injuries and poor hygiene of the patient not allowed to leave her without stoma.

Evans et al1 reported three cases of patients with CD and difficulties with stoma related to excess adipose tissue and paracolostomy hernia. These three were treated for abdominoplasty and repositioning of the stoma, with good results.

Although perianal involvement occurs in approximately one-third of patients with CD, skin involvement can be found in 22%–44%, whereas genital manifestations are extremely rare. Also, such injuries usually occur after intestinal manifestation and not preceding, as occurred in this patient.2 In such situations, in addition to conventional treatment with corticosteroids, antibiotics, immunosuppressants, and biologic therapy, the realization of a stoma is described as a saving option for many authors.1–4

Despite the undoubted advantages of fecal diversion in patients with severe genital and perianal involvement, we must also consider the high rate of complications of these procedures. Post et al5 showed that the main indication for stoma in patients with celiac disease was genital and perianal fistulas; the complication rate of stoma was 31% versus 5% for colostomies and ileostomies, respectively. The patient case presented complications of colostomy and opted for realization of an ileostomy, taking into account the intention of avoiding further complications. These authors evaluated 746 patients with CD treated surgically, of which 227 had a stoma performed and concluded that the main factors related to a permanent stoma are rectal inflammation, perianal fistulas or abscesses, and absence of bowel involvement.5, 6

Also according Post et al,5 the chance of closure of stoma in patients with CD are 79% when performed after surgical complications, and 75% for anastomotic protection and drops dramatically to 40% for genital or perianal involvement, as the case in this article.

Thus, we can conclude that CD with perianal dermatological involvement exclusively is rare, often requires diversion of their treatment, and the development of active disease in the proximal bowel segment is more common than in the excluded segment, which makes this case even more rare. 1

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Figure 1. Perineal and colostomy disease. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]

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Figure 2. Colostomy disease. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]

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REFERENCES

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Carlos Henrique Marques dos Santos MD, PhD*, Patrícia Costa de Oliveira Campos MD*, Adriana Covatti Luza MD*, * Federal University of Mato Grosso do Sul Campo Grande, Brazil.