The family physician made the presumptive diagnosis of pyoderma gangrenosum with partial healing. (The areas of active disease are shown with arrows.) As is the case with about half of all patients with pyoderma gangrenosum, this patient had no associated systemic diseases such as inflammatory bowel disease, hematologic malignancy, or arthritis. She also had no known pathergy (initiation at the site of trauma or injury).
The lesion was in the most typical location: the leg. The physician performed a punch biopsy including the active ulcer and the border to rule out other causes of ulcerative skin lesions. The biopsy showed a neutrophilic infiltrate consistent with pyoderma gangrenosum.
Treatment options include:
- topical medications, such as potent steroid ointments, tacrolimus ointment, or silver sulfadiazine
- intralesional injections with corticosteroids
- systemic treatment with oral corticosteroids
- treatment with mycophenolate mofetil, oral tacrolimus, dapsone, azathioprine, or infliximab (each used successfully according to published case reports).
Surgical debridement is contraindicated since pathergy will make the lesions worse.
The physician treated the patient with oral dapsone. The pain finally subsided and the remaining active areas healed.
Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Flowers D, Usatine R. Pyoderma gangrenosum. In: Usatine R, Smith M, Mayeaux EJ, et al, eds. The Color Atlas of Family Medicine. New York, NY: McGraw-Hill; 2009:735-739.
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