Treating Pyoderma Gangrenosum: A Case Study
One cannot diagnose a wound by appearances only. The classic features of a venous wound or pressure wound, which we have seen numerous times, can lure us into treating them without further work-up. We recently had a case in the Denver Wound Healing Center at P/SL that demonstrates the pitfalls of such actions.
A 24-year-old Japanese female was referred to the Denver Wound Healing Center from a nursing home where she developed a wound over lateral forefoot. Her past medical history included a severe brain injury from an auto-pedestrian accident, leaving her paraplegic and non-communicative, with hypertension and tachycardia. The wound was being treated empirically with antibiotics and topical wound care with no benefit.
When she presented to our clinic, she was slightly cushinoid with severe contractures. She did not have changes associated with venous insufficiency and she had strong pulses and brisk capillary refill time. The wound was below her lateral malleolus and was expansive with raised, purple borders.
The wound bed was hypergranular with a visible tendon exposed. The skin surrounding the wound had mild dermatitis. We performed several diagnostic tests including, an X-ray, which was negative for osteomyelitis, blood work which was also unremarkable, and a wound culture which revealed less than 100,00 Staph Aureus.
However, when we performed a skin biopsy, the findings were consistent with the diagnosis of pyoderma gangrenosum.
Pyoderma Gangrenosum (PG) is an ulcerative cutaneous condition that is relatively uncommon, occurring in about one in every 100,000 people each year. The etiology is uncertain, and it is associated with systemic diseases such as an inflammatory bowel disease and hepatitis in more than half of the cases. There are two variations of PG.
The classic ulceration is typically observed on the legs, while the more superficial version involves the hands. The prognosis for PG is good but the chance of recurrence, and residual scarring is common.
Treatment typically includes the use of anti-inflammatory and immunosuppressive agents. To avoid potentially dangerous immunosuppressive treatment, we in the Denver Wound Healing Center have had good results using topical salicylic acid ointment with this diagnosis. The patient we started on the 5 ASA Cream 10% covered with Telfa and Kling then foam blocks for pressure relief. The wound had an excellent response to the treatment, and was healed in 6 weeks.