Improvement of Ulcerations in Treatment-Resistant Chronic Scarring in a Patient with Pyoderma Gangrenosum After Improving Vascular Insufficiency, Gently Removing Necrotic Debris, and Decreasing Wound Fluid
Unusual or unexpected effect of treatment, Rare disease, Clinical situation which can not be reproduced for ethical reasons
William J. Nahm, Jorge A. Mota, Sarah Rojas, Brian J. Hizon, Chris Gordon
Department of Family Medicine, Family Health Centers of San Diego, San Diego, CA, USA
Am J Case Rep 2018; 19:844-848
Classical pyoderma gangrenosum is a rare, inflammatory, neutrophilic dermatosis that commonly presents with severe ulcerations on the lower extremities and is often misdiagnosed and mistreated. Delay in treatments can lead to worsening of the ulcerations and allows for multiple comorbid factors. Pyoderma gangrenosum is most commonly treated with immunosuppressants or anti-inflammatory agents and is often worsened by surgical procedures due to the presence of pathergy. In acute cases, a course of anti-inflammatory treatments works well in alleviating symptoms and reducing ulcerations and residual scarring. However, in chronic cases with the presence of severe scarring and necrotic ulcerations, the simple implementation of systemic immunosuppressants is frequently ineffective alone. Although not mentioned in most case reports on pyoderma gangrenosum, the chronicity of its inflammatory component can lead to necrosis and scarring and subsequent vascular insufficiency.
CASE REPORT: We present a severe case of chronic ulcerative pyoderma gangrenosum in a patient who had treatment-resistant ulcerations and cribriform edematous scarring with subsequent vascular insufficiency of the right lower extremity. This patient, while receiving topical clobetasol, had marked improvement in the healing of his ulcerations only after starting a novel course of cadexomer iodine, compression stockings, and pentoxifylline.
CONCLUSIONS: The efficacy of non-anti-inflammatory treatments indicates that chronic pyoderma gangrenosum with extensive scarring is commonly associated with the comorbid factors of vascular insufficiency, necrotic debris, and extensive wound fluid. In cases of ulcerations in chronic pyoderma gangrenosum that are resistant to anti-inflammatory treatments alone, one should identify and address other compounding factors that may inhibit wound healing.
Keywords: Cicatrix, Clobetasol, Iodine Compounds, pentoxifylline, Pyoderma Gangrenosum, Venous Insufficiency