Pyoderma Gangrenosum: Three Cases

The dark red plaques seen here (A) developed rapidly under both arms of this markedly obese 43-year-old woman. The lesions spread concentrically, forming necrotic ulcerations with overhanging borders, and there was surrounding violaceous discoloration. No other areas of the patient's body were involved, and she was otherwise in good health.

A 59-year-old man with rheumatoid arthritis had a 6-year history of recurrent, painful ulcers on his shins (B). He was currently being assessed for hepatitis C.

A 34-year-old man had three tender ulcers on his lower left leg (C). They started out as scrapes, progressed to pustules, and then became ulcerated. This man also suffered from ulcerative colitis.

All of these patients display the typical manifestations of pyoderma gangrenosum, a poorly understood inflammatory condition. The deep, sharply marginated ulcers have characteristic overhanging edges and may be exquisitely painful. They may appear anywhere on the body, but the majority develop on the shins and at sites of trauma.

Pyoderma gangrenosum occurs most frequently in persons between the ages of 20 and 49 and is more common among women. Although about 50% of the cases are idiopathic, the condition is frequently associated with a wide variety of underlying illnesses that include inflammatory bowel disease, rheumatoid arthritis, hematologic dyscrasias, and lymphoreticular malignancies. Recently, anecdotal reports have linked pyoderma gangrenosum with hepatitis C.

In the case of the first patient, who showed no evidence of associated internal disorders, Dr Reynold C. Wong of Sacramento, Calif, confirmed his clinical diagnosis of pyoderma gangrenosum with a biopsy. This woman was treated with oral prednisone, 40 mg/d, and the lesions healed completely in 4 weeks. She is currently receiving dapsone for long-term control of the condition.

Drs Charles E. Crutchfield III and Eric J. Lewis of Minneapolis, who sent photos of the second and third patients, note that in addition to corticosteroids (topical and intralesional as well as systemic) and dapsone, many other agents have been used successfully to manage pyoderma gangrenosum. These include cromolyn, sulfapyridine, azathioprine, cyclophosphamide, chlorambucil, cyclosporine, minocycline, rifampin, and clofazimine. Protection of the lesion and compresses are also helpful, and medication for pain control may be indicated. The underlying disease must be managed as well.

The second and third patients were free of associated disease. They were treated with combination therapy-systemic prednisone and cyclosporine-for 2 and 3 months, respectively, and both recovered remarkably well.