Pyoderma Gangrenosum in a Woman With Crohn Disease, Clinical Depression, and Borderline Diabetes Mellitus

A 56-year-old woman noted the abrupt onset of several very painful ulcerations on her back. The patient had known (and active) Crohn disease, clinical depression requiring ongoing psychiatric care, and borderline diabetes mellitus. She was regularly taking an oral non-absorbable corticosteroid and mesalamine for the inflammatory bowel disease (IBD), with some improvement in signs and symptoms of IBD.

Key point: The cleanly “punched-out” appearance of painful ulcerations, as well as the rolled-border, especially in conjunction with IBD, strongly suggests the diagnosis: pyoderma gangrenosum.

Treatment: Various topical regimens were tried to no avail. Cyclopsorine has proved beneficial in some patients, but it did not help in this case. While oral corticosteroids may heal such lesions, both the high dose and the long duration required may result in significant adverse events. The patient eventually received anti-TNF alpha blockade (adalimumab), and the IBD improved. Concurrent to this improvement, the pyoderma gangrenosum healed.

Note: Pyoderma gangrenosum may also be seen in conjunction with rheumatoid arthritis.