A 46-year-old male presented with an erythematous papule progressing into a vegetative plaque on the right cheek that resolved with cribriform scarring. Eight months after, a similar looking erythematous papule appeared on his left cheek. This papule rapidly progressed into a vegetative plaque within a week, and was associated with a pain score of 7 out of 10. Histopathology of the second lesion revealed suppurative dermatitis with diffuse dense infiltrates composed mostly of neutrophils. Cultures revealed few colonies of Enterobacter cloacae which was inconclusive. Pathergy test was negative. High dose systemic corticosteroids were started, with an observed rapid reduction of pain, inflammation, and ultimately resolution of the lesion with formation of cribriform scarring, confirming a case of vegetative pyoderma gangrenosum. It is important to note that not all inflamed and purulent lesions are infectiousneutrophilic dermatoses should always be considered.

Pyoderma gangrenosum (PG) is a chronic inflammatory neutrophilic dermatosis often presenting as a solitary enlarging painful ulcer with red to violaceous undermined borders. This report delves into the role of doxycycline in the treatment of PG in a 44-year-old male COVID-19 positive patient who has concomitant active tuberculosis infection and end-stage kidney disease, for which both first-line treatments (systemic corticosteroid and cyclosporine) are contraindicated. After three months on doxycycline and topical corticosteroids, there was resolution of the ulcers and no note of recurrence up to three months from completion of the treatment regimen.

Cutaneous tuberculosis is a rare form of extrapulmonary tuberculosis seen in 1% of all cases. Lupus vulgaris is one of the most common types of cutaneous tuberculosis. Its cutaneous patterns may mimic other dermatologic conditions such as pyoderma gangrenosum. Clinical, diagnostics and histopathologic correlation is important in diagnosing lupus vulgaris.

This is a case of a 17-year-old Filipino male with multi-drug resistant Pulmonary Tuberculosis who presented with three-months history of erythematous papule that gradually progressed into plaque on the scalp, abdomen and left popliteal area with associated pruritus 5/10. The initial working diagnosis was cutaneous tuberculosis versus pyoderma gangrenosum. Incision biopsy revealed a granulomatous dermatitis surrounded by a dense mixed cell infiltrate of lymphohistiocytes from superficial to mid dermis suggestive of an infectious process. Chest radiograph confirmed pulmonary tuberculosis, interferon gamma detection by enzyme linked immunosorbent assay (Quantiferon TB Gold Plus) and nucleic acid amplification test (GeneXpert TB) further verified the presence of Mycobacterium tuberculosis (MTB). The patient was managed as lupus vulgaris, plaque type and started on second line anti-Koch’s medications. Excellent clinical response was seen after 3 months of treatment.

Lupus vulgaris is a challenging disease and may mimic a myriad of other cutaneous disorders, in this case pyoderma gangrenosum. This case highlights a high index of suspicion, trained clinical eye and multi-specialty care to diagnose and treat complicated cutaneous tuberculosis cases. In geographic locations where MTB is still endemic and drug resistance burdens pose complications in treatment, second line pharmacologic interventions for MTB treatment is a viable option.

Pyoderma gangrenosum causes the destruction of skin tissue and then ulceration. There are currently no international treatment guidelines. Abrocitinib, a JAK1 selective inhibitor, has been used as treatment in some case reports.

A 54-year-old female, diagnosed for 20 years with ulcerative colitis and mostly treated with Chinese herbal medicine, admitted for a solitary painful ulcer on the right lateral ankle, measuring 10x8 cm, with swelling of the right lower leg. Antibiotics were given and wound debridement, exploration, then vacuum-assisted closure dressing were done. She was then referred to dermatology service. Wound care was done by light cleansing of the wound with cold-pressed virgin coconut oil (CP-VCO) - soaked gauze, gentle removal of wound and edge scabs, application of 30% Trichloroacetic Acid on the rounded edges of the ulcer, and covered with a gauze saturated with CP-VCO dressing. Abrocitinib 200 mg/tablet was started once a day. After being discharged, abrocitinib and wound care, with an added pharmacist-compounding of 4% monolaurin, 1% monocaprin, and 10% tranexamic acid in a petrolatum base, was maintained with the same dosage and frequency. At the end of the fourth month, the ulcer completely healed into a solitary pinkish to skin-colored linear scar, measuring at 1.8x4 cm. Dermoscopy monitoring of the wound healing showed progressive lines of epithelialization advancing into the ulcer to a scar with a cribriform pattern of epithelialized red dots.

The excellent results from this pyoderma gangrenosum case report using a combination of these treatment modalities are an opportunity to consider in future clinical cases.

Introduction: Pyoderma gangrenosum (PG) is a rare inflammatory disease with unknown etiology. Ulcerative PG presents with a rapidly enlarging painful ulcer with erythematous and undermined border often misdiagnosed as infection, vascular disorder, malignancy, and other inflammatory disease. Hence, this poses a diagnostic challenge for clinicians leading to a delay in the management and significant morbidity. The treatment of PG is equally challenging due to the rarity of the disease and the scarcity of clinical trials. Currently, there are no clinical practice guidelines for the management of PG. Case Report: Our patient presented with multiple large ulcers with erythematous and undermined borders over the chest, abdomen, and the lower back. Cribriform scars and contractures were noted as well. She underwent several sessions of surgical debridement and was given different broad-spectrum antibiotics with noted worsening of the lesions. Due to extensive involvement of the disease, her quality of life has been significantly affected. A diagnosis of PG was made after the biopsy showed predominantly neutrophilic infiltrate. Prednisone 1mg/kg/day and clobetasol propionate ointment were initiated with significant decrease in pain and size of the ulcers after one month of therapy. Doxycycline was used as an adjunct therapy with excellent response. Conclusion Pyoderma gangrenosum is a rare, debilitating disease that remains a diagnostic dilemma. The worsening of ulcers despite surgical debridement and antibiotics is a clue that should prompt clinicians to consider PG. This case highlights the important role of dermatology in individuals who present with non-healing chronic ulcers because as seen in this case, not all ulcers are just ulcers.
pyoderma gangrenosum ; neutrophilic dermatosis ; ulcers

Humans ; Pyoderma Gangrenosum ; Myeloproliferative Disorders ; Neoplasms

Background: Pyoderma gangrenosum is a rare ulcerative skin disease that can present as an ulcerative skin disease with the prominence of pain. The pathogenesis may be related to disruptions in the immune pathways. Targeted therapy is lacking and current treatment is largely empirical and consists of corticosteroids and cyclosporine first line. Early recognition can improve clinical outcomes. Case: This case is a 67-year-old male diabetic who was admitted for a progressive ulcerative lesion on the right leg. Arterial Doppler studies and CT angiogram of the right lower extremity were normal. Blood and deep wound cultures of the lesion showed Klebsiella pneumoniae and Pseudomonas aeruginosa. Multiple antibiotic regimens were given with no improvement of the ulcerating lesions of the leg. Pain on the lesion remained persistent. The tissue biopsy of the lesion taken during debridement revealed that it was a pyoderma gangrenosum with dystrophic sclerosis. Oral prednisone at 1 mg/kg was added to the regimen which improved pain but the lesion did not improve. The persistence of the pain and progression to sepsis during the hospital course prompted the decision to do an above-knee amputation of the right leg. He was discharged improved. Conclusion Pyoderma gangrenosum is a rare non-infectious cause of an ulcerative lesion in the lower extremity. Diabetes is a strong risk factor for this disease. The course is prolonged with the possibility of secondary infections. Upon histopathologic confirmation, an anti-inflammatory regimen could help improve outcomes.
Pyoderma Gangrenosum ; Diabetic Foot ; Leg Ulcer ; Inflammation ; Anti-Bacterial Agents ; Amputation, Surgical

Objective: To explore the clinical features and treatment of pyoderma gangrenosum (PG). Methods: A retrospective observational study was conducted. From January 2012 to July 2021, 25 patients with PG who met the inclusion criteria were admitted to Beijing Fucheng Hospital, including 16 males and 9 females, with the age of onset of disease being 14 to 75 years. Among them, the classification of PG identified 17 cases of ulcerative type, 6 cases of pustular type, 1 case of proliferative type, and 1 case of bullous type. Six patients were accompanied with systemic diseases, while 19 patients were not accompanied with systemic diseases. At the same time of systemic treatment with glucocorticoids, dressing changes or surgical skin grafting was performed on the wounds. The results of laboratory and histopathological examinations, the overall curative effects and follow-up of patients, the wound healing time of patients with negative and positive microbial culture results of wound secretion specimens, and the curative effects of patients with and without systemic diseases were analyzed. Results: The results of blood routine examination of 19 patients were abnormal, and all the immunological indexes were normal in all the patients; the microbial culture results of wound secretion specimens were positive in 14 patients; and the histopathological examination results of ulcer boundary tissue in 15 patients with rapid wound progress were mainly local tissue inflammatory changes. The wounds were cured in 17 patients, mostly healed in 7 patients, and not healed in 1 patient. After one-year's follow-up, the PG in 3 patients relapsed due to self-discontinuation of medication after discharge, and the wounds were healed gradually after adjustment of medication, while the remaining patients had no relapse. The days of wound healing in 14 patients with positive microbial culture results of wound secretion specimens were 21-55 days, and the days of wound healing in 11 patients with negative microbial culture results in wound secretion specimens were 20-54 days. In the 6 patients with systemic diseases, the wounds of 3 patients were cured, and the wounds of the other 3 patients were mostly healed. In the 19 patients without systemic diseases, the wounds of 14 patients were cured, the wounds of 4 patients were mostly healed, and the wound of 1 patient was not healed. Conclusions: The laboratory examination and pathological manifestations of patients with PG lacks characteristics, and their clinical manifestations are rich and diverse, thus PG can be easily misdiagnosed. The glucocorticoids combined with immunosuppressive therapy have good effects on PG. Surgical intervention can be performed on the wounds. Specifically, excessive debridement is not recommended in the acute phase, but skin grafting can be performed in the contraction phase.
Administration, Cutaneous ; Adolescent ; Adult ; Aged ; Female ; Glucocorticoids ; Humans ; Male ; Middle Aged ; Pyoderma Gangrenosum/therapy* ; Skin Transplantation ; Wound Healing ; Young Adult

Pyoderma gangrenosum (PG) is a rare neutrophilic dermatosis, closely associated with the immune system. Its pathogenesis is currently not clear. The lack of specificity in the clinical manifestations and histopathological changes of PG leads to a long clinical diagnosis cycle and even misdiagnosis, which is easy to delay treatment or promote the deterioration of ulcer wound. The diagnosis of this disease is still very difficult, which poses a great challenge to wound repair practitioners. This article reviews the research advances on the pathophysiology, clinical features, and diagnosis of PG in recent years, with the aim of providing reference for relevant clinical practitioners.
Humans ; Pyoderma Gangrenosum/pathology*

Pyoderma gangrenosum (PG) is a rare chronic inflammatory non-infectious skin dermatosis, and there is no clear treatment guideline for this disease at home and abroad. There are a variety of clinical treatment methods for PG, including local therapy and systemic application of glucocorticoids, immunosuppressants, intravenous immuno- globulin, and biologics. Glucocorticoids are the first-line drugs commonly used in clinical practice, and immunosuppressants can be used alone or in combination with glucocorticoids. In recent years, more and more evidence has shown that biologics are a new trend in the treatment of PG, mainly including tumor necrosis factor α inhibitors, interleukin-1 (IL-1) inhibitors, IL-12/23 inhibitors, IL-17 inhibitors, rituximab, and small molecular inhibitors. This article summarizes the current status and latest progress in the treatment of PG, hoping to provide clinicians with ideas for the treatment of PG.
Biological Products ; Glucocorticoids ; Humans ; Immunosuppressive Agents ; Immunotherapy ; Interleukin Inhibitors ; Pyoderma Gangrenosum/drug therapy*