Pyoderma gangrenosum

Case Report

Pyoderma gangrenosum is an inflammatory disease of unknown etiology that primarily affects adults and consists of recurrent destructive ulcers.1 Several variants have been identified, with typical lesions having inflamed, undermined borders. Management includes a combination of local and systemic modalities.2 For small ulcers, whirlpool baths, topical antibacterials, and topical steroids are usually sufficient. Immunosuppressive and cytotoxic agents have been employed in moderate to severe cases. In some cases, the ulcerative process can become extensive and recalcitrant, adversely affecting a patient's medical condition.

CASE REPORT

A 57-year-old woman with pyoderma gangrenosum confirmed by biopsy and a history of hypertension and chronic renal insufficiency presented with a lower left extremity ulcer of 3 years' duration that had failed to heal with conventional wound care and elevation. Due to progressive ulceration, the patient experienced significant fluid and electrolyte losses that exacerbated her underlying renal condition. Recurrent infections led to sepsis, requiring hospital admission for intravenous antibiotic administration. After unsuccessful trials of hyperbaric oxygen, immunosuppressive therapy, anti-infectives, and surgical debridement with occlusive dressings, below-the-knee amputation was recommended (Figure 1).

After surgical debridement, a 410 cm^sup 2^, circumferential, fullthickness soft tissue defect remained over the distal left leg and ankle. Recombinant human platelet-derived growth factor-BB (becaplermin gel [Regranex; Ortho-McNeil, Raritan, NJ]) was applied once daily to the wound and covered with moist saline gauze that was changed twice daily. Although the Food and Drug Administration approved becaplermin for the treatment of lower extremity diabetic neuropathic ulcers, there is no legal contraindication to prescribing becaplermin in nondiabetic patients. Off-label applications are left to the clinician's medical judgment in treating each patient's specific condition.

Eight weeks after initiating becaplermin therapy, granulation buds were noted in the soft tissue and over the exposed tendons and bone (Figure 2). After 12 weeks, the connective tissue structures were completely covered by a healthy bed of granulation tissue (Figure 3). In this case, the dangers associated with obtaining autogenous tissue to promote reepithelization necessitated the use of a meshed allograft. The grafts healed uneventfully; complete wound closure was achieved 8 weeks following allograft placement (Figure 4). The patient regained full functional use of the lower extremity and has since maintained skin integrity and remained infection-free.

DISCUSSION

Pyoderma gangrenosum is a chronic and ulcerative condition of the skin that can take several forms, including pustular, bullous, ulcerative, and peristomal variants. Treatment should be tailored to the patients type of lesion, the extent and duration of disease, other associated systemic diseases, age, gender, and prior treatment.3 Topical antibacterial and anti-inflammatory medications are usually effective for treating limited disease, while systemic therapy may be required for more severe and widespread disease. Systemic therapies include pulsed steroids, antibiotics, and in-imunosuppressive agents such as cyclosporine, methotrexate, chlorambucil, and granulocytemacrophage colony-stimulating factor.4 Some ulcers become recalcitrant and present serious threats to a patients well-being. Restoring the subcutaneous tissue to preserve the exposed connective tissue, improving the environment for reepithelization, and imposing an environmental barrier is critical for managing these wounds.

In this case, severe pyoderma gangrenosum ulcerations created circumferential exposure of connective tissue structures vital to limb integrity. It was theorized that accelerated wound healing via the chemotactic recruitment and proliferation of reparative cells by exogenous plateletderived growth factor-BB (becaplermin) would be beneficial. Becaplermin has been shown to accelerate wound healing and increase the incidence of complete healing of lower extremity diabetic ulcers.56

After treatment with becaplermin, granulation tissue formation was seen in this wound. Becaplermin induced granulation that covered the vital structures and optimized the soft tissue bed. Use of becaplermin and allograft placement led to successful wound closure, resulting in limb preservation and resumption of the patients normal activities of living. It is believed that becaplermin could be used in other cases of pyoderma gangrenosum, based on the positive results of this case.

REFERENCES

1. Powell RS, Holbrook ME, Stevens A. Pyoderma gangrenosum and its treatment. Lancet 1997;350:1720-1.

2. Powell FC, Su WP, Perry HO. Pyoderma gangrenosum: clarification and management. J Am Acad Dermatol 1996;34:395-409.

3.Trent J, Kirsner RS. Diagnosing pyoderma gangrenosum. Adv Skin Wound Care 2001;14:151-3.

4. Chow RK Ho VC.Treatment of pyoderma gangrenosum.J Am Acad Dermatol 1996;34;1047-60.

5. Smiell JM, Wieman TJ, Steed DL, Perry BH, Sampson AR, Schwab BH. Efficacy and safety of becaplermin (recombinant human platelet-derived growth factor-BB) in patients with nonhealing, lower extremity diabetic foot ulcers: a combined analysis of four randomized studies. Wound Rep Reg 1999;7:335-46.

6.Steed, DL. Clinical evaluation of recombinant human platelet-derived growth factor for the treatment of lower extremity diabetic foot ulcers: the diabetic ulcer study group. J Vasc Surg 1995;21:71-81.

Bruce M. Freedman, MD, FACS, and Elisabeth H. Oplinger, MPT

Bruce M. Freedman, MD, FACS, is Medical Director and Elisabeth H.Oplinger, MPT, is a staff physical therapist at Plastic Surgery Associates of Northern Virginia, McLean, VA. Presented at the 59th Annual Meeting of the American Academy of Dermatology, Washington, DC, March 2-7, 2001.

Submitted June 22,2001; accepted August 16,2001.

Copyright Springhouse Corporation Jul/Aug 2002
Provided by ProQuest Information and Learning Company. All rights Reserved