When A Non-Healing Wound Has A Dermatologic Origin
- Volume 27 - Issue 2 - February 2014
- 3075 reads
- 2 comments
Anthrax is caused by a bacterium called Bacillus anthracis. Humans can become infected with the spore-forming bacteria by close contact with farm animals that are infected. The bacterium typically enters the body through an open skin lesion. Active infection not only includes skin breakdown but there is typically nausea, vomiting, malaise, fever and sore throat.
What You Should Know About Pyoderma Gangrenosum
Pyoderma gangrenosum is a non-infectious neutrophilic dermatosis. Typically, the wounds start with vesicles, bullae and/or pustules. Later in the disease process, the skin breaks down to full-thickness ulcerations of skin with undermined violaceous borders.
Ulcers associated with pyoderma gangrenosum are painful. Legs are the most common anatomic region associated with pyoderma gangrenosum but all skin including mucous membranes can be affected. In many cases, pyoderma gangrenosum may be associated with an underlying medical condition. These conditions include inflammatory bowel disease, rheumatologic disorders, hepatitis C, leukemia, lymphoma and drug-induced cases.
One can make the diagnosis via biopsy and exclusion. There are no laboratory parameters to aid in the diagnosis. Histopathology is typically non-specific. Suppurative folliculitis and dense neutrophil infiltrates are typically visible. Treatment of pyoderma gangrenosum lesions is usually more medically oriented versus surgical. Debridement of a pyoderma gangrenosum wound can trigger pathergy and the wound can worsen. Medical treatment usually includes oral and topical corticosteroids, immunosuppressive agents, sulfa drugs and/or cytotoxic drugs.
For review of the laboratory data from our patient, she had a white blood cell count of 7.2 with a normal differential. Her hemoglobin was 9.8 g/dL. All serology markers were negative. Her radiographs showed mild periosteal reaction of the leg, the MRI was negative for osteomyelitis and Doppler studies were negative for venous reflux or obstruction. The cultures of the wound and blood were negative. The biopsy of the wound revealed no vasculitis and various stages of ulceration and granulation tissue.
Despite not having classic neutrophil infiltrates in the biopsy, I made the diagnosis of pyoderma gangrenosum by exclusion. The patient is currently undergoing medical treatment and has shown improvement over the past six months. Initially, she took methylprednisolone (Solu-Medrol, Pfizer) 1 g daily for three days and the wound showed immediate improvement. She is currently on a regimen of minocycline and dapsone. She is applying clobetasol (Temovate, GlaxoSmithKline) ointment and Adaptic (Systagenix) with a light dressing daily. Every other day, she is performing a bleach bath of the leg, which is composed of 1 tablespoon of bleach per gallon of water.
Pyoderma gangrenosum can be a limb- and life-threatening dermatosis. The diagnosis occurs by biopsy and exclusion of other dermatologic conditions. If one suspects pyoderma gangrenosum, be cautious with any surgical debridement, which can make the ulcer worse. This difficult case’s diagnosis and management entailed a multidisciplinary approach including podiatry, internal medicine, vascular specialists and dermatology. Ultimately, the definitive diagnosis occurred with negative serological markers and biopsy that ruled out carcinoma and infection.
Dr. Fishco is board-certified in foot surgery and reconstructive rearfoot and ankle surgery by the American Board of Podiatric Surgery. He is in private practice in Phoenix. Dr. Fishco is also a faculty member of the Podiatry Institute.
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