The Danger Of Disputed And Delayed Management Of Pyoderma Gangrenosum

Pyoderma Gangrenosum (PG) is an ulcerative inflammatory disorder causing rapidly progressive, painful skin lesions not amenable to debridement or amputation. Often associated with inflammatory bowel disease (IBD), rheumatoid arthritis, and malignancy, PG is commonly viewed as a diagnosis of exclusion. Despite better prognosis with early recognition and intervention, definitive guidelines for therapy and management are lacking. While not yet labeled for use in PG treatment, biologic agents, Adalimumab and Infliximab, have shown promise in resolving resistant PG wounds. We herein report a case of a 78-year-old male with no known underlying IBD, autoimmune disorders or hematologic malignancies, who presented with new, painful, enlarging leg ulcerations. The wounds were initially diagnosed as recurrent venous stasis ulcers. Worsening of the lesions and histological analysis eventually confirmed PG. Silver nitrate dressings were used to cover the wound, although this is controversial due to caustic properties that can induce pathergy in the disease. Subsequent treatment with local and systemic steroids was started. As the patient quickly deteriorated, these first line therapies were continued for nine months without success. Further management was protracted due to disputes in management between providers and lack of insurance coverage for intensive biologic treatments. This case illustrates the need for a more definitive, multispecialty protocol for managing PG that consists of local, systemic, and biologic therapies.

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