Case report Pyoderma gangrenosum associated with melanoma


“This case describes an unusual and


worrying clinical scenario that


suggests underlying malignancy should be considered in pyoderma


gangrenosum cases.”


A 6-mm punch biopsy taken from the edge of the lower-leg ulcer showed necrosis and inflammatory dermal infiltrates composed of mature neutrophils, compatible with PG. A computed tomography scan of the chest- abdomen-pelvic and bone marrow biopsy revealed no underlying disease. Two days after presentation, the ulcer on


the lower leg had increased in size to 13 cm x 10 cm. There were no signs of infection in either wound. CRP had decreased to 22 mg/L, erythrocyte sedimentation rate to 33 mm/ hour, and leukocytes to 16.6 x 109/L. A week after commencement of treatment no further reduction in ulcer size had been achieved on either the lower leg or hip. Local treatment of the wound was betamethasone cream with chinoform cream with a nonadherent, absorbent dressing. In July 2010, 5 weeks after the first


REFERENCES 1. Powell FC et al (1985) Q J Med 55(217):


173–86


2. Powell FC et al (1996) J Am Acad Dermatol 34(3): 395–409


3. Ahmadi S, Powell C (2005) Clin Dermatol 23(6): 612–20


4. Ruocco E et al (2009) J Eur Acad Dermatol Venereol 23(9): 1008–17


5. Ahronowitz I et al (2012) Am J Clin Dermatol 13(3): 191–211


6. Su WPD et al (2004) Int J Dermatol 43(11): 790–800


7. Vignon- ‐Pennamen MD (2000) Clin Dermatol 18(3): 339–47


8. Duguid CM et al (1993) Australas J Dermatol 34(1): 17–22


9. Nikolaou V, Stratigos AJ (2013) Br J Dermatol 170(1):11–9


10. Lang PG (2002) Am J Clin Dermatol 3(6): 401–26


11. Douglas JG, Margolin K (2002) Semin Oncol 29(5): 518–24


12. Karran P (2006) Br Med Bull 79–80: 153–70


presentation to the authors’ institution, treatment with azathioprine (dose escalation to 200 mg per day) was commenced, phasing out prednisolone and within a couple of months and the wounds showed marked improvement. The wounds were treated locally with a zinc ointment to the periwound area and a foam dressing. Granulation began and there was an initial epithelialization. In March 2011, the patient presented to her GP with skin alteration on the back and swelling in the armpit. After excision, she was diagnosed with malignant melanoma. She was confused and magnetic resonance imaging revealed cerebral metastases. Treatment with azathioprine was discontinued and intravenous steroids commenced. The patient died in May 2011.


DISCUSSION PG lesions are described as painful, sharply outlined, necrotic ulcers, creating haemorrhagic or purulent exudates, and with undermined, violaceous borders and a surrounding zone of erythema.[6]


diagnosis; there is no specific histological or serological marker for the condition that can alone provide the diagnosis.[5]


Topical potent corticosteroids are useful to reduce the irritation in the skin surrounding the ulcer. Nonadherent foam dressing are recommended.[3] The systemic diseases associated with PG are seen in approximately 50% of the overall cases of PG, but in patients with the ulcerative type of PG they occur in >70% of patients.[2] Ahronowitz et al[5]


report IBD to be the most


common PG-associated disease, followed by arthritis, haematologic abnormalities, and haematologic malignancies. Other associations listed as rare or questionable include hidradenitis suppurativa, pyogenic arthritis–pyoderma gangrenosum–acne syndrome, pulmonary disease, systemic lupus erythematosus, thyroid disease, solid organ malignancy, autoimmune hepatitis, and sarcoidosis.[5]


The most common malignant


disease associated with PG is haematologic malignancy,[5]


this is seen in up to 7% of PG


cases – predominantly acute myeloid leukemia, which has a 1- year mortality rate as high as 75%.[8] In the present case, the authors describe PG in association with malignant melanoma. The global incidence of cutaneous melanoma is increasing.[9,10]


Melanoma, which commonly PG is a clinical However,


histologically, PG is characterised by the presence of inflammatory dermal infiltrates with a predominance of mature neutrophils.[7] Local wound care of PG is important to


improve conditions for healing and prevent secondary bacterial infection. The ulcers should be cleansed daily and application of potassium permanganate solution or silver sulphadiazine cream can be helpful.


26


spreads via the central nervous system (CNS), is challenging to treat due to the lack of active systemic agents and the limited CNS penetration of available agents. Consequently, a poor prognosis is associated with CNS metastasis from malignant melanoma.[11] This patient with PG reported here subsequently developed cancer and died of metastatic disease. The presence of both these diseases concomitantly may be unrelated. However it could be postulated that there is a link and it may be worth thinking about malignancy, when a patient develops PG with no other related systemic disease. It is suggested that immunosuppressive treatment increases the risk of skin cancer, however this is usually related to non-melanoma skin cancer and the long-term administration of immunosuppressive treatment in transplant patients.[12]


CONCLUSION This case describes an unusual and worrying clinical scenario that suggests underlying malignancy should be considered in PG cases. The increasing incidence of cutaneous melanoma means that presentations associated with PG may become more common and clinicians should be vigilant. n


Wounds International Vol 5 | Issue 2 | ©Wounds International 2014 | www.woundsinternational.com


Case report


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