Case report Pyoderma gangrenosum associated with melanoma


Expert commentary


Joon Pio Hong, Professor of Plastic Surgery, Asan Medical Center, University of Ulsan, Seoul, Korea


P


yoderma gangrenosum is an ulcerative, cutaneous condition that usually occurs on the legs. Ulcers initially look like small insect bites or papules, progress to become


larger wounds, and frequently become chronic. Patients of any age may be affected by the condition, but it predominantly occurs in the fourth and fifth decades of life. Though mortality is rare and the prognosis generally good, pyoderma gangrenosum causes pain, scarring, and often recurs.


Pyoderma gangrenosum does not have characteristic serologic or histologic features. Thus, all other potential causes of similar lesions must be excluded prior to making a diagnosis of pyoderma gangrenosum. Other causes of cutaneous ulceration that is similar in appearance to pyoderma gangrenosum include infection, malignancy, vasculitis, collagen vascular diseases, diabetes, and trauma.


The aetiology of pyoderma gangrenosum is still vague, but dysregulation of the immune system is suspected to be a major feature and the condition is associated with underlying systemic diseases in half of case.[1]


Ascertaining the underlying systemic condition associated with a given case of pyoderma gangrenosumt can be clinically challenging.


There is no consensus on the treatment of pyoderma gangrenosum, due in part to the rarity of the condition itself. Systemic medications that have been successfully used in treatment include corticosteroids, sulfasalazine, dapsone, thalidomide, minocycline, clofazamine, mycophenolate mofetil, cyclosporine, intravenous immunoglobulin, cyclophosphamide, and biologic medications.[2]


To date, only one controlled, clinical trial has been published


that reports the safety and efficacy of infliximab – an antitumor necrosis factor monoclonal antibody – for the treatment of pyoderma gangrenosum.[3]


Although there are some reports of successful flap coverage, sites of pyoderma gangrenosum-induced ulceration are not generally considered good candidates for skin grafts. Further skin breakdown at the harvest site is also a clue to diagnosis, and pathergy is often seen.


Given these limitations, the current treatment strategy for pyoderma gangrenosum is to: 1. Reduce inflammation by multiple modalities, and 2. Optimise wound healing by conservative methods.


The case report provided here by Carøe and Fogh demonstrates the difficulties of treating pyoderma gangrenosum. The diagnostic approach and treatment strategy used were in accordance with currently accepted strategies. Although it is difficult to determine whether the malignant melanoma played a role in the formation or aggravation of the ulcer in this case, malignancy should be evaluated as a possible underlying cause of pyoderma gangrenosum.


The authors should be congratulated for their efforts in treating this difficult condition, and for their vigorous search for the underlying cause. n


“The authors should be congratulated for their efforts in treating this difficult condition, and for their vigorous search for the underlying cause.”


REFERENCES 1. Callen JP, Jackson JM (2007)


Rheum Dis Clin North Am 33(4): 787–802


2. Goodarzi H et al (2012) Adv Wound Care (New Rochelle) 1(5): 194–9


3. Brooklyn TN et al (2006) Gut 55(4): 505–9


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


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Case report


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