Pyoderma gangrenosum and vasculitis?

[H.D.]

I am a 26 WM with a leg ulcer (on outside of left calf) that has lasted over a year.  It has been diagnosed as pyoderma gangrenosum, and I have also had small-vessel vasculitis.

Although my mother has ulcerative colitis, I was tested and came up clean.  (I have exhibited no UC symptoms.)

Typical PG therapies (prednisone, dapsone, Cellcept, cyclosporine) have been unsuccessful.

Recommendations for new treatments have included: methotrexate, Cytoxan, skin grafting, IV prednisone pulse treatments.

I am looking for additional input and any ideas concerning my diagnosis.  (For example, is it possible that PG is an incorrect diagnosis?)

Thanks very much!

[dorothyd]

A related discussion, I have recently been diagnosed with pyoderma gangrenosum.  Does anyone else also have lichen planus or lichen schlerosis?  I am wondering if they are related. was started.

[Dr. M.E.]

I have a simialr problem.  The initiating factor for the pyoderma gangrenosum was freezing of two small nodules on my ankles. I had had the repeated episodes these nodules for years.  They moved around the ankle.  Periodic frezing and injections of cortisone did destroy most or kept them from enlarging.  The last freezing done in early September caused the current problem.  It is now 4 months down the road and the healing of the ulcer is extremely slow.  Prednisone
did not work.  Because the etiology is unknown my treating dermatologist does not want to use any invasive prodecures.  I have a long history of having these nodules and have had 5 biopsies.  Four were inconclusive.  One called for a rule-out of lupus which we did.  So far no other underlying conditions have been identified.  I get these nodules on both arms and legs and a few on my torso.  None of the others turned into pyoderma gangrenosum.  The condition began after I had benn on and off on antibiotics for 7 months for sinus infections caused by allergies.  I also noted that the nodules follow major blood vessels, and are opportunistic in that if one is open and there is a break in the skin nearby a new one will develop were the break is.  Others seem to "move" along the path of the blood vessel.  When the nodels puff up and open (about every 4 to 6 weeks)application of hydogen pyroxide causes a reation like that found with infection.  Long term treatment with hydrogen pyroxide works but it is slow and it is painful.  Has anyone had a similar experience.

[Nancy Andrist]

After 9 years of multiple ulcers on multiple sites we tried Thalidomide with much success. We tried everything anyone could come up with including injections of steroids, grafting, cyclosporin, debridement etc. I was on thalidomide for 1 year with complete healing of my hand, and good progress on my leg. I have, however, perepheral neuropathy from the drug. Good luck.

[Alan Rockoff, MD]

H.D.:

Your case is too complex to make a meaningful comment on sight unseen.  I have three suggestions: 1) ask your current physicians whether they think a biopsy might clarify the diagnosis; 2) ask them if injections of cortisone might be worth trying; 3) have another pair of eyes look at you and evaluate your case, even if only for peace of mind.  Pyoderma Gangrenosum can occur without colitis, but perhaps other causes of ulcers, uncommon though they may be, are worth considering.

A good resource is your local academic teaching hospital dermatology department.  If you're at on already, try another one across town or nearby.  Bring all your records.

best.

Dr. R