Pyoderma gangrenosum of the scalp treated with cyclosporine A

Abstract

A 56‐year‐old woman presented with an ulcer, with a depth of 9 mm, on the vertex and frontal parietal regions of the scalp. The lesion had a round shape (diameter, 7 cm), with clear‐cut margins and vertical borders sinking vertically to a bottom that was entirely covered with purulent fibrinous yellowish matter and greenish colored necrotic tissue. Other numerous small roundish ulcers were present next to the large ulcer. These had irregular margins with a yellowish fibrinous bottom (Fig. 1). The patient reported the appearance of two small ulcers on the left and on the right frontal parietal regions about 1 year earlier. These had been treated locally with antimicrobials and antiseptics with no result. During the 2 months prior to our evaluation, a few small round‐shaped ulcers had appeared on the scalp. These had progressively increased in size and number. Figure 1  Large ulcer with clear‐cut margins, covered by purulent fibrinous matter, and other small roundish ulcers The patient had been an insulin‐dependent diabetic for 23 years. Hematochemical examinations showed no significant alterations, except for a rise in glycemia. Urine examination gave normal results. Carcinoembryonic antigen and lymphocytic phenotyping indices were normal. Echographic, endoscopic, and radiocontrast studies of the abdomen did not reveal the presence of lesions either in the gastrointestinal tract or in other organs. Samples of ulcerous tissue were collected from the scalp to perform histologic and microbiologic analysis in search of fungi and bacteria. This last examination revealed the presence of Staphylococcus aureus and Candida parapsylosis. Direct search for mycobacteria was negative. Histology indicated the presence of dermal granulomatous inflammation with giant multinucleate cells, associated with large zones of suppuration and colliquative necrosis. While waiting to complete the diagnostic course, topical antiseptic, antimicrobial, and fibrinolytic therapy was administered; subsequently, as this did not lead to any improvement, systemic treatment with cyclosporine A (5 mg/kg/day) was started. Rapid improvement of the clinical picture occurred. The ulcers appeared cleaner from the first 2 weeks of treatment, radial growth stopped, and the margins were slightly more superficial. The patient continued with immunomodulating therapy at home over a period of 7 months. The dose was progressively reduced until, over a period of about 3 months, complete re‐epithelialization of the lesion, with subsequent partial regrowth of the hair, was obtained (Figs 2 and 3). No relapses were observed 1 year after treatment was suspended. 2 Partial re‐epithelialization of the lesion with partial regrowth of the hair 3 Scar and hair regrowth

Secondary cicatricial and other permanent alopecias

“…In about 50% of cases, there is an underlying systemic disorder, such as inflammatory bowel disease, a myeloproliferative malignancy, rheumatoid arthritis or chronic hepatitis. Management involves careful wound care, treatment of the underlying condition and the use of immunosuppressing agents (74–76).…”

Pyoderma gangrenosum: an expert commentary

“…Successful systemic therapies for PG have included corticosteroids, azathioprine, cyclosporin [48][49][50], tacrolimus, mycophenolate mofetil [51][52][53], methotrexate [54], chlorambucil [55], thalidomide [56], colchicine [57], cyclophosphamide [58,59], and dapsone, minocycline or sulfapyridine [60]. [61], infliximab [62][63][64][65][66] and adalimumab [67], have been reported as being beneficial in the treatment of PG.…”

Therapeutic management of pyoderma gangrenosum

“…The classification of PG is still inconsistent, and there are no generally accepted “international criteria” for it. Thus, authors differentiate among ulcerative PG (classic form) and pustular, bullous, vegetative, visceral, malignant, peristomal, superficial granulomatous, and postoperative PG (3, 5, 8, 9, 12–22).…”

“…For treatment of PG, doses of CSA (2–6 mg/kg/day) are usually lower than those used in transplantation (3, 13, 17, 22, 31, 32). Response of severe PG was seen within 1–3 weeks following CSA administration at doses of 4.5–6.6 mg/kg/day, which also resulted in low relapse rates (32).…”