Indian Journal of Paediatric Dermatology

LETTER TO EDITOR
Year
: 2019  |  Volume : 20  |  Issue : 4  |  Page : 355--356

A case report of pediatric pyoderma gangrenosum: A diagnostic and treatment challenge


Margaret Stephanie Lagman Jimenez, Jennifer Aileen Ang Tangtatco, Maria Vinna Nicodemus Crisostomo, Michaela Mendoza Tabalon 
 Department of Dermatology, Southern Philippines Medical Center, Davao, Philippines

Correspondence Address:
Dr Margaret Stephanie Lagman Jimenez
Southern Philippines Medical Center, JP Laurel Street, Davao
Philippines




How to cite this article:
Jimenez MS, Tangtatco JA, Crisostomo MV, Tabalon MM. A case report of pediatric pyoderma gangrenosum: A diagnostic and treatment challenge.Indian J Paediatr Dermatol 2019;20:355-356


How to cite this URL:
Jimenez MS, Tangtatco JA, Crisostomo MV, Tabalon MM. A case report of pediatric pyoderma gangrenosum: A diagnostic and treatment challenge. Indian J Paediatr Dermatol [serial online] 2019 [cited 2019 Dec 9 ];20:355-356
Available from: http://www.ijpd.in/text.asp?2019/20/4/355/268392


Full Text



Sir,

Pyoderma gangrenosum (PG) is a rare neutrophilic disease. Its etiology remains unknown.[1] Incidence is estimated at 3–10 patients per million per year where it is rare among the pediatric population.[2],[3],[4]

We present a 14-year-old male who presented with 3-year history of recurrent pruritic exudative ulcers on the lower extremities despite treatment with oral antibiotics.

A month prior to consult, the patient noted recurrence of ulcers on the lateral region of the right leg and on the anterior region of the left leg, rapidly increasing in size with severe pruritus. Physical examination of the skin showed a solitary 5 cm × 3 cm ulcer on the lateral aspect of the right leg and a solitary 20 cm × 7 cm ulcer spanning the anterior, medial, and lateral region of the left leg. Both ulcers had serous discharge and with violaceous, well-defined, and undermined borders [Figure 1]. Wound culture was positive for Pseudomonas aeruginosa while a 4-mm skin punch biopsy revealed findings suggestive of cellulitis. Baseline laboratory results were normal. The initial assessment was PG with the secondary bacterial infection.{Figure 1}

The patient was started on oral ciprofloxacin to treat the underlying infection and later started on mupirocin + betamethasone dipropionate ointment applied twice daily on the ulcers. After 5 months, there was note of complete resolution of the ulcer on the right leg and decrease in the size of the ulcer on the left leg (18 cm × 7 cm). There was also note of string-like projections of epithelium at the edges of healing ulcers representing the Gulliver's sign of PG [Figure 2]. A repeat skin punch biopsy was done which showed the neutrophilic dermatosis consistent with PG [Figure 3].{Figure 2}{Figure 3}

With this he was started on prednisone at 40 mg/day (0.5 mkd) for 3 weeks but with no improvement. Due to this, prednisone was increased to 60 mg/day (0.75 mkd) for 2 weeks where there was note of decrease in size of ulcer on the right leg (17 cm × 5 cm). Dapsone was then initiated at 50 mg/day (0.6 mkd) when G6PD level was found adequate. It was later increased to 100 mg/day (1.25 mkd), whereas prednisone was gradually tapered to nil. After 17 months, the ulcer on the left leg completely healed [Figure 4].{Figure 4}

PG is a rare disease which poses as a diagnostic and therapeutic challenge. There are no accepted international diagnostic criteria to date. For the untrained eye, clinicians may unknowingly treat this case as a recurrent infection.

Further, there is also no universally accepted gold standard of treatment. Systemic steroids may be the line but pose numerous side effects.[4],[5] Steroid-sparing drugs, such as dapsone, may be given as adjunct therapy or an alternative monotherapy.[1] PG is rarely seen in children but must be highly suspected in the setting of the chronic nonhealing wound.[3] Early recognition is of utmost importance as it leads to proper treatment, prevents rapid progression, and improves disease outcomes.

Acknowledgment

The authors would like to thank Dr. Mary Jo Kristine S. Bunagan for guiding the clinical findings and therapeutic management and also Dr. Maricarr Pamela M. Lacuesta for teaching the histological findings.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understand that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

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2Soleimani T, Sasor SE, Spera L, Eppley BE, Socas J, Chu MW, et al. Pediatric pyoderma gangrenosum: Is it just big wounds on little adults? J Surg Res 2016;206:113-7.
3Ruocco E, Sangiuliano S, Gravina AG, Miranda A, Nicoletti G. Pyoderma gangrenosum: An updated review. J Eur Acad Dermatol Venereol 2009;23:1008-17.
4Ehling A, Karrer S, Klebl F, Schäffler A, Müller-Ladner U. Therapeutic management of pyoderma gangrenosum. Arthritis Rheum 2004;50:3076-84.
5Yasin F, Assad S, Zahid M, Malik SA. Extensive pyoderma gangrenosum: A challenging diagnosis and literature review of management. Cureus 2017;9:e1486.