Pyoderma gangrenosum: skin grafting and hyperbaric oxygen as adjuvants in\nthe treatment of a deep and extensive ulcer
A fifty year-old male presented with an erythemato-violaceous nodule on the anterior\npart of the left leg, which evolved to an ulcer with local pain after a surgical\nintervention. After three surgical debridements and progressive worsening of the ulcer,\nhe was referred to the emergency room of a tertiary hospital. Physical examination\nshowed a deep and extensive ulcer on the left leg, with exposure of muscular tissue and\nareas of purulent secretion and necrosis; the borders were altered by the recent\nsurgical intervention ().\nAfter the exclusion of vascular and infectious causes, and based on clinical and\nhistological findings, the diagnosis of pyoderma gangrenosum (PG) was established (). The patient responded well to the therapy\ninitially started: antibiotics for the secondary infection and immunosuppression with\ncorticosteroid in a dose equivalent to 1mg/kg/day prednisone. Considering the extension\nof the lesion and the aggressive behavior of the disease, azathioprine was introduced\nearly on, 20 days after the start of the corticosteroid therapy, with the goal of\nweaning from the corticosteroids in a medium time frame. Because of the wound extension,\nHBO was introduced concomitantly, to help in the cicatrization process. Forty-five days\nafter treatment beginning, there was a prominent superficial neovascularization on the\nulcer ().\nCorticosteroid therapy was maintained until significant improvement in the aspect of the\nlesion was achieved, followed by a slow and gradual reduction of dosage after 40 days of\nuse, and complete suspension 90 days after the medication was introduced.\nDue to incomplete re-epithelization of the wound, and considering its large dimensions\nand the presence of well-vascularized granular tissue, we opted, five months after the\nstarting of the treatment, for a partial autologous skin graft on the ulcer bed. The\ngraft was performed whilst the patient was still receiving azathioprine and HBO. There\nwas graft take and complete closure of the wound ( and ). The patient is still using\nazathioprine, and in 10 months of follow-up did not have relapses or complications.\nThe final diagnosis of ulcerative PG without subjacent disease was established after\nextensive complementary investigation, after excluding intestinal inflammatory diseases,\nhematologic and rheumatologic illnesses and neoplasia.