Facial Pyoderma Gangrenosum in Senescence
A 90-year-old woman was referred to our department with a 3-week history of an ulcer on the lateral corner of the left eye. The painless wound appeared spontaneously, without any apparent trauma, and it had gradually enlarged. Concerning comorbidities, the patient suffered from hypertension and rheumatoid arthritis. The latter was treated with methotrexate 10 mg/week and prednisolone 2 mg/day. Initial physical examination in our outpatient department showed a deep ulcer on the lateral corner of the left eye, 1.5 × 1.5 cm in size, with a necrotic and fibrinoid surface (fig. ). The left eyelids were erythematously swollen and showed accompanying conjunctivitis. Histology from a skin biopsy taken from the edge of the ulcer showed a dense, mixed-cell, dermal infiltrate with numerous neutrophilic granulocytes and some macrophages (fig. ). Periodic acid-Schiff and Giemsa stains failed to indicate any infectious disease with bacteria or fungi. The laboratory investigation of the peripheral blood revealed normocytic anemia, lymphocytopenia and neutrophilia. C-reactive protein was increased with 21.08 mg/l (normal value < 5 mg/l) and antinuclear antibodies were negative. Bacteriological examination of an ulcer smear revealed growth of physiologic skin flora only. To sum up, the lesion was interpreted as PG. We started systemic therapy with high-dose prednisolone (75 mg/day), gradually tapered after 7 days. For topical treatment, rinsing with a physiological salt solution and ofloxacine eyedrops (5 times/day) were recommended after the ophthalmologic consultation. Within 2 weeks, the ulcer was reduced in size, showed a clean base without necrotic debris, and the border was less inflamed (fig. ).