Facial Pyoderma Gangrenosum in Senescence
An 89-year-old man was admitted to our department with a post-surgery wound dehiscence on the left part of the lower lip after squamous cell carcinoma surgery 13 days ago (tumor thickness 6.5 mm, depth of invasion level V). A wound revision was performed with suturing of the lesion by a three-layer wound closure and an antibiotic therapy with cefuroxim 500 mg twice daily for 8 days. In the following 6 weeks, the patient was re-admitted to our department several times because he suffered from recurrent wound dehiscence. The patient reported that the dehiscence was triggered by mechanical irritation, such as food intake or sneezing. He described a progressive pain in the suture area. Physical examination showed an ulcer with violaceous undermined borders on the left part of the lower lip (fig. ). After each admittance, he was treated with an extensive excision of fibrinoid debris and necrotic tissue, following an antiseptic lavage with betaisodona®. A synthetic wound dressing (Syspur Derm®, Paul Hartmann AG, Germany) was inserted. Bacterial swab examinations were sterile. Furthermore, incisional biopsy from the edge of the wound was performed. Histopathological examination showed a dense neutrophilic dermatitis without any evidence of residual neoplastic disease. Based on clinical and histopathological correlation, PG was suspected. To exclude the possibility of an allergic reaction to suture material, we performed an intracutaneous insertion of 7 different suture stitches (Vicryl rapide, PDS, Ethilon, Vicryl, Monocryl, Mersilene and Prolene, Johnson & Johnson MEDICAL GmbH, Germany) on the patient's upper right arm. After 48 h at all 7 testing sites, erythematous papules up to 3 mm in diameter were visible (fig. ). Histopathological examination of a biopsy specimen from the upper right arm showed a superficial mixed cell infiltrate of neutrophilic, but also some eosinophilic granulocytes. These findings were consistent with the pathergy phenomenon of PG. The patient's past medical history revealed no PG-associated comorbidities. Detailed examination failed to detect any systemic complications including inflammatory bowel diseases, hematological disorders or rheumatoid arthritis. Laboratory examination of peripheral blood was unsuspicious, including a negative serology for syphilis. Topical treatment with a triamcinolone acetonide-containing ointment significantly improved healing, and the patient suffered no relapses afterwards (fig. ).