Alta Dermatology Residency
Abstract: 66-year-old woman with 3 year history of leg ulcers
A) R lateral calf: fibrinous base, 3.3 cm x 1.3 cm
B) L dorsal foot: Fibrinous base, 1.8 cm x 1.0 cm
C) L lateral calf: Fibrinous base, 2.5 cm x 1.6 cm
D) L medial calf: Clean granulation tissue at base, 5.0 cm x 4.8 cm x 0.5 cm
Pedal pulses 1+ and 2+ pitting edema bilaterally
1. Diagnosis: Her chronic ulcers were considered to be multifactorial. Likely contributors include trauma, infection, rheumatoid arthritis, venous insufficiency, ulceration from methotrexate toxicity.
2. Procedures: Debridement and Kenalog injection(10mg/cc) to the left medial calf
3. Diagnostic Studies: Wound culture (pending)
4. Dressings: Acticoat 7 for lesions A and D, and then continue hydrofera blue to lesions A and D. Santyl, adaptic, gauze, kerlex for lesions B and C.
5. Compression: Soft cotton between the skin and the SurePress; will try penumoboots for home and leg elevation.
What are your thoughts regarding the etiology of this woman's leg ulcers?
How would you manage her to facilitate healing?
Do you think her medications play a role? or her rheumatoid arthritis?
1. Ben-Amitai D, Hodak E, David M. Cutaneous ulceration: an unusual sign of methotrexate toxicity - first report in a patient without psoriasis. Ann Pharmacother. 1998; 32 (6): 651-3
Objective: To describe a case of skin ulcer related to methotrexate toxicity
Case Summary: A 67-year-old white man with seronegative arthralgia developed recurrent skin ulcer concurrent with 3-year treatment with methotrexate 5 mg daily. The skin ulcer resolved on discontinuation of methotrexate
Discussion: To the best of our knowledge, this is the first reported case of skin ulcer believed to be induced by methotrexate in a patient without psoriasis
Conclusions: Skin ulceration should be added to the list of possible toxic adverse effects of methotrexate, not only in psoriatic patients but also in those without psoriasis.
2. Stolman LP, Rosenthal D, Yaworsky R, et al. Pyoderma Gangrenosum and rheumatoid arthritis. Arch Dermatol. 1975; 111(8): 1020-3.
Two patients had pyoderma gangrenosum and rheumatoid arthritis. Biopsy specimens of the cutaneous ulcers in the paitents showed a necrotizing vasculitis. Complement (C3) and immunoglobulines were not detected in the skin lesions. There was no important impairment of cell-mediated immunity observed.
3. Seitz CS, Berens N, Brocker EB, et al. Leg ulceration in rheumatoid arthritis -- an underreported multicausal complication with considerable morbidity: analysis of thrity-six patients and review of the literature. Dermatology. 2010; 220 (3): 268-73
CONCLUSIONS: The majority of leg ulcers in patients with RA are due to underlying venous/arterial malfunction while vasculitic or traumatic ulcers are less common. Additionally, we identified a relevant subgroup of patients with 'inactivity ulcers' due to impaired mobility and consecutive lymphedema. Morphology and localization of ulcerations as well as duplex sonography provide the most important clues for accurate diagnosis, ensuring adequate treatment.