21 year-old woman with solitary eschar

This 21 year-old college student presented with a 5 week history of an evolving lesion on the right leg.  She is in good health and takes no medications by mouth.  The lesion started with pruritus and pain and a solitary evolving bulla on her right leg.  She had walked through a wooded area the night before this developed. It has evolved into a dry eschar.  She has a history of a DVT on her right leg 2 years ago after tonsillectomy, bed rest and a long plane trip while on oral contraceptives.  To date, she has been treated with mupirocin ointment and a topical corticosteroid.

O/E: When seen there was a solitary 2 cm eschar on her right leg.  No erythema, no purulence.

Photos:

September 8, 2019 a.m.

September 8, 2019 p.m.

September 9, 2019

September 28, 2019

October 9, 2019

October 16, 2019 (Date of visit)

Labs: Pending

Diagnosis: Eschar.  Etiologic considerations:

Envenomation – Brown Recluse Spider Bite

Echthyma gangrenosum
Pyoderma gangrenosum (Antiphospholipid syndrome)

A lesion such as this in a young healthy immunocompetent woman suggests an antecedent insult such as a brown recluse spider bite, but we have no history to confirm that.  She is being worked up for underlying disorders that might predispose to echthyma.  However the antecedent DVT makes one consider an underlying problem such as the antiphospholipid syndrome.

Questions:

1.  What diagnoses do you entertain?

2.  At this time, what therapies do you recommend?

About Hydrocolloid Dressings.
1. Background.
2. Another useful resource on hydrogels.
3. Video Demonstration.

Reference:

The rash that leads to eschar formation. Dunn C, Rosen T.

Clin Dermatol. 2019 Mar - Apr;37(2):99-108. Author information

Abstract:  When confronted with an existent or evolving eschar, the history is often the most important factor used to put the lesion into proper context. Determining whether the patient has a past medical history of significance, such as renal failure or diabetes mellitus, exposure to dead or live wildlife, or underwent a recent surgical procedure, can help differentiate between many etiologies of eschars. Similarly, the patient's overall clinical condition and the presence or absence of fever can allow infectious processes to be differentiated from other causes. This contribution is intended to help dermatologists identify and manage these various dermatologic conditions, as well as provide an algorithm that can be utilized when approaching a patient presenting with an eschar.  Full Text.

Pyoderma Gangrenosum

Abstract: 46 yo man with 1.5 year history of leg ulcers
History: The patient, a disabled 46 yo Cambodian man, has a four year history of poorly controlled ulcerative colitis. He has had painful leg ulcers for the past two years. These begin with pustules or vesicles by history. At present he is taking 1200 mg of Asacol t.i.d. and prednisone 30 mg. per day. In addition to the prednisone he has used potent topical steroids for his ulcers and has been treated at a wound care clinic.
Social History: The patient emigrated from Cambodia 25 years ago. He is married with three children and was employed until he became disabled 2 years ago from colitis and leg ulcers. His English is limited and I had no Cambodian translator.
O/E: There are two ulcers with raised overhanging borders on the left medial malleolus. In addition, there is post-inflammatory hyperpigmentation and proximal scarring secondary to previous ulcerations. The patient has Cushingoid facies.
Clinical Photos:



Lab: N/A
Histopath: N/A
Diagnosis: Pyoderma gangrenosum (P.g.)
Discussion: There is no effective therapeutic protocol for P.g. He has been treated with high dose prednisone for months and his P.g. is only poorly controlled. Super-potent topical steroids have been used without improvement. It seems to us that tacrolimus ointment should be tried because there are many reports of its efficacy with P.g. and it is a more benign therapy than oral cysclsporin or mycophenolate mofetil. Colectomy may be a more permanent solution, but the patient and his gastroenterologists are not ready for that.
Questions: Your suggestions are welcome.
References:
1. eMedicine.com: P.G.

2. Reichrath J, Bens G, Bonowitz A, Tilgen W. Treatment recommendations for pyoderma gangrenosum: an evidence-based review of the literature based on more than 350 patients. J Am Acad Dermatol. 2005 Aug;53(2):273-83.

Dermatology Clinic, The Saarland University Hospital, Homburg/Saar, Germany. hajrei@uniklinik-saarland.de

Because the incidence of pyoderma gangrenosum (PG) is low, no prospective randomized controlled trials and only a few studies with case numbers of more than 15 patients have been published. To date no guidelines for treatment of PG have been established far. The aim of the study was to provide an evidence-based review of the literature and an evaluation of recommendations for PG treatment. We performed an electronic search using the PubMed database and the term "pyoderma- gangrenosum." Literature published in the English language during the past two decades was reviewed. All relevant studies that could be obtained regardless of the study design were evaluated for grades of recommendation and levels of evidence. Data on patient characteristics including severity of the disease, localization of lesions, associated diseases, and treatment procedures were abstracted and evaluated for therapeutic outcome. We conclude that therapeutic efficacy of systemic treatment with corticosteroids and cyclosporine is best documented in the literature for disseminated as well as for localized disease and should be considered first-line therapy. In cases that do not respond to this treatment, we recommend alternative therapeutic procedures (eg, systemic treatment with corticosteroids and mycophenolate mofetil; mycophenolate mofetil and cyclosporine; tacrolimus; infliximab; or plasmapheresis), considering additional factors including associated diseases.