The Journal of the Arkansas Medical Society Medical Journal November 2019 Vol. 116 No. 5

Special Section: Short Dermatological Cases Kevin St. Clair, MD Derm Dilemma: Purulent Ulcer Ashley Ederle, MD; Kevin St. Clair, MD A 45-year-old woman presents with violaceous border on her lower a few months ago as a “tender bump” that rap- idly progressed into the lesion pictured below. The patient denies fever, but has experienced vague malaise and mild arthralgias. There has been no improvement noted with over-the-counter topical antibiotics. Issam Makhoul, MD Oncology Naveen Patil, MD, MHSA, MA, FIDSA Internal Medicine/Infectious Disease Benjamin Tharian, MD, MRCP, FACP, FRACP Gastroenterologist/Hepatologist Robert Zimmerman, MD Urology Figure 1. Correct answer: D. Biopsy of ulcer edge. trauma or injury), aggressive surgical debridement should be avoided. Approximately one-third of pa- tients with PG exhibit pathergy. Systemic disease is present in over 50% of PG cases, most commonly inflammatory bowel disease, symmetric polyarthri- tis, or hematologic disorders. Therefore, pertinent history and evaluation regarding the presence of associated comorbidities, if not already known, is critical. This patient has pyoderma gangrenosum (PG), a sterile neutrophilic dermatosis that most com- monly presents in middle-aged adults as a tender papule or vesicle that rapidly progresses into an ulcer with a purulent, necrotic base and violaceous border with surrounding erythema. The diagnosis of PG is one of exclusion; a thorough history, physical, and biopsy are essential to rule out the presence of other diagnostic possibilities, including infection and malignancy. Because of the pathergy phe- nomenon (inducement of ulceration at the site of Treatment for PG depends on severity and whether the lesion occurs independently or in as- sociation with aforementioned systemic diseases. Mild PG may be treated with superpotent topical corticosteroids or topical tacrolimus, whereas exten- sive disease may warrant systemic therapy with cy- closporine with or without systemic corticosteroids, dapsone, mycophenolate mofetil, or tumor necrosis factor-alpha inhibitors. Control of an associated un- derlying systemic disorder may be accompanied by concomitant improvement in the PG. D. Biopsy of ulcer edge E. Initiation of anti-staphylococcal antibiotic therapy Jeremy Henderson Art Director Sandra Johnson, MD Dermatology Subsequent appropriate step(s) in the evaluation or management of this patient should include: C. Silver nitrate application Nicole Richards Managing Editor Tim Paden, MD Family Medicine extremity. She reports the lesion first appeared B. Wet to dry dressing changes Penny Henderson Executive Assistant Journal Advertising EDITORIAL BOARD Appathurai Balamurugan, MD, DrPH, MPH Family & Preventative Medicine/Public Health a painful, purulent ulcer with a A. Urgent, aggressive debridement of the lesion David Wroten Executive Vice President 100 • THE JOURNAL OF THE ARKANSAS MEDICAL SOCIETY Tobias Vancil, MD Internal Medicine Darrell Over, MD Family Medicine EDITOR EMERITUS Alfred Kahn Jr., MD (1916-2013) ARKANSAS MEDICAL SOCIETY 2019-2020 OFFICERS Dennis Yelvington, MD, Stuttgart President Lee Archer, MD, Little Rock Immediate Past President Chad Rodgers, MD, Little Rock President Elect Seth Barnes, MD, Hot Springs Vice President George Conner, MD, Forrest City Secretary Bradley Bibb, MD, Jonesboro Treasurer Danny Wilkerson, MD, Little Rock Chairman of the Board of Trustees VOLUME 116

The Journal of the Arkansas Medical Society Medical Journal November 2019 Vol. 116 No. 5 | Page 4