Definition

Pyogenic ulcers or granulomas, also known as pyoderma gangrenosum, are a rare skin condition characterized by rapidly enlarging and painful wounds (ulcers). This type of ulcer most commonly occurs on the skin of the limbs. Pyoderma gangrenosum ulcers can develop rapidly and usually heal with treatment while leaving scars and rarely recur.

Causes

The exact cause of pyogenic ulcers is unknown, but it is believed to be an immune system disorder in which the body responds excessively to antigens. The condition is not caused by infection and is not contagious.

Pyogenic ulcers are frequently associated with autoimmune conditions such as ulcerative colitis, Chron's disease, and rheumatic arthritis. Furthermore, it is believed that genetic factors contribute to the development of this condition.

In patients with pyogenic ulcers, a skin injury, such as a scratch, cut, or puncture wound, can cause a new ulcer. In addition, certain medications can also trigger the condition, such as cocaine, isotretinoin, propylthiouracil, and sunitinib.

Risk factor

Several factors can increase a person's risk of developing pyogenic ulcers, such as:

• Age. Pyogenic ulcers affect all age groups, but they are more common in those over the age of 50. This condition is very rare in children
• Having certain medical conditions such as:
• Inflammatory bowel disease (IBD), which includes ulcerative colitis and Chron's disease. Pyogenic ulcers are the second most common cause of skin symptoms in people with IBD (1–3%). It is more common in ulcerative colitis compared to Crohn's disease. When pyogenic ulcers develop, 50% of patients have active IBD. Even after IBD treatment, pyogenic ulcers may still persist
• Rheumatic arthritis
• Blood disorders, such as acute myelogenic, myelodysplasia, or myeloproliferative disorders, as well as blood cancer
• Monoclonal gammopathy
• Active chronic hepatitis
• Granulomatosis with polyangiitis
• PAPA syndrome
• Bechet's disease
• Tumors

About half of people with pyogenic ulcers have one of the above risk factors.

Symptoms

Symptoms of pyogenic ulcers usually appear suddenly, often at the site of the skin damage. Symptoms typically begin with a small reddish lump on the skin, which resembles an insect bite. Within a few days, these lumps can develop into large, painful open sores. The sores may enlarge and deepen rapidly. Pyogenic ulcers are distinguished by their purplish edge or border.

Ulcers are most commonly found on the limbs, but they can develop anywhere on the body. Occasionally, wounds may also develop in the surgical wound area. Some ulcers may increase in size and merge into one larger ulcer. If left untreated, the ulcer may grow in size, remain unchanged, or heal slowly.

Diagnosis

To diagnose pyogenic ulcers, the doctor will ask about your medical history and examine the ulcer, which has a distinctive shape and causes severe pain. There are no additional tests that can confirm the diagnosis of pyogenic ulcers. However, the doctor may perform various tests to rule out other causes of similar ulcers. These may include blood tests, skin biopsy, etc.

Management

Treatment of pyogenic ulcers aims to reduce inflammation, control pain, facilitate wound healing, and control underlying medical conditions. Treatment is usually successful in halting the disease process, but complete healing can take up to several months, especially if venous disease is present.

The treatment depends on several factors, such as the health of the body as well as the number, size, depth, and rate of growth of the skin ulcers. Treatment is mainly focused on non-surgical approaches.

Some people respond well to a combination of therapies using medications, creams, or injections. However, some require inpatient treatment at a hospital or wound care center. Despite successful therapy, new ulcers often form.

Medications used to treat pyogenic ulcers include:

• Corticosteroids. Daily corticosteroids are the most commonly used treatment option. These can be applied to the skin, injected into a wound, or taken orally. However, long-term or high-dose corticosteroid use can lead to serious side effects. Therefore, your doctor may prescribe nonsteroidal drugs to reduce the use of corticosteroids if you need long-term therapy
• Nonsteroidal drug. An example of an effective nonsteroidal drug is cyclosporine. Other options are mycophenolate mofetil, dapsone, azathioprine, tetracycline, potassium iodide solution, methotrexate, cyclophosphamide, chlorambucil, infliximab, tacrolimus (calcineurin inhibitor), intravenous immunoglobulin, and plasmapheresis. The way these drugs are used varies depending on the type of drug, with some being applied to the skin, injected, or taken orally
• Pain medication. Depending on the severity of the ulcer, pain medication may be useful to reduce pain, especially during wound care (dressing changes)

In addition to medication, wound care by a doctor or wound care professional is also required. Dead tissue will be gently removed. The wound will be covered with a non-sticky, moist (neither dry nor wet) bandage, and an elastic wrap may also be used. The doctor may ask you to elevate the affected area.

It is important to follow your doctor's recommendations on how to care for the wound. This is because people with pyogenic ulcers usually take medications that suppress the immune system, increasing the risk of infection. Infection of the wound will slow down healing.

Because the symptoms of pyogenic ulcers can worsen due to skin damage, surgery to remove dead tissue is not recommended or considered an appropriate treatment option, particularly in active disease. In surgery, there will be damage to the skin that will aggravate existing ulcers or trigger new ulcers.

However, if the skin ulcer is large and requires treatment to heal, the doctor may recommend a skin graft procedure, which involves placing sheets of skin or synthetic skin over the open wound. This is done after the inflammation in the wound has subsided and the ulcer begins to heal.

Complications

Possible complications of pyogenic ulcers are infection, scarring, uncontrolled pain, depression, and impaired daily functioning.

Prevention

Pyogenic ulcers cannot be completely avoided. If you have this condition, try to avoid anything that could cause skin damage, including surgery, which can lead to new ulcers. Furthermore, if you have any medical conditions that may contribute to the formation of ulcers, treating them may help to prevent ulcers from developing.

When to see a doctor?

If you have a painful and rapidly enlarging skin wound, then you should consult a doctor.

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