Statement of the Problem: The patient is a 79 year old morbidly obese female with a history of chronic venous insufficiency and recurrent venous stasis ulcers of both lower extremities. She presented with a large right lower extremity necrotic wound, erythematous periwound, and exquisitely painful. Descrition of Past Management: The patient had been treated by her primary care physician and home health care for a venous stasis ulcer on and off for almost a year. Initially, the wound responded to unna boot, silver calcium alginate, silver gel, but became violacious and recalcitrant and unable to tolerate any compression. Clinical Approach: Initial work up showed no infection. Due to lack of response, the patient was referred to dermatology for tissue biopsy which supported the diagnosis of pyoderma gangrenosum. She was treated with cyclosporine and carefully monitored due to a history of CHF and cardiomyopathy. Patient Outcomes: The patient showed favorable response to treatment with cyclosporine almost immediately; wound progress and siginifiacntly decreased pain. She did have an episode of CHF requiring hospitalization, and the dose of cyclosporine was adjusted with no further adverse events. Once the wound was almost completely healed, dermatology discontinued cyclosporine but within a week, the wound regressed significantly. Cyclosporine was continued with immediate favorable response and continued for two months after complete resolution of the wound. Conclusions: Biopsy of a chronic wound is advisable and would have prevented prolonged wound care, which in fact affected this pateint's quality of life significantly. Continuing cyclosporing until the wound has healed completely and for an extended period may be beneficial to prevent regression soon after the initial healing phase. Clsoe follow-up for at least 3 months is also advisable. The patient was also taught good skin care and placed in compression stockings.