Complex Peristomal Pyoderma Gangrenosum: Integrated Treatment of a Not So Common Skin Disorder

Pyoderma Gangrenosum (PG) is a skin disorder which can cause painful skin ulcers requiring aggressive treatment depending on the severity of the condition. This case study will explicate the treatment options utilized during an 11 month history of complex peristomal skin ulcers caused by pyoderma gangrenosum.

In this case study, Ms. K, a 50 year old female came in to the outpatient clinic a few weeks post restorative proctocolectomy with a loop ileostomy for ulcerative colitis complaining of peristomal skin pain. Ms. K initially presented with an inflammatory halo surrounding a 2mm ulcerated lesion located near the ileostomy stoma. Over the course of several months, treatments included high dose systemic steroids, topical tacrolimus, oral sulfa drug, topical steroid foam, and topical hydrofiber and hydrocolloid dressings. Cyclosporine was considered but never initiated. The skin ulcers varied in size encompassing up to a 20cm wide area extending across her abdomen. Eventually, the ileostomy was reversed after many months delay due to the use of steroids and peristomal skin condition.

This complex and long course of treatment was challenging and required collaborative efforts of the dermatologist, WOC Nurse, GI surgeon, and patient. It appeared that at times, conventional and not so conventional approaches were necessary to individualize a plan of care to treat peristomal ulcers caused by pyoderma gangrenosum. The plan of care variations will be outlined with digital photography as evidence compiled to show the effectiveness of concurrent skin ulcer treatments.