Meeting the challenges of post-operative Pyoderma Gangrenosum

Pyoderma gangrenosum (PG) occurs in 1 in 100,000 patients annually nationwide. Standard treatment includes autolytic debridement, exudate management, protection from trauma, and steroid therapy. Here we present management of a case of PG which developed postoperatively after abdominoperineal resection (APR) for rectal adenocarcinoma.

Perineal dehiscence was noted prior to abdominal ulceration development.  Due to unknown etiology, uncontrolled pain, and degree of wound necrosis dressing, initial management and care were carried out under anesthesia in the operating room, utilizing of advanced wound care products, such as antimicrobial foams, alginates, and negative pressure wound therapy (NPWT) foam.

Upon suspicion of PG, all sharp debridement was discontinued.  Baseline abdominal ulcer measurements were 8 x 13 x 0.3cm. Full thickness ulceration completely encompassed the peristomal plane not allowing for standard application of an ostomy wafer and pouch, which significantly increased the level of complexity.

Use of an antimicrobial silicone contact layer on the abdominal wound bed was paramount in addressing the needs of this patient.  Goals of care focused on protecting the wound bed from trauma, pain reduction, exudate control, reduction in the level of bioburden within the wound bed, and support autolytic debridement; all while trying to maintain a seal around the stoma to reduce contamination of effluent into the wound bed and ensure sufficient pouch wear time.

We maintained a seal on the abdominal wound and around the stoma to allow for a seven day wear time. Upon discharge from the hospital, patient returned weekly for dressing change in the outpatient office by the Wound Ostomy Continence (WOC) nurse.  The abdominal wound was fully epithelialized and healed within 13 weeks.  No systemic signs of infection were noted throughout entire course of treatment. The perineal wound was fully epithelialized 51 weeks after initial APR.