Negative pressure wound therapy and pediatric pyoderma gangrenosum: an unlikely combination

Introduction

A 15 year old obese female with refractory ulcerative colitis status post colectomy, proctectomy with staged Jpouch ileoanal reconstruction presented to the pediatric surgery clinic in July with 2 tender, suprapubic wounds which were initially treated with silver hydrofiber and calcium alginate dressings. She later presented to the ED in December with a wound dehiscence at the incision under her pannus with redness, drainage, malodor, and a black lining around the wound. WBCs were 8.3. Dermatology was consulted and recommended mupirocin and triamcinolone creams to affected areas. The wound was surgically debrided with subsequent deterioration. A punch biopsy was obtained and the patient was diagnosed with pyoderma gangrenosum (PG). Systemic steroids were refused by patient/family due to prior weight gain attributed to steroids. Her wound cultured positive for Acinetobacter and she completed a course of Ciprofloxacin.

Management Approach

The wound measured 7.5cm(L) x 18.5cm(W) x 6cm(D) and the wound care team was consulted for negative pressure wound therapy (NPWT) dressing changes performed under sedation due to patient’s intolerance of wound care. Initially, the NPWT was set at 125mmHg continuously with dressing changes 3x/week. Dermatology added topical clobetasol ointment and intra-lesional triamcinolone injections with each dressing change. To minimize pathergy, the WOC team added a non-adherent silicone contact layer over the ointments but under the polyvinyl alcohol and polyurethane foams, decreased the NPWT settings to 75 mmHg and reduced the dressing frequency to twice weekly.

Outcome

After one month, the wound had granulated to skin surface and management was modified to only the aforementioned ointments with an absorbent pad changed daily. The wound progressed on to healing within a few months.

Conclusion

Atraumatic NPWT modified to reduce PG associated pathergy was an unusual but essential management technique for this patient who was unable to tolerate appropriate, conservative wound care.