Pyoderma Gangrenosum Can Mimic Other Ulcers, Without Associated Systemic Disease: Case Report
Nepal: Pyoderma gangrenosum (PG) can occur without associated systemic disease and may resemble infectious or vascular ulcers. Recognizing atypical presentations, performing early biopsy, and initiating timely corticosteroid therapy are crucial to prevent misdiagnosis and ensure better clinical outcomes.
Researchers have presented a rare case of an elderly woman who developed bilateral ulcerative Pyoderma gangrenosum without any associated comorbid conditions.
The case report, published in Clinical Case Reports, was authored by Sanjog Thapa Magar from the Department of Dermatology and Venereology, Patan Academy of Health Sciences, Lalitpur, Nepal, and colleagues. The authors described an unusual bilateral presentation of this rare neutrophilic dermatosis, highlighting the diagnostic challenges and the importance of early recognition and appropriate treatment.
Pyoderma gangrenosum is a non-infectious inflammatory skin disorder characterized by rapidly progressive, painful ulcers with undermined borders. It is often associated with systemic conditions such as inflammatory bowel disease, arthritis, or hematological disorders. However, PG can also occur idiopathically, and bilateral involvement is exceptionally uncommon, increasing the risk of misdiagnosis and delayed management.
In this case, a 76-year-old woman presented with painful, crusted lesions on both lower legs that had developed over two weeks. The lesions initially appeared as erythematous papules that rapidly enlarged, began to ooze, and subsequently ulcerated. The patient reported no preceding trauma, fever, weight loss, or prior history of ulceration. She had no known comorbidities, including diabetes, hypertension, autoimmune disease, malignancy, or inflammatory bowel disease, and was not taking any long-term medications.
On examination, multiple tender, ill-defined plaques with yellowish and hemorrhagic crusting were noted over the shins and ankles bilaterally. Surrounding erythema and edema were present, but peripheral pulses were intact and there was no regional lymphadenopathy. Initial laboratory investigations revealed mild anemia and an elevated C-reactive protein level, suggesting an inflammatory process.
A wound swab culture grew Pseudomonas aeruginosa, and the patient was initially treated with antibiotics. However, there was no clinical improvement, raising suspicion of a non-infective cause. To clarify the diagnosis, an incisional skin biopsy was performed. Histopathological examination demonstrated dense neutrophilic infiltration with dermal necrosis, without evidence of vasculitis or infection. These findings were consistent with a neutrophilic dermatosis and supported the diagnosis of pyoderma gangrenosum.
Following the diagnosis, the patient was started on oral prednisolone and local saline dressings. Marked clinical improvement was observed within two weeks, and the ulcers healed completely without recurrence. The rapid response to corticosteroid therapy further reinforced the diagnosis.
The authors emphasized that PG may closely mimic infectious or vascular ulcers, particularly when it presents bilaterally and without underlying systemic disease. Misdiagnosis can lead to unnecessary antibiotic use, surgical interventions, and prolonged morbidity. This case underscores the importance of maintaining a high index of suspicion, performing early biopsy, and promptly initiating immunosuppressive therapy to achieve favorable outcomes and avoid preventable complications.
Reference:
Magar, S. T., Sitaula, D., Rijal, S., Paudel, V., & M. Kayastha, B. M. (2026). Bilateral Idiopathic Pyoderma Gangrenosum: A Case Report of an Atypical Presentation. Clinical Case Reports, 14(2), e71964. https://doi.org/10.1002/ccr3.71964
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