Recurrent pyoderma gangrenosum after cesarean delivery successfully treated with vacuum‐assisted closure and split thickness skin graft: A case report

Abstract

We describe the case of a 32-year-old woman (gravidity: 4; parity: 2) who underwent cesarean delivery at 37 weeks of gestation and presented with dehiscence and infection of the surgical wound. She had a history of wound infection and dehiscence of the scar from a previous cesarean delivery and dehiscence in the dorsal side of her left hand at the site of intravenous catheterization. The patient was initially diagnosed with a skin infection and later with pyoderma gangrenosum. No evidence of any underlying disease was found. The lesions were treated with systemic corticosteroids and azathioprine, but the lesions were unresponsive to treatment. This complicated case of pyoderma gangrenosum after cesarean delivery, which initially mimicked wound infection, was successfully treated with vacuum-assisted closure and split-thickness skin graft. This synergistic approach with vacuum-assisted closure could be an important treatment option for aggressive and slow-healing lesions.

Pathophysiology of pyoderma gangrenosum (PG): An updated review

“…[40][41][42][43][44][45][46][47][48][49][50][51][52][53][54][55][56] A portion of these cases may be explained by pathergy as they occurred at the site of cesarean section [40][41][42][43][44][45][46][47][48][49] or on the extremities, 40,[50][51][52][53][54][55][56] which are more prone to trauma. Two patients possessed a background of systemic inflammatory disease (relapsing polychondritis 50 and antiphospholipid syndrome 51 ), likely contributing to a predilection for PG formation.…”

Pyoderma gangrenosum and pregnancy: an example of abnormal inflammation and challenging treatment

“…Idiosyncratic side‐effects include agranulocytosis, dapsone hypersensitivity syndrome, cutaneous hypersensitivity reactions, gastrointestinal irritation, peripheral neuropathy and psychosis. Azathioprine, which inhibits DNA synthesis in lymphocytes and has a slower onset of action, was used in two cases . Its main side‐effects are bone marrow suppression, hepatotoxicity, infections and gastrointestinal intolerance.…”

“…Pathergy may have been involved in the development of PG in several of the reviewed clinical cases. Eleven reports described women aged 24–43 years who developed PG at the site of caesarean incision 1 day to 4 weeks after delivery …”

“…Several patients were treated with systemic corticosteroids alone, while others were treated with topical or intralesional steroids or both systemic and topical steroids . Around half of the reviewed cases involved treatment with a combination of corticosteroids and other immunomodulating agents, including ciclosporin, dapsone, cyclophosphamide, intravenous immunoglobulin and azathioprine, sometimes to reduce the amount of steroids used in pregnancy or because the patient did not respond to corticosteroids alone …”

“…Interestingly, nine patients were noted to have had prior episodes of PG 28,31,[41][42][43][44][45] or wound dehiscence. 30,46 Pathergy as a trigger of pyoderma gangrenosum in pregnancy Pathergy may have been involved in the development of PG in several of the reviewed clinical cases. Eleven reports described women aged 24-43 years who developed PG at the site of caesarean incision 1 day to 4 weeks after delivery.…”