Pyoderma gangrenosum treated with sulfasalazine and dapsone

M FM Miranda

 Department of Dermatology, Venereolgy and Leprology, Goa Medical College, Bambolim - Goa - 403 202, India

Correspondence Address:
M FM Miranda
Department of Dermatology, Venereolgy and Leprology, Goa Medical College, Bambolim - Goa - 403 202
India

Introduction

Pyoderma gangrenosum is a destructive, ulcerative disease of unknown etiology. It starts as a nodule or haemorrhagic bulla which breaks down and forms an ulcer which persists indefinitely until therapeutic intervention. Various drugs have been used to treat the condition like corticosteroids[1], sulfasalazine,[2] clofazimine,[3] and minocycline,[2] with varying results. Dapsone has been used with good results. A case treated initially with sulfasalazine and later successfully controlled with dapsone is being reported.

Case Report

A 50-year-old woman presented to the Dermatology Department with ulcerations on the extremities of 20 days duration. She had suffered from recurrent ulcers for 3 years. The lesions started as tender, erythematous nodules which increased in size and broke down to form large ulcers. Clinical examination revealed 5 large ulcers on the lower extremities, the largest being 10 cms X 7 cms. The margins were raised, perforated and purplish in colour. The floor was covered with boggy granulation tissue. There were atrophic, cribriform scars on the legs and upper extremities. Inguinal lymph nodes were enlarged but not tender. Systemic examination did not reveal any abnormality.

Inevstigations showed a haemoglobin of 14 gms % and total count of 6400/- cumm. Differential count showed neutrophils 32%, eosinophils 14%, lymphocytes 52%, monocytes 1 %, basophils 1%. Platelets were adequate. E.S.R was 32mm/ 1st hour by Wintrobe method. Kidney functions, liver functions, electrolytes, X-ray chest and barium studies of the gastro-intestinal tract were within normal limit. [Figure - 1]

Histopathology showed that the base of the ulcer was made up of granulation tissue comprising of proliferating blood vessels and fibroblasts. There was neutrophilic infiltrate with microabscesses. Chronic inflammatory infiltrate was extending into the deep dermis and subcutis and was also seen around the blood vessels.

The patient was diagnosed as pyoderma gangrenosum. After a course of ampicillin and cloxacillin she was given sulfasalazine 500 mg thrice daily for 3 weeks, twice daily for 1 week and once daily for 1 week. The lesions had reduced in size. As the patient could not continue further sulfasalazine she was given 100 mg dapsone daily.

The lesions healed completely in 3 weeks. She was discharged on 100 mg dapsone which was reduced to 50 mg after 2 months. She stopped further treatment on her own after 1 month. There was a recurrence. She was again given dapsone 100 mg per day. The lesions healed completely after 1 month.

Discussion

The diagnosis was based on clinical and histopathological parameters. The initial control of the condition and that of the relapse on withdrawal of dapsone suggests that it played an active role. The patient is in remission for last 3 years. Dapsone was used successfully in 4 cases by Khatri et al.[4] It is cheap, easily available and comparatively safe drug and merits further trials.

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