Necrotizing ulceration after breast reduction

Pyoderma gangrenosum is an enigmatic disorder of rapidly spreading ulceration virtually indistinguishable from synergistic gangrene. Because management of the two conditions is so different correct diagnosis is crucial.

CASE HISTORY

A woman of 54 underwent breast reduction. Four days postoperatively, oral antibiotics were started for presumed wound infection but her condition worsened and she was admitted with severe pain, foul discharge and general malaise. On examination she was tachycardic, dehydrated and pyrexial (38.5°C); both breasts were swollen and tender, with erythema and desquamation well demarcated by purple-blue margins. Suture lines were spared. Initial treatment was wound toilet and broad-spectrum intravenous antibiotics. After forty-eight hours, despite subjective improvement and loss of pyrexia, ulceration had extended (Figure 1) and inflammatory markers were raised. A dermatologist suspected pyoderma gangrenosum despite the absence of associated systemic diseases, and ciclosporin 5 mg/kg daily was started. Within forty-eight hours the pain diminished greatly and ulceration ceased to progress. The patient was discharged after twelve days and continued on oral ciclosporin for one month. After six weeks the wounds had epithelialized (Figure 2).

Figure 1.

Appearance of wounds after forty-eight hours of local wound care and broad-spectrum antibiotics

Figure 2.

Wounds after six weeks of ciclosporin treatment and no operative intervention

COMMENT

Pyoderma gangrenosum is believed to result from a misdirected immune response to injury.¹ As in Behçet's disease, new lesions can develop even after trivial trauma such as venepuncture. Typically the condition first appears in the pretibial area with erythematous pustules which become boggy plaques with violaceous margins and an erythematous halo. There is then rapid progression to cutaneous ulceration and spreading necrosis. The patient is pyrexial and complains of disproportionate pain. A hallmark of the condition is a rapid response to immunosuppressive treatment with ciclosporin or tacrolimus.² Healing may be accompanied by atrophic scarring.

Because there are no pathognomonic clinical features,³ biopsy was formerly recommended to exclude other causes of necrotizing ulceration; however, this carries a hazard of worsening the disease and, as shown in the present case, a therapeutic trial of immunosuppressive therapy can be diagnostic. In the original series of Brunsting et al., 80% of cases were associated with ulcerative colitis.⁴ Other comorbidities are polyarthritis and monoclonal gammopathies, but pyoderma gangrenosum is idiopathic in 10-20% of cases.

There is one previous reported case of pyoderma gangrenosum developing after breast reduction⁵. The patient had several operations over twenty-eight months before diagnosis, and was then treated with topical steroids. The wounds healed, but she was left with skin atrophy.

As a condition that is rarely encountered even by dermatologists,⁶ pyoderma gangrenosum may seem of limited interest to surgeons. However, it does need to be borne in mind in wound management. With postoperative infection or synergistic gangrene, which can be clinically similar, the correct management is wound debridement, but pyoderma gangrenosum can be worsened by any surgical intervention and is also resistant to local wound care and antibiotics.⁴ The condition is of particular relevance to the surgeon called upon to assist with a ‘difficult’ wound. Unexpected sparing of suture lines may trigger suspicion; and likewise the presence of a systemic disease. Immunosuppressant treatment can then be started.