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I have a 28 yo male patient with Cutaneous Crohn's Disease and Rheumatoid Arthritis, both diagnosed when he was 8 years old. Patient is currently taking Taltz for his autoimmune disease. Patient states he has been on biologics since the age of 15 for RA. Patient was also placed on Remicade when he was 14 years old and was on it for 11 years. Patient is allergic to Sulfa.
He developed an abscess on his right leg 2/2020 prior to seeing me and had tegaderm applied directly to his skin which created new wounds to form. He was trying to manage the wounds himself, however, has been unsuccessful. He recently was seen by another specialist that used xeroform on his legs which created a worse reaction on his skin.
Patient was seen by a vascular surgeon who performed an ultrasound on his bilateral legs and diagnosed him with Venous stasis. The vascular surgeon also placed an unnaboot on his right leg, which helped. A biopsy was taken from an abscess on his left leg which results showed: Pandermal and subcutaneous suppurative and granulamatous inflammation with necrosis, leukcytoclasis and granulation tissue formation.
He started coming to see me end of January, 2021. Since he has seen me I have placed him on unnaboot's which have helped. I took a wound culture which grew 3+ staph aureus. Patient finished a 10 day course of Doxycycline 100mg BID. He is constantly developing new pustules on his right leg. I have been seeing him 3x a week, recently, for debridements and chlorohexidene scrubs. Applying mupirocin ointment 2%, adaptic, abd pads and a multi-layer dressing. Originally, patient was scratching his wounds which negatively affected him, however, now that they are wrapped he cannot do so which has helped.

I am at a standstill. If anyone has any recommendations please let me know. Thanks in advance.
Feb 9, 2021 by Romina Vincenti Liss,
3 replies
Elaine Horibe Song
MD, PhD, MBA
Hi Romina
Thank you for sharing this case! Other colleagues might have other thoughts, but I was wondering if besides the biopsy taken from one of his abscesses, a biopsy of the edge of an active non-infected ulcer has been taken? Inflammatory bowel disease (e.g., Crohn's disease) and arthritis are two of the most common disorders associated with pyoderma gangrenosum. Pustular pyoderma gangrenosum is a specific variant that appears to be limited to patients with inflammatory bowel disease and tends to occur on extensor surfaces of the limb and trunk. The process begins as a pustule or cluster of pustules that later coalesce and ulcerate. The process stops at the pustular stage and the patient may have painful pustular lesions that may persist for months. The topic below provides resources on how to rule out pyoderma gangrenosum and assess for differential diagnosis (diagnostic criteria, biopsy procedure, workup, etc) https://woundreference.com/app/topic?id=pyoderma-gangrenosum-introduction-and-assessment#-diagnosis 
The etiology of the ulcers may be mixed/multifactorial
Feb 9, 2021
Cathy Milne
APRN, MSN, CWOCN-AP
Taltz can be associated with fungal infections...was the biopsy also sent for culture? I would also consider PCR culture in this patient’s case, just to see what he might grow out. I had a similar case like this...the patient stopped taking her biological..and she had all these crazy skin eruptions...and reactions to zinc, xeroform, etc....it appeared that her immune system recognized anything topically as “foreign”..when we figured out she was non adherent to her regimen and she restarted her medication at a lower dose, she turned around. Also, avoid creams on patients like this..they have so many additives that can be irritants...if you have to use a topical med try to prescribe in ointment form
Feb 9, 2021
Thank you so much for taking the time to read my case and for your responses!

Pyoderma gangrenosum is a possibility, especially given his history. It truely did not look like it clinically, but it wouldn't hurt to take a biopsy of the edge of a non-infected ulcer as well. I'll bring it up to the patient during his next visit.
Also I did culture the wound for fungal and it did not grow back any fungus, luckily. But I did notice that cream like products were affecting his skin and he is doing a lot better with the mupirocin ointment.

Thanks again!
Feb 10, 2021
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