Management of Pyoderma Gangrenosum in a Patient with Amelanotic Melanoma on Pembrolizumab

Background: Inflammatory ulcers such as pyoderma gangrenosum (PG) require immunosuppression with corticosteroids and cyclosporine. Recently, more advanced immunosuppressive therapies such as TNF inhibitors have been incorporated into routine management. At the same time, individuals with metastatic disease are living longer partly due to therapy with targeted immunomodulatory agents. This presents a unique challenge to the wound clinician because in cases of inflammatory ulcers in the setting of malignancy, immunosuppression may exacerbate quiescent malignancy. Furthermore, the interaction between immune modulating agents and immunosuppression in patients with malignancy has not been fully elucidated. Therefore, optimization of current therapies, elucidation of systemic drug interactions and alternative therapies are warranted for this growing population.

Purpose: Herein, we present a case of a 62-year-old woman with an inflammatory ulcer and metastatic melanoma on pembrolizumab who presented to the wound clinic 5 months after receiving wide local excision, sural flap and radiation. We leverage the management of this case to discuss treatment options available to the wound expert that can be utilized when the interplay between inflammatory wounds, immunosuppression and cancer becomes a delicate balance. 

Methods and Results: At presentation, a well-demarcated ulcer was noted and surveillance biopsies were taken to rule out underlying melanoma. Pathology demonstrated radiation dermatitis. After multimodal treatment, she presented to clinic with 2 new ulcers that contained 2 pink papules at the wound edge. Again, biopsies were taken to rule out underlying malignancy and clinical and pathologic results were consistent with PG. Systemic therapy including prednisone, cyclosporine, colchicine and curcumin were initiated as well as various grafting techniques and skin substitutes all in the context of excellent local wound care.

Conclusion: In the context of malignancy, a management strategy must be developed and employed that takes into account the potential for underlying malignancy and the balance between immunosuppression and cancer exacerbation when treating an inflammatory ulcer.