Multimodal Therapy of Ulcers on the Dorsum of the Hand With Exposed Tendons Caused by Pyoderma Gangrenosum

The authors present the case of a 54-year-old man with ulcers on the dorsal hand and forearm with exposed extensor tendons after he received misdiagnoses at 2 other hospitals, leading to deep soft tissue defects from multiple debridements. Due to the complicated nature of the wound, the ulcers did not heal under the systemic medication. After careful debridement, the defect was primarily closed with a collagen-glycosaminoglycan biodegradable matrix (Integra Matrix Wound Dressing, Integra LifeSciences, Plainsboro, NJ) on the dorsal hand and covered with a mesh graft 14 days later. Necrosis and superinfection over the index finger was treated again with systemic antibiotics and an unmeshed skin graft under a vacuum bandage with a mesh wound contact layer (Mepitel, Mölnlycke Health Care, Norcross, GA). The patient was satisfied with the functional and aesthetic outcome 1 month later when wounds were completely healed. The authors conclude that in cases where patients are living with pyoderma gangrenosum, even a challenging and complicated wound can be handled successfully with correct systemic immunosuppression and appropriate soft tissue coverage.

Pyoderma gangrenosum is a painful, rare, atypical, ulcerative disease of uncertain etiology. It usually appears on the trunk and lower extremities, but can also occur on the hand, with its ulcerative lesions progressing rapidly. It can be associated with systemic diseases in approximately 50%-70% of cases,¹ mostly with inflammatory bowel disease, ulcerative colitis, or Crohn’s disease,² and it develops after minor trauma 30% of the time.³ It is frequently misdiagnosed as a fulminant infection, leading to unnecessary and harmful surgical treatment which often complicates the therapy that follows. Invasive surgical treatment such as multiple debridements may accelerate the characteristic pathogenic process of this disease, worsen the condition as a result, and may even lead to limb amputations in severe cases. 

The most effective therapy for pyoderma gangrenosum is less invasive and primarily nonsurgical intervention. Immunosuppression is essential in the healing process of an inflamed area which may lead to ulcers when left untreated. The surgical treatment should contain wound cleaning and protection from infection by aseptic covering of the lesions. 

The authors treated a 54-year-old man with ulcers on the dorsum of his hand and forearm. Misdiagnoses in 2 other hospitals and a therapeutic attempt with multiple debridements led to a deep soft tissue defect (Figure 1). After negative bacterial cultures and inflammation-related hematologic and biochemical parameters within normal limits showed no significant results, a biopsy was taken by dermatologists at the Ludwig-Maximilians-University Clinic in Munich which revealed a nodular dermatitis with a predominance of neutrophils. The presented deep ulcerations, supported by the unspecific histopathology and absence of other preexisting systemic diseases, led the authors to the working diagnosis of pyoderma gangrenosum. There were no signs of an occult systemic disease or an inflammatory disorder. The patient was in good health and did not have any comorbidities. 

The patient received immunosuppressive therapy with prednisolone 20 mg (1-0-0) and Azathioprine 150 mg (1-0-1); however, due to the complicated nature of the wound, the persistent ulcers did not heal under systemic medications. This made plastic surgical intervention necessary. 

Ulcers were seen on the dorsal right hand along with the dorsal and palmar right forearm. The affected areas represented approximately 3% of the body surface. The ulcer on the dorsal hand exposed the extension tendons of digits 2, 3, and 4. After careful debridement, the soft tissue defects were covered with an artificial bilayer membrane from acellular bovine collagen-glycosamine complex and a silicone layer (Integra Matrix Wound Dressing, Integra LifeSciences, Plainsboro, NJ) (Figure 2). 

The patient received a compression bandage and a palmar splint. After removing the bandage, it was observed that the wound was slowly healing 5 days after the bilayer membrane dressing was placed on the wound. Two weeks later, a 1:1.5 mesh graft from the lateral thigh was placed on the artificial skin bilayer membrane in a second operation. It was fixed with surgical staples, and the patient received a vacuum dressing as well as perioperative antibiotic therapy with cefuroxime. The vacuum dressing was removed 5 days later. Except for a small area of 25 mm x 10 mm on the dorsal hand over the extension tendon of the index finger, the mesh graft healed sufficiently. Despite intensive wound care over the next 2 weeks, the area over the extensor tendon of the index finger became necrotic and superinfected, thus making an additional antibiotic therapy necessary. This necrotic area was removed and covered with an unmeshed skin graft. The patient received a vacuum bandage with an open mesh wound contact layer (Mepitel, Mölnlycke Health Care, Norcross, GA) and the patient’s hand was stabilized with a splint. After removing the vacuum bandage 6 days postoperatively, the unmeshed graft healed completely. The immunosuppressive medications were then reduced slowly. After another 3 days, the patient was sent home for ambulatory care with the recommendation of changing the dressing every 3 days following disinfection and wound care. After the wound healed completely, the patient’s hand was carefully mobilized. In a 1-month postsurgical follow-up, the patient was satisfied and the lesions healed completely (Figure 3). 

This case demonstrates the management of consequences following inappropriate treatment of a patient living with pyoderma gangrenosum. Unfortunately, pyoderma gangrenosum is still often misdiagnosed as a simple infection,^4,5 which may lead to unwarranted invasive surgical treatments that often worsen the condition of the lesions, sometimes resulting in unnecessary and avoidable amputations. Therefore, the authors recommend that surgeons consider pyoderma gangrenosum as a differential diagnosis in obscure cases before initiating surgical treatment. Negative bacterial cultures or ineffective antibiotic therapy should lead to a reconsideration of the diagnosis of an infection.⁶ The correct diagnosis of ulcers caused by pyoderma gangrenosum is based on the clinical presentation and absence of other systemic reasons for the patient’s lesion or lesions. Therefore, immunosuppression is essential as the primary therapy. Prior to surgical treatment, the risk of ulcer deterioration and spreading should be decreased and there must be clinical improvement. Surgery should not be performed in a phase of recent ulcer aggravation without immunosuppression of the disease.⁷ If immunosuppression does not lead to a complete healing of the ulcerative lesions and instead they keep persisting, soft tissue coverage should be handled with minimal invasive techniques. For the challenging procedure described, the artificial bilayer membrane seems to be an effective option to cover the ulcerative lesions in a gentle way. This case shows the artificial bilayer membrane can be used successfully even on exposed tendons, thereby avoiding complex surgical treatment such as free tissue transfer. 

The authors conclude that even in cases where patients are suffering from symptoms of pyoderma gangrenosum, even after misdiagnosis and mistreatment, challenging, complicated wounds and lesions can be handled successfully with correct systemic immunosuppression and appropriate soft tissue coverage.

From the Department for Hand Surgery, Plastic Surgery and Aesthetic Surgery at the Ludwig Maximilian University of Munich, Munich, Germany

Address correspondence to:
Konstantin Christoph Koban, MD
Department for Hand Surgery, Plastic Surgery and Aesthetic Surgery
Ludwig Maximilian University of Munich
Munich, Germany
konstantin.koban@med.uni-muenchen.de 

Disclosure: The authors disclose no financial or other conflicts of interest.