When hearing the word “ulcer” the thoughts of open sores comes to mind (i.e. skin or internal organ). Ulcers of the skin expose deeper tissues in the body and can occur when there is trauma to the skin (i.e. excessive pressure application, skin punctures, and cuts). Since the foot is under constant pressure when we are standing or walking, the risk of ulcers occurring increases, especially if a trauma occurs. There are many individuals suffering from conditions such as diabetes and vascular diseases who may not feel the pain caused by ulcerations due to loss of sensation (neuropathy). However, there are distinct ulcers associated with a skin disease called Pyoderma Gangrenosum that are different in nature, and can be painful, misdiagnosed, and difficult to treat.
For more information on ulcers, see our Ulcers/Wound Topic
About Pyoderma Gangrenosum
Pyoderma gangrenosum is a skin disease that results in painful ulcerations commonly seen on the top of the foot and shins. The name of the disease is associated with the appearance of the wounds that occur, which is dead tissue in the center of the wound (necrotic center), and a dusky red color around the edge of the wound. The appearance of the wound starts off as small, tender papulopustule(s), which having a similar appearance of acne on the face, and is often not recognized immediately upon examination by physicians. As the papulopustule breaks down, it starts to form small ulcers in the area, and eventually they progress together into to a full-thickness ulcer in the skin.
Causes and Risk Factors for Pyoderma Gangrenosum
The exact cause of pyoderma gangrenosum is not currently known, but is often associated with other debilitating conditions. These conditions include: inflammatory bowel diseases (Crohn’s disease and ulcerative colitis), arthritis, diverticulitis, hepatitis, myeloma, leukemia, or Behcet’s disease. While it is not understood why pyoderma gangrenosum is linked to these diseases, pyoderma gangrenosum is often seen in up to 50% of patients with one or more of mentioned conditions.
Diagnosis and Treatment
Since no specific test exists to detect pyoderma gangrenosum specifically, the diagnosis if often made by exclusion, and ruling out all other possible causes (diabetes, neuropathy, vascular diseases, etc.). Therefore, a detailed patient history is done to determine if the cause is due to trauma of the affected area, venous stasis, increased pressure, or pyoderma gangrenosum. It is also important to note if previous treatments have been done before since these ulcers tend to worsen with ulcer debridement or if the wound dries out. Also, obtaining a wound culture helps make the diagnosis since it helps ensure the patient does not have a wound caused by gangrene (requires surgical treatment).
Treating pyoderma gangrenosum is challenging since no specific treatment for it exists. The main priority will be to avoid trauma to the wound and this includes debridement since these ulcers enlarge with debridement. However, immunosuppression is the primary treatment. The following the most commonly use medications and treatment options:
- Topical anesthetics for the pain
- Topical and oral antibiotics while awaiting culture results
- Ciclosporin if corticosteroids are not effective
The wound should be inspected every week to ensure treatment is not enlarging the wound, have proper dressing changes, and should be kept dry from bathing to prevent bacterial growth in the wound. It can take a few months to heal pyoderma gangrenosum, but the wound will heal if it is treated correctly.
If you been experiencing pain due to ulcers on your foot and/or leg, please do not hesitate to schedule an appointment with Dr. Gary N. Friedlander or Dr. Jay C. Larson at Sole Foot and Ankle Specialists in Glendale, Arizona, and have all your treatment options presented to you and ensure you and your family maintain healthy feet.