Concurrent Scleredema and Pyoderma Gangrenosum: Case Report and Review of Comorbid Conditions

Abstract

Scleredema is a connective tissue disorder that presents as diffuse induration of skin, most often involving the upper body. Scleredema can be associated with prior infection, monoclonal gammopathy, and diabetes mellitus. Pyoderma gangrenosum is a neutrophilic dermatosis that presents as an ulcer with violaceous borders. Pyoderma gangrenosum can be idiopathic or associated with various conditions. A 66-year-old man with a 20-year history of scleredema diabeticorum presented with idiopathic pyoderma gangrenosum in the affected area of scleredema on his neck. His pyoderma gangrenosum resolved after treatment with topical and intralesional corticosteroids. Diseases associated with scleredema, pyoderma gangrenosum or both are reviewed.

Keywords: arthritis; bowel; diabetes; disease; gammopathy; gangrenosum; inflammatory; myeloma; pyoderma; scleredema.

Figure 1. Scleredema of the back

Distant (A) and closer (B) views of the scleredema diabeticorum of the upper back of a 66-year-old man with a 20-year history of diabetes. His scleredema appeared as chronic brown hyperkeratosis (black asterix) and induration on his central upper back; similar clinical findings were also present on his posterior neck.

Figure 2. Pyoderma gangrenosum of the posterior neck

Distant (A) and closer (B) views of the posterior neck of a man with scleredema diabeticorum that affected his upper back and neck. Pyoderma gangrenosum on his posterior neck presented as an ulcer (black arrow) that measured five by five centimeters in greatest diameter; the ulcer had overhanging edges that extended toward the wound center.

Figure 3. Progressive improvement of pyoderma gangrenosum

The sequential images (A, B, C, and D) show improvement of the posterior neck pyoderma gangrenosum. Progressive healing of the ulcer (black arrow) is demonstrated five weeks (A), 10 weeks (B), 24 weeks (C), and 29 weeks (D) after starting intralesional triamcinolone every two weeks and topical betamethasone 0.05% cream twice daily. The initial concentration of triamcinolone was 10 milligrams per milliliter; after 14 weeks of treatment, the dose was increased to 20 milligrams per milliliter in an attempt to expedite the clinical improvement. At each treatment session, he received either 1 milliliter or 2 milliliters of triamcinolone.

Figure 4. The pyoderma gangrenosum has resolved and the scleredema diabeticorum persists

Distant (A) and closer (B) views of the patient’s back and posterior neck at a follow-up examination 14 months after his initial office visit. Eight months following the initial presentation of pyoderma gangrenosum, the ulcer had completely resolved. A hypertrophic scar (between the black arrows) developed at the location of the superior border of the ulcer.