A 69-year-old female with past medical history of hypertension and ulcerative colitis presented with right foot and ankle pain which she had been experiencing for about a week. She had no known trauma. The day prior to her visit, she had noticed some skin breakdown in the area. She had been applying over-the-counter antibiotic cream, Voltaren analgesic gel, and took some aspirin. About 8 months prior, the patient had started having crampy abdominal pain and blood in her stool. She was seeing a gastroenterologist for this.

Vitals were normal, except for elevated blood pressure of 150/80 mmHg. On exam, there was right ankle hyperemia, edema , and tenderness to palpation over the lateral malleolus with 1 cm of ulceration, and no lymphagitic streaking. Her complete blood count (CBC) revealed normal white blood cells, but significant anemia with a hemoglobin/hematocrit of 27.9/8.6.

This was initially treated as cellulitis with Bactrim DS BID for 10 days and topical Bactroban 2 % ointment TID.

Four days later, the patient returned with increased ankle pain and swelling, as well as a larger area of ulceration. At that point, her right foot and ankle had 2+ edema with a 2 cm pus-filled ulceration, which was exquisitely tender with surrounding erythema and warmth. The patient was sent to the Emergency Room for possible IV antibiotics given the lack of improvement on oral antibiotics.

She was admitted to the hospital and was treated with IV antibiotics for cellulitis without any improvement. The wound was surgically debrided and wound cultures showed no growth. She was then diagnosed with pyoderma gangrenosum and treated with oral prednisone and the wound started to improve.

These photos were taken 3 weeks after initially presenting at the Primary Care office.