Recurrence of pyoderma gangrenosum within a chronic wound following microvascular free-tissue transfer

The authors present a 29-year-old woman with a chronic foot wound that failed to heal, despite extensive medical and surgical therapy. The diagnosis of pyoderma gangrenosum was ultimately made, and the patient was started on systemic cyclosporine therapy. In the absence of apparent active disease, surgical debridement and microvascular free flap reconstruction were performed to achieve wound closure. Six weeks postoperatively, recurrence of the pyoderma gangrenosum was identified in the free flap, resulting in partial, superficial, flap necrosis. Laboratory evaluation at that time demonstrated subtherapeutic cyclosporine levels. Once the cyclosporine level was increased to the therapeutic range, the wound healed, and the microvascular free flap was salvaged. Because of the relative lack of precision in both the clinical and pathologic determination of acuity level, as well as the tendency toward pathergy, surgical treatment of any form poses many potential risks for these patients. For this reason, surgery should serve only as an adjunct to medical therapy, which remains the mainstay for treatment of pyoderma gangrenosum.