Malignant pyoderma gangrenosum eroding the parotid gland successfully treated with dexamethasone pulse therapy

Malignant pyoderma gangrenosum is a rare ulcerative variant of pyoderma gangrenosum (PG) involving the head and neck. Early intervention is crucial to prevent an aggressive outcome.

We report a patient with malignant PG eroding into the parotid gland treated with dexamethasone pulse therapy.

A 47-year-old man presented with necrotic ulcers, predominantly over the face and neck, of one month's duration. Findings of a thorough systemic evaluation were within normal limits. A Mantoux test and pathergy test were negative. Tissue specimens for acid-fast bacilli and fungal cultures were negative. A biopsy showed epidermal necrosis along with perivascular and periappendageal neutrophilic infiltrate without granuloma or vasculitis, consistent with PG. Over the next two weeks, the ulcers progressed in depth and width. The ulcer overlying the right parotid gland continuously discharged clear fluid. The invasive nature of the ulcers and histopathological findings confirmed the diagnosis of malignant PG. Dexamethasone pulse therapy was administered as 100 mg dexamethasone in 500 ml 5% dextrose infused over 3-4 hours on three consecutive days.

This treatment resulted in complete healing of the ulcers within six weeks. The patient subsequently received nine similar pulses administered at 28-day intervals and has shown no evidence of relapse over the past year.

In the present patient, parenteral antibiotics and daily steroids, colchicine, and oral minocycline had failed to halt the progression of ulcers. However, dexamethasone pulse therapy resulted in complete healing without sequelae and also proved cost-effective.