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

The authors present a 29-year-old woman with a chronic Foot wound that fail ed to heal, despite extensive medical and surgical therapy. The diagnosis o f pyoderma gangrenosum was ultimately made, and the patient was started on systemic cyclosporine therapy. In the absence of apparent active disease, s urgical debridement and microvascular free flap reconstruction were perform ed to achieve wound closure. Six weeks postoperatively, recurrence of the p yoderma 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 increa sed to the therapeutic range, the wound healed, and the microvascular free flap was salvaged. Because of the relative lack of precision in both the cl inical and pathologic determination of acuity level, as well as the tendenc y toward pathergy, surgical treatment of any form poses many potential risk s for these patients. For this reason, surgery should serve only as an adju nct to medical therapy, which remains the mainstay for treatment of pyoderm a gangrenosum.