Pyoderma gangrenosum associated with sarcoidosis.

Sir, Pyoderma gangrenosum (PG) is a rare, destructive, inflammatory skin disease of unknown aetiology which belongs to the group of neutrophilic dermatoses (1 – 3). In about 50% of patients, an underlying disease will be found, such as inflammatory bowel disease and haematological malignancies. In others, the diagnosis of idiopathic PG is reluctantly made. We report here a case of PG associated with systemic sarcoidosis. A 53-year-old man was admitted to our hospital in September 2001 with a pretibial ulcer on the right leg of 7 months’ duration. Initially, the ulcer presented as a bulla that later ulcerated and progressively expanded laterally. Examination disclosed a large, 668 cm, relatively flat ulcer, with a swollen necrotic base and a raised violaceous border (Fig. 1a). The patient had a 30-month history of generalized lymphadenitis. Laboratory tests revealed hypergammaglobulinaemia (2.1 g/dl, normal 0.7 – 1.6) as well as elevated ACE (angiotensin converting enzyme) (60 mg/dl, normal v52). A chest X-ray showed bilateral hilar lympadenopathy. Infections, such as tuberculosis and malignancies had been excluded. A biopsy specimen of an inguinal lymph node showed granulomatous infiltration and led to the diagnosis of sarcoidosis. Histological examination of a skin biopsy from the border of the ulcer revealed necrotizing inflammation with perivascular infiltration of neutrophils, consistent with the diagnosis of PG. The patient was treated with prednisolone at a dose of 75 mg/day, whichresulted inresolutionof lymphadenopathy over the next 8 weeks, but only partial control of PG. The addition of colchicine at a dose of 2 mg/day led to rapid healing of the skin ulcer. The prednisolone dosage was gradually reduced, and finally stopped. The patient continued therapy with colchicine and no relapse occurred during a follow-up period of 6 months (Fig. 1b).