Pyoderma gangrenosum of the scalp treated with cyclosporine A

A 56‐year‐old woman presented with an ulcer, with a depth of 9 mm, on the vertex and frontal parietal regions of the scalp. The lesion had a round shape (diameter, 7 cm), with clear‐cut margins and vertical borders sinking vertically to a bottom that was entirely covered with purulent fibrinous yellowish matter and greenish colored necrotic tissue. Other numerous small roundish ulcers were present next to the large ulcer. These had irregular margins with a yellowish fibrinous bottom ( Fig. 1). The patient reported the appearance of two small ulcers on the left and on the right frontal parietal regions about 1 year earlier. These had been treated locally with antimicrobials and antiseptics with no result. During the 2 months prior to our evaluation, a few small round‐shaped ulcers had appeared on the scalp. These had progressively increased in size and number. Figure 1 Large ulcer with clear‐cut margins, covered by purulent fibrinous matter, and other small roundish ulcers The patient had been an insulin‐dependent diabetic for 23 years. Hematochemical examinations showed no significant alterations, except for a rise in glycemia. Urine examination gave normal results. Carcinoembryonic antigen and lymphocytic phenotyping indices were normal. Echographic, endoscopic, and radiocontrast studies of the abdomen did not reveal the presence of lesions either in the gastrointestinal tract or in other organs. Samples of ulcerous tissue were collected from the scalp to perform histologic and microbiologic analysis in search of fungi and bacteria. This last examination revealed the presence of Staphylococcus aureus and Candida parapsylosis . Direct search for mycobacteria was negative. Histology indicated the presence of dermal granulomatous inflammation with giant multinucleate cells, associated with large zones of suppuration and colliquative necrosis. While waiting to complete the diagnostic course, topical antiseptic, antimicrobial, and fibrinolytic therapy was administered; subsequently, as this did not lead to any improvement, systemic treatment with cyclosporine A (5 mg/kg/day) was started. Rapid improvement of the clinical picture occurred. The ulcers appeared cleaner from the first 2 weeks of treatment, radial growth stopped, and the margins were slightly more superficial. The patient continued with immunomodulating therapy at home over a period of 7 months. The dose was progressively reduced until, over a period of about 3 months, complete re‐epithelialization of the lesion, with subsequent partial regrowth of the hair, was obtained ( Figs 2 and 3). No relapses were observed 1 year after treatment was suspended. 2Partial re‐epithelialization of the lesion with partial regrowth of the hair3Scar and hair regrowth