P017 A multifaceted case of pyoderma gangrenosum: insights into diagnosis and management in the presence of comorbid conditions

Abstract Pyoderma gangrenosum (PG) is a rare and debilitating neutrophilic dermatosis known for painful ulcers with undermined borders. Its diagnosis is challenging due to varied presentations and frequent misdiagnoses, especially in patients with complex comorbidities. Early identification and targeted treatment are critical for reducing complications and improving outcomes. We report the case of a woman in her early fifties with a complex medical history, including autoimmune hepatitis, thrombocytopenia, renal dysfunction and diverticulitis. She initially presented with a large ulcerative lesion that was misdiagnosed as a fungal infection and treated unsuccessfully with terbinafine. When symptoms persisted, a biopsy confirmed PG. The patient’s treatment journey involved multiple immunosuppressive therapies, such as prednisolone and ciclosporin, although ciclosporin was later discontinued due to kidney complications. She was also treated with mycophenolate mofetil, which was halted after it aggravated her diverticular disease, and with dapsone, which was eventually stopped due to liver-related concerns. Over time, the patient’s condition worsened, resulting in a nearly circumferential leg ulcer that caused significant pain and was resistant to compression therapy. She also faced severe pain, recurrent episodes of sepsis, and impaired absorption due to her bowel complications, adding complexity to her clinical management. Despite high-dose analgesics, her ulceration remains extremely painful. Given her hepatic and renal impairment, her medication options are limited. She is currently under close, multidisciplinary monitoring and is awaiting approval for biologic therapy with risankizumab, which her gastroenterology team favours over infliximab because of liver concerns. This case highlights the complexities of managing PG in patients with extensive comorbidities. Effective management often demands a multidisciplinary approach, involving dermatologists, gastroenterologists and other specialists to craft tailored, patient-specific treatment plans. In this patient’s case, the recurrent nature of her lesions and poor response to conventional therapies have led to considering biologics like risankizumab. These biologics, although not yet approved for PG, are under investigation as effective treatments for refractory cases. Evidence suggests they may offer significant benefits for patients who do not respond well to standard immunosuppressive treatments. However, accessibility is limited, underscoring the need for continued research and potential policy adjustments to broaden treatment options for severe cases. In conclusion, this case emphasizes the importance of individualized, multidisciplinary strategies for managing complex cases of PG with multiple comorbidities. Biologic therapies, although currently restricted, represent a promising option for refractory PG. Continuous collaboration among specialists, careful monitoring of treatment impacts on comorbidities, and further research into biologic efficacy are essential to improving patient quality of life and achieving better outcomes in challenging cases like this.