Multimodal Management of Pyoderma Gangrenosum Using a Thermoplastic Elastomer NPWT Interface, Morphine-Infused Antibiotic Cement, and Patient-Directed Antimicrobial Irrigation

Pyoderma gangrenosum is a rare neutrophilic dermatosis characterized by painful, rapidly progressive ulceration and a marked propensity for pathergy, making lower-extremity wound management particularly challenging. Severe pain, exaggerated inflammatory response, and susceptibility to mechanical trauma often limit tolerance of standard wound care interventions and delay initiation of disease-directed therapy. This case report describes a multimodal stabilization strategy used during a defined six-week treatment period in a patient with biopsy-proven pyoderma gangrenosum of the medial ankle that had progressed despite prolonged outpatient care. Management focused on interruption of pain-driven deterioration, suppression of local infection, and minimization of mechanical trauma rather than immediate wound closure. The approach combined morphine-infused antibiotic-loaded resorbable calcium sulfate cement for sustained local analgesia and local antimicrobial therapy, low-pressure extended-interval negative pressure wound therapy delivered through a thermoplastic elastomer interface, and a patient-directed antimicrobial irrigation technique that preserved dressing integrity. During this period, pain control improved substantially, tolerance of advanced wound therapy was achieved, and fluoroquinolone-resistant Pseudomonas aeruginosa infection resolved without evidence of pathergic worsening. The wound transitioned to a clinically stable, infection-free state, allowing subsequent initiation of topical and systemic immunosuppressive therapy. To the authors’ knowledge, this represents the first reported use of morphine-infused resorbable calcium sulfate cement as a local analgesic adjunct in lower-extremity wound care. This case highlights the importance of reframing success in complex inflammatory wounds around stabilization and tolerance of therapy and suggests a potential framework for managing pain-limited, pathergy-prone ulcers.