35-Year-Old Woman With Ulcerating Skin Lesions

Abstract

A 35-year-old female day-care worker sought medical assis­ tance because of a history of small tender nodules develop­ ing on the left lateral buttock area. These nodules had appeared 4 days earlier, after the patient had been working in her garden; therefore, they were ascribed to a possible insect bite. The skin lesions began as red, warm, tender, and indurated areas (Fig. 1) associated, 4 to 5 days later, with spontaneous drainage of serosanguineous fluid. For the next few months, multiple ulcerated lesions (up to 3 by 2 em) developed on the buttocks and thighs (Fig. 2). The lesions then stopped draining and healed, but subcutaneous atrophy and hyperpigmentation remained. A skin biopsy specimen obtained by her local physician revealed nonspecific chronic dermatitis. Topically applied corticosteroids seemed to ex­ acerbate the lesions. During this time, she remained afebrile and had no chills, sweats, cough, arthralgia, fatigue, or dyspnea. During the 3 months before the patient was exam­ ined at our institution, several regimens of antibiotics and oral corticosteroid therapy yielded no appreciable improve­ ment or cessation of recurrent ulcerations. 1. Which one of the following is the most likely dermatologic diagnosis at this point? a. Erythema nodosum b. Pyoderma gangrenosum c. Panniculitis d. Bacterial cellulitis e. Cutaneous polyarteritis nodosa Eruption due to erythema nodosum can be associated with various disease processes, although it is not character­ ized by ulcerating lesions. Recurrence, as noted in this patient, is uncommon in erythema nodosum. Pyoderma gangrenosum, considered noninfectious in origin, clinically exhibits a painful nodule or pustule that ulcerates and drains a purulent exudate and has a necrotic base. In our patient, the lesions did not demonstrate the rapid expansion and ulcer