Pyoderma Gangrenosum Following Cesarean Section: A Case Report With Individualized Management.

INTRODUCTION

Pyoderma gangrenosum (PG) is a rare neutrophilic dermatosis characterized by rapidly progressive necrotizing skin ulcers. PG following cesarean section (CS) is extremely rare and frequently misdiagnosed as surgical site infection, leading to inappropriate debridement and disease exacerbation. We report a case of severe postcesarean PG successfully managed with early immunosuppressive therapy.

CASE PRESENTATION: A 24-year-old primiparous woman at 29 + 4 weeks gestation underwent emergency CS due to umbilical cord prolapse. On postoperative day (POD) 7, she developed painful ulcers with undermined violaceous borders around the incision. Despite broad-spectrum antibiotics, lesions progressed rapidly. Pathergy occurred following surgical debridement on POD 9 (wound enlarged to 21.5 × 11.0 cm). PG was diagnosed on POD 11 based on clinical features, sterile cultures, and neutrophilic infiltrate on histopathology. Treatment included methylprednisolone pulse therapy (500 mg intravenously daily for 3 days), followed by tapering to 60 mg/day with concurrent initiation of cyclosporine (75 mg oral twice daily) and etanercept (25 mg subcutaneously twice weekly). The patient was discharged on POD 30. Complete epithelialization was achieved by the 4th postoperative month without recurrence or adverse drug reactions.

DISCUSSION: This case highlights the diagnostic challenges of postcesarean PG, which requires high clinical suspicion to distinguish from infectious complications. Triple immunosuppressive therapy (high-dose corticosteroids, calcineurin inhibitor, and TNF-α antagonist) represents an effective strategy for severe, rapidly progressive disease, allowing rapid disease control while facilitating corticosteroid tapering. Long-term follow-up confirmed sustained remission despite extensive initial ulceration.