Chronic Ulcers

Presented by Yoon Cohen, D.O.
Alta Dermatology Residency
Mesa Arizona

Abstract: 66-year-old woman with 3 year history of leg ulcers

HPI: The patient is a 66-year-old retired elementary school teacher who was seen for evaluation of chronic leg ulcers. The most recent injury was sustained on her right lower leg when she bumped into her grandson’s toy.  This  eventually caused a new leg ulcer. Subsequently, she was hospitalized, and seen and evaluated by the Plastics Wound Clinic at a major hospital center. The patient presented for continuity care after discharge from the hospital.  Her chronic leg ulcers started in 2011 when she had a cat scratch on the right foot which resulted in cellulitis and ulcer on the right leg. After that episode, she noticed the development of ulcers whenever she gets even minor injury to her legs. She has a long history of rheumatoid arthritis that she has been on multiple treatments including prednisone, methotrexate and Remicade. Her current medications include prednisone 5mg daily, methotrexate 20mg weekly with folic acid, Celebrex 200mg bid, and oxycontin 50mg daily.

O/E: The skin exam shows a pleasant, somewhat depressed woman with several various seized leg ulcers with healthy granulation tissues at base on the lower legs.
A) R lateral calf: fibrinous base, 3.3 cm x 1.3 cm
B) L dorsal foot: Fibrinous base, 1.8 cm x 1.0 cm
C) L lateral calf: Fibrinous base, 2.5 cm x 1.6 cm
D) L medial calf: Clean granulation tissue at base, 5.0 cm x 4.8 cm x 0.5 cm
Pedal pulses 1+ and 2+ pitting edema bilaterally

Clinical Photos:

Hospital Courses:
1. Diagnosis: Her chronic ulcers were considered to be multifactorial. Likely contributors include trauma, infection, rheumatoid arthritis, venous insufficiency, ulceration from methotrexate toxicity.
2. Procedures: Debridement and Kenalog injection(10mg/cc) to the left medial calf
3. Diagnostic Studies: Wound culture (pending)
4. Dressings: Acticoat 7 for lesions A and D, and then continue hydrofera blue to lesions A and D. Santyl, adaptic, gauze, kerlex for lesions B and C.
5. Compression: Soft cotton between the skin and the SurePress; will try penumoboots for home and leg elevation.

Discussion: The possible etiologies can be trauma, rheumatoid arthritis, venous insufficiency, infection, or prolonged use of methotrexate or Remicade. There are 9 reports of ulcerations from methotrexate and 1 report of ulcerations  of foot from Remicade (infliximab) according to Litt’s DERM Drug Eruptions & Reactions Manual. There are two major questions. What is (are) causing these ulcerations which occur with even minor injuries? Could it be methotrexate toxicity? Could this be a variant form of pyoderma gangrenosum related to RA? She does not heal well even in other locations of her body. It seems to be more than just venous insufficiency. Lastly, how can we help heal these ulcers? 

Questions: 
What are your thoughts regarding the etiology of this woman's leg ulcers? 
How would you manage her to facilitate healing?
Do you think her medications play a role?  or her rheumatoid arthritis?

References:
1. Ben-Amitai D, Hodak E, David M. Cutaneous ulceration: an unusual sign of methotrexate toxicity - first report in a patient without psoriasis. Ann Pharmacother. 1998; 32 (6): 651-3
Abstract
Objective: To describe a case of skin ulcer related to methotrexate toxicity
Case Summary: A 67-year-old white man with seronegative arthralgia developed recurrent skin ulcer concurrent with 3-year treatment with methotrexate 5 mg daily. The skin ulcer resolved on discontinuation of methotrexate
Discussion: To the best of our knowledge, this is the first reported case of skin ulcer believed to be induced by methotrexate in a patient without psoriasis
Conclusions: Skin ulceration should be added to the list of possible toxic adverse effects of methotrexate, not only in psoriatic patients but also in those without psoriasis.

2. Stolman LP, Rosenthal D, Yaworsky R, et al. Pyoderma Gangrenosum and rheumatoid arthritis. Arch Dermatol. 1975; 111(8): 1020-3. 
Abstract
Two patients had pyoderma gangrenosum and rheumatoid arthritis. Biopsy specimens of the cutaneous ulcers in the paitents showed a necrotizing vasculitis. Complement (C3) and immunoglobulines were not detected in the skin lesions. There was no important impairment of cell-mediated immunity observed.

3. Seitz CS, Berens N, Brocker EB, et al. Leg ulceration in rheumatoid arthritis -- an underreported multicausal complication with considerable morbidity: analysis of thrity-six patients and review of the literature. Dermatology. 2010; 220 (3): 268-73
CONCLUSIONS: The majority of leg ulcers in patients with RA are due to underlying venous/arterial malfunction while vasculitic or traumatic ulcers are less common. Additionally, we identified a relevant subgroup of patients with 'inactivity ulcers' due to impaired mobility and consecutive lymphedema. Morphology and localization of ulcerations as well as duplex sonography provide the most important clues for accurate diagnosis, ensuring adequate treatment.

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