Pediatric Pyoderma Gangrenosum: Multidisciplinary Care
Multidisciplinary Management of Refractory Pediatric Wounds Suspected to Be Pyoderma Gangrenosum—From Amputation Talk to Measured Progress
Disclaimer: Educational only; not a substitute for patient‑specific medical advice.
Executive summary
A 16‑year‑old female with scleroderma presented with circumferential bilateral lower‑extremity ulcers suspected for pyoderma gangrenosum (PG). After months of extensive care elsewhere and systemic therapy, healing had stalled and the family had been advised to consider amputation. In a resource‑limited setting with insurance restrictions and limited specialty access, the team implemented a Wound Balance plan: high‑dose corticosteroids, topical antimicrobials, wicking silver fabric, and advanced dressing layers (including superabsorbents and silicone interfaces), with frequent adjustments for efficacy and cost. Wound size decreased, pain fell enough to stop narcotics, and mobility and social participation improved. [1, 2]
The case in brief
Patient: 16‑year‑old female; history of scleroderma; bilateral circumferential leg ulcers suspected to be PG.
Barriers: State‑funded insurance formulary limits, scarce pediatric dermatology/rheumatology coverage, transportation and social hurdles.
First exam: Extensive ulceration, bioburden, slough, and severe pain.
Initial regimen: High‑dose steroids, topical antimicrobials, wicking silver fabric, superabsorbent layers, and silicone interfaces; dressings were re‑tuned repeatedly to match wound response and budget. Care was anchored to Wound Balance principles (patient‑centered decisions, early moves to limit chronicity).
Why “Wound Balance” matters in suspected PG—especially in underserved settings
Wound Balance (as referenced by the authors) emphasizes a measured, patient‑centered program: control inflammation/bioburden, optimize exudate and protease levels (e.g., with superabsorbents and silicone interfaces), and adapt dressings as the bed evolves—without losing sight of pain, function, and access. In this case, that framework enabled consistent progress despite formulary limits and delayed specialist input. [3, 9]
What the team actually did (replicable elements)
Treat the inflammatory driver early. Initiated high‑dose corticosteroids for suspected PG; sought pediatric rheumatology/dermatology input (access was limited). [6, 1]
Engineer exudate control + protease modulation. Employed wicking silver fabric to manage bioburden and superabsorbent dressings with silicone interfaces to protect margins and maintain balance—swapping components as drainage, cost, and tolerance changed.
Iterate, don’t fixate. Dressing stacks were revised frequently for response and availability; the plan favored pragmatic substitutions over ideal but unavailable products.
Prioritize analgesia and function. Pain fell substantially; opioids were stopped as mobility and participation increased.
Keep the long view. The team tracked surface area and clinical milestones, and documented persistent system barriers for advocacy and follow‑up.
Clinical pearls
Suspect PG when you see rapidly painful ulcers with undermined edges in autoimmune backgrounds (e.g., scleroderma) and recalcitrant behavior despite sound fundamentals. In such scenarios, a steroid‑centered anti‑inflammatory plan alongside meticulous local care is reasonable while pursuing specialist input. [1, 2]
Balance beats brand. In resource‑limited contexts, principles (wicking, protease control, silicone protection) trump specific SKUs; frequent plan edits improved outcomes here. [3, 9]
Measure what matters. Area change, pain, narcotic use, and mobility are meaningful signals of trajectory—especially when full specialty workups are delayed.
A practical workflow you can use on Monday
Step 1 – Confirm the cliff notes & risks.
Map ulcer extent, bioburden, pain, and slough; document autoimmune history and prior therapies. If PG is suspected, start anti‑inflammatory therapy per local protocol while arranging specialty follow‑up. [1, 2]
Step 2 – Create Wound Balance locally.
Topical antimicrobials for bioburden. [4, 9]
Wicking silver fabric for moisture/bioburden. [4, 9]
Superabsorbent core to modulate exudate/proteases. [5, 9]
Silicone interfaces to protect margins and reduce trauma.
Iterate components based on drainage, tolerance, and coverage. [3, 9]
Step 3 – Track and adapt.
Reassess weekly to biweekly: surface area (PAR), pain score, opioid use, function. Scale dressings up or down and record substitutions needed for coverage/cost. [3, 9]
Step 4 – Coordinate & advocate.
Escalate to dermatology/rheumatology and document formulary barriers; use progress data to support exceptions or policy appeals.
Outcomes & quality‑of‑life wins (from the case)
(Patient's left foot after 1 year of healing)
LLE: 151.6 → 125.5 cm² (PAR 17.2%).
RLE: 161.0 → 123.0 cm² (PAR 23.6%).
Pain: Substantial drop → narcotics discontinued.
Function: Improved mobility and social engagement; patient expressed future goals.
Reality check: Insurance formulary and specialty shortages remained active barriers even as the wound trajectory improved.
Where this fits (and limits)
Best‑fit: Suspected PG or severe inflammatory ulcers in pediatric or underserved contexts where rapid access to subspecialists is limited. [1, 2]
Caveats: This is a single‑patient poster case; diagnosis was suspected PG; outcomes reflect a multifactor plan (systemic steroids + local wound balance), not a single product effect. [7, 1]
FAQ
What is “Wound Balance”?
A care framework emphasizing patient‑centered decisions, exudate and protease control, bioburden management, and early, responsive adjustments to prevent chronicity—used here to guide dressing choices and steroid timing. [7, 1]
Which dressings were used?
The team layered wicking silver fabric, superabsorbents, and silicone interfaces, swapping components to match clinical response and coverage/cost realities. [4, 9]
What outcomes were achieved?
Bilateral leg wounds reduced in area (17–24% PAR), pain fell enough to stop opioids, and function improved, despite ongoing insurance and access barriers.
Why not just debride more?
For suspected PG, the emphasis was on inflammation control and balanced local care rather than aggressive procedures alone; the team prioritized steroids plus protease/exudate management while specialty input was arranged. [7, 1]
Bottom line
In a teen with suspected PG and major access constraints, a Wound Balance approach—steroids plus adaptive, protease‑modulating dressings—produced measurable wound and quality‑of‑life gains without immediate access to an ideal formulary or subspecialists. This case offers a practical blueprint for clinicians working in resource‑limited settings. [1, 2]
References
[1] George C, Deroide F, Rustin M. Pyoderma gangrenosum – guide to diagnosis & management (Clin Med, 2019) — https://pmc.ncbi.nlm.nih.gov/articles/PMC6542232/
[2] Maverakis E, et al. Diagnostic criteria of ulcerative PG (JAMA Dermatol, 2018) – open PDF — https://air.unimi.it/bitstream/2434/555642/2/jamadermatology_Maverakis_2018_cs_170003.pdf
[3] WUWHS. Implementing Wound Balance: outcomes & future recommendations (2025) — https://woundsinternational.com/wp-content/uploads/2025/05/HAR25_Wound-Balance_WUWHS_web.pdf
[4] Leaper D, et al. International Consensus: Appropriate Use of Silver Dressings (2012, PMC) — https://pmc.ncbi.nlm.nih.gov/articles/PMC7950978/
[5] Wounds UK. Best Practice Statement: Effective Exudate Management (2024) — https://wounds-uk.com/wp-content/uploads/2023/02/ab600a1fc6d7a34a5b146cbe0c7088a8.pdf
[6] Kechichian E, et al. Pediatric pyoderma gangrenum: systematic review (JAAD, 2017) — https://pubmed.ncbi.nlm.nih.gov/28233293/
[7] Ormerod AD, et al. STOP GAP RCT: ciclosporin vs prednisolone for PG (BMJ, 2015) — https://pubmed.ncbi.nlm.nih.gov/26071094/
[8] Wounds International. Soft silicone dressings – Made Easy (2013/2023 update) — https://woundsinternational.com/wp-content/uploads/2023/02/c6c17c8108884b42545f060eabc1d29f.pdf
[9] WUWHS. Wound exudate: effective assessment & management (consensus) — https://woundsinternational.com/wp-content/uploads/2023/02/836aed9753c3d8e3d8694bcaee336395.pdf
[10] BAD Patient Information: Pyoderma gangrenum (overview) — https://www.bad.org.uk/pils/pyoderma-gangrenum
