Therapierefraktäres Pyoderma gangraenosum nach Tätowierung

A 49-year-old female patient with polycythaemia vera presented with multiple ulcerations in a recent tattoo. A topical steroid prescribed by the general practitioner for suspected allergic contact dermatitis led to initial improvement; however, progression with pain and fever occurred after 1 month. Under clindamycin treatment the condition deteriorated further. In our clinic, a sharply defined ulcer with erythema was found in the tattoo area. Laboratory tests revealed no specific autoimmune or infection markers. Pseudomonas aeruginosa and Staphylococcus aureus were detected on bacterial smears. The histopathology revealed an ulcer with a neutrophilic infiltrate. Angiological examinations were unremarkable. The diagnosis of pyoderma gangraenosum (PG) after tattooing in the presence of a myeloproliferative disease was established based on the clinical findings, histology and additional examinations (Paracelsus score: 15/20). After initial antibiotic treatment, methylprednisolone was administered, followed by ciclosporin (discontinued due to renal failure), intravenous immunoglobulins and finally infliximab, all without success. Only anakinra showed a clear arrest of activity, so that a split-thickness skin transplantation could be performed. Tattoos can lead to a variety of skin reactions, including allergic reactions, infections and autoimmune or autoinflammatory diseases such as PG, especially in patients with a hematological disease. A PG is a rare neutrophilic and often trauma-induced dermatosis characterized by painful sterile skin ulcerations. The diagnostics and treatment are often challenging and include glucocorticoids, ciclosporin, immunoglobulins and biologics such as anakinra.