Vet Dermatol 2013; 24: 552–e132 DOI: 10.1111/vde.

12065

Canine pyoderma gangrenosum: a case series of two

dogs
Deborah L. Simpson*, Gregory G. Burton† and Lydia E. Hambrook‡
*Animal Dermatology Solutions, 26 Fowler Street, Box Hill South, Victoria 3128, Australia
†Animal Skin, Ear and Allergy Service, 70 Blackburn Road, Glen Waverley, Melbourne, Victoria 3150, Australia
‡Advanced Vetcare, 26 Robertson Street, Kensington, Melbourne, Victoria 3031, Australia
Correspondence: Deborah L. Simpson, Animal Dermatology Solutions, 26 Fowler Street, Box Hill South, Victoria 3128, Australia.
E-mail: debbiesimpson@icloud.com

Background – Pyoderma gangrenosum (PG) is a rare disease, which, to the best of the authors’ knowledge, has
been the subject of only one case report in the peer-reviewed veterinary literature.
Hypothesis/Objectives – To describe the history, clinical signs, diagnostic findings and treatment outcome in
two cases of canine PG.
Animals – Two client-owned dogs presented to a private veterinary referral practice between 2008 and 2010
who received a diagnosis of PG by specialist veterinary dermatologists.
Methods – Medical records were analysed to retrieve relevant information.
Results – Both dogs were treated with prednisolone; this was combined with ciclosporin in case 1 and azathio-
prine in case 2. Case 2 had a more complete response of lesions to treatment and a longer survival time after
diagnosis (763 days) than case 1 (81 days).
Conclusions and clinical importance – Pyoderma gangrenosum is a rare disease distinguished by rapid pro-
gression of painful, necrolytic, cutaneous ulcers with irregular, violaceous undermined borders. Azathioprine with
glucocorticoids may lead to a better outcome than ciclosporin and glucocorticoids (currently the first-line treat-
ment in humans and the only reported treatment in dogs).

and septic thrombi, spider bite, Sweet’s syndrome (SS)

Introduction
Pyoderma gangrenosum (PG) is a rare disease in dogs,
with one case reported in the peer-reviewed literature and
two textbook entries.1–3 It is included among the neutro-
philic dermatoses (reactive sterile dermal neutrophilias).4
In humans it has a classic ulcerative form, a diffuse pustu-
lar type, an erosive and bullous type and a chronic superfi-
cial granulomatous form.5 There are no diagnostic
histological or serological markers of PG.5 Diagnosis of the
classic ulcerative form in humans requires the presence of
both major criteria (rapid progression of a painful, necrolyt-
ic, cutaneous ulcer with an irregular, violaceous and under-
mined border, with exclusion of other causes of
cutaneous ulceration) and at least two of the following
minor criteria: (i) history suggestive of pathergy (new
lesions forming in response to minor trauma) or a clinical
finding of cribriform scarring; (ii) systemic diseases asso-
ciated with PG; (iii) histopathological findings (sterile
dermal neutrophilia, with/without mixed inflammation,
with/without lymphocytic vasculitis; and (iv) treatment
response (rapid response to systemic steroid treatment).4
Possible differential diagnoses for PG in dogs include
bacterial or fungal infections, such as necrotizing fasciitis
Accepted 6 June 2013
Sources of Funding: This study was self-funded.
Conflict of Interest: No conflicts of interest have been declared.
and vasculitis. Pyoderma gangrenosum shares the phe-
nomenon of pathergy with SS but is clinically distin-
guished from it by ulcerative lesions with an undermined,
violaceous edge. Lesions of SS (in humans and dogs) are
typically red papules, nodules or transparent vesicular
lesions that coalesce to form plaques.3,6–8 Pyoderma gan-
grenosum and SS may represent variants of a single con-
dition.6 The pathogenesis of PG is poorly understood; an
association with immunological or inflammatory diseases
suggests an immune-mediated aetiology.9 Neutrophil
dysfunction (defects in chemotaxis or hyper-reactivity)
may contribute.4 Possible genetic links have been identi-
fied in humans.9
Case 1
An 11-year-old male entire Hungarian puli presented with
a 7 month history of painful pustules and erosions on
the body. Treatment prior to referral included three
2 week courses of 13.9 mg/kg twice daily oral amoxicil-
lin–clavulanate (Amoxyclav; Apex Laboratories, Somers-
by, NSW, Australia), two 5 day courses of 22 mg/kg
twice daily oral cefalexin (Rilexine; Virbac, Milperra,
NSW, Australia) and three 4 week courses of 5 mg/kg
once daily oral enrofloxacin (Baytril; Bayer, Pymble,
NSW, Australia). Physical examination revealed cutane-
ous ulcers with violaceous borders, necrotic eschars,
moist exudation and purpuric plaques involving large

552 © 2013 ESVD and ACVD, Veterinary Dermatology, 24, 552–e132.


regions of the dorsum, tail base and tail. Cytology
showed suppurative sterile inflammation.
A complete blood count showed moderate neutrophilia
33.3 9 109/L (normal range 3.0–11.5 9 109/L) with a left
shift and mild monocytosis, rare metamyelocytes and a
few enlarged platelets. Necrotic skin was debrided and
biopsies were submitted for histopathology and tissue
culture. Amoxicillin–clavulanate (Clavulox; Pfizer, West
Ryde, NSW, Australia) 13.9 mg/kg twice daily per os (p.o.)
and marbofloxacin (Zenequin; Pfizer) 2.8 mg/kg once daily
p.o. were commenced. A bandage change 6 days after
admission revealed marked loss of epithelium to the full
extent of the purpuric regions, leaving ulcers with under-
mined violaceous borders. Cultures yielded no aerobic or
anaerobic bacterial growth after 48 h and no fungi after
21 days. Histopathology revealed a severe leukocytoclas-
tic neutrophilic vasculitis, dermatitis and panniculitis, with
no evidence of micro-organisms on haematoxylin and
eosin, Gram or periodic acid Schiff stains (see Figure 1).
Seventeen days after admission four new areas of
macular purpura, ulceration and vesiculation were noted
at the periphery of the bandages. The light bandage pres-
sure appeared to be causing new lesions (consistent with
pathergy). A diagnosis of pyoderma gangrenosum was
reached. Prednisolone (Macrolone; Mavlab, Slacks Creek,
Queensland, Australia) 1 mg/kg twice daily p.o. and sulfa-
salazine (Salazopyrin; Pfizer) 13.9 mg/kg twice daily p.o.
were commenced. Five days later pain appeared to have
decreased markedly (described in human literature as the
first sign of remission).4 Only dry, healing lesions
remained.
By day 25 after diagnosis prednisolone had been
reduced to 0.58 mg/kg every second day. On day 35 the
skin was fully healed; previously affected areas were hy-
perpigmented and alopecic. Sulfasalazine was discontin-
ued, and ciclosporin 5.8 mg/kg once daily was p.o. added
(Atopica; Novartis, North Ryde, NSW, Australia). On
day 53 after diagnosis multiple new violaceous plaques
appeared, varying from 1 to 11 cm in diameter (some
with central ulceration) on the face, dorsal bridge of the
nose, neck, mid-dorsum, lateral thorax, hip and flank.
Figure 1. Photomicrograph of skin biopsy from the dorsum of
case 1. Neutrophilic exocytosis, subepidermal clefting and marked
superficial dermal sterile neutrophilic infiltrate. Haematoxylin and
eosin x400.
© 2013 ESVD and ACVD, Veterinary Dermatology, 24, 552–e132.
Canine pyoderma gangrenosum
Prednisolone was increased to 1 mg/kg twice daily, sulfa-
salazine was restarted at 14 mg/kg twice daily and ciclo-
sporin was continued.
A bone marrow biopsy was performed on day 68 due
to the previous finding of metamyelocytes and enlarged
platelets and because bullous PG in humans is associated
with haematological disease.5 This returned a diagnosis
of myeloid hyperplasia, with no indication of myeloprolif-
erative disease or neoplasia. On day 81 after diagnosis
case 1 was re-presented to the clinic due to the appear-
ance of new cutaneous lesions. Thoracic radiographs
revealed no abnormalities. Abdominal ultrasound
revealed a mildly hyperechoic liver. The dog was euthan-
ased. No significant abnormal findings were made at
postmortem examination other than the previously diag-
nosed hyperplastic bone marrow.
Case 2
An 11-year-old male neutered Weimaraner presented
with a long history of intermittent lameness and gastroin-
testinal disease (vomiting, diarrhoea and haematochezia)
and a 3 day history of an ulcer over the left dorsal scapula
and subcutaneous nodules on the lateral neck, thorax and
flank. On physical examination there was a large painful
nodule on the right lower eyelid, swelling of the entire
right side of the face and a draining wound on the flank.
Rectal temperature was 40.3°C. Intravenous amoxicillin
18 mg/kg four times daily, subcutaneous enrofloxacin
(Baytril) 4.5 mg/kg once daily and intravenous metronida-
zole (Metrogyl; Alphapharm, Glebe, NSW, Australia)
9 mg/kg twice daily were commenced. The wounds were
clipped and cleaned with saline. Over the next few days
painful, purpuric macules and vesicles and multifocal
ulcers with violaceous borders developed over the trunk
(see Figures 2 and 3). Biopsies were taken for histopa-
thology and deep tissue culture. Fine-needle aspirates
showed neutrophilic inflammation. No micro-organisms
were identified on cytology or histopathology, including
special stains (haematoxylin and eosin, Gram stain, peri-
odic acid Schiff and Ziehl-Neelsen).
Figure 2. Photograph of the dorsum of case 2. Purpuric macule and
adjacent ulcer on the day of diagnosis of pyoderma gangrenosum.
553
Simpson et al.
Figure 3. Photograph of the flank of case 2. Large necrotic ulcer
with undermined violaceous border on the day of diagnosis of pyo-
derma gangrenosum.
Histopathology showed moderate to marked neutro-
philic and histiocytic interstitial ulcerative dermatitis and
panniculitis, leukocytoclastic vasculitis and dermo-epider-
mal clefting with moderate mural neutrophilic folliculitis.
Bacterial culture returned a light growth of Staphylococ-
cus pseudintermedius sensitive to all antibiotics on the
testing panel (including enrofloxacin), which was pre-
sumed to be a contaminant due to lack of micro-organ-
isms on cytology/histopathology and lack of response to
appropriate antibiotic therapy. A fungal culture also
returned negative results. Pyoderma gangrenosum was
diagnosed and antibiotics were stopped. Oral predniso-
lone (Macrolone; Mavlab) was commenced at 0.75 mg/
kg twice daily, and 7 days later azathioprine (Imuran;
Aspen Pharmacare, St Leonards, NSW, Australia)
2.14 mg/kg once daily was added. Ten days later the pain
and facial swelling had resolved. A complete blood count
was normal. Biochemistry indicated a steroid hepatopa-
thy (alkaline phosphatase 1113 IU/L, normal range 1–
150 IU/L and alanine aminotransferase 339 IU/L, normal
range 16–90 IU/L). After 3 weeks of azathioprine and
prednisolone the PG lesions resolved, leaving only cribri-
form scarring (Figure 4).
On day 65 gastric dilatation and volvulus were diag-
nosed. Postoperatively the right lateral abdomen devel-
oped several 0.7 cm diameter violaceous macules. The
right forelimb became ulcerated at the intravenous cathe-
ter site (consistent with pathergy). Topical betametha-
sone diproprionate (Diprosone OV cream 0.5 mg/g;
Schering Plough, North Ryde, NSW, Australia) was
applied twice daily. The skin lesions resolved within
3 days.
One hundred days after diagnosis the skin lesions had
resolved except for alopecia, depigmentation and cribri-
form scarring. Prednisolone and azathioprine were gradu-
ally tapered over 6 months to 0.6 mg/kg azathioprine
every second day and 0.25 mg/kg prednisolone every
third day without relapse of skin lesions. This dosage regi-
men was maintained until day 762, when the dog
554
Figure 4. Photograph of the dorsum of case 2. Cribriform scarring
over dorsum on day 30 after diagnosis of pyoderma gangrenosum.
collapsed due to a third-degree heart block, and the dog
was euthanased on day 763.
Discussion
In common with humans, pain, malaise and lethargy were
features of our PG cases; they fulfilled the two major
human diagnostic requirements of a consistent clinical
presentation and exclusion of infectious diseases. Both
dogs also satisfied minor diagnostic criteria of pathergy,
cribriform scarring (case 2), consistent histopathological
results and rapid response to systemic immunosuppres-
sive treatment. About 25% of humans with ulcerative PG
have a history of a precipitating event, such as minor
trauma, insect bites or surgical procedures, and 50–70%
of cases of human PG are associated with an underlying
systemic disorder.10,11 In cases where no disease is iden-
tified or where treatment of underlying disease does not
result in remission of PG, a combination of corticosteroids
and either azathioprine or ciclosporin are the first choice
of therapy in humans.12
Underlying disorders could not be identified in the two
presented cases, but both responded quickly to immuno-
suppressive therapy. Due to concurrent medications it is
not possible to assess accurately the effect of the sulfa-
salazine. Sulfasalazine has been reported as an adjunct
treatment in canine vasculitis.13 Pyoderma gangrenosum
is a chronic disease, with as many as 50% of human
patients requiring long-term therapy to avoid recurrences;
therefore, careful consideration has to be given to the
sustainability of maintenance treatments.14
The number of cases of PG in the veterinary literature
is too small to draw any meaningful conclusions regard-
ing comparative treatments; however, we propose that
azathioprine may be considered in conjunction with corti-
costeroids as an effective first-line treatment of PG in
dogs.
Acknowledgements
We would like to acknowledge a donation from Novartis
of 90 9 100 mg ciclosporin (Atopica; Novartis) capsules
© 2013 ESVD and ACVD, Veterinary Dermatology, 24, 552–e132.
 Canine pyoderma gangrenosum

for the treatment of case 1. We thank David Robson and
Richard Ploeg for assistance with the photographs and
photomicrograph.
References
1. Bardagi M, Lloret A, Fondati A et al. Neutrophilic dermatosis
resembling pyoderma gangrenosum in a dog with polyarthritis. J
Small Anim Pract 2007; 48: 229–232.
2. Gross TL, Ihrke PJ, Walder EJ et al. Canine pyoderma gangreno-
sum. In: Skin Diseases of the Dog and Cat, 2nd edition. Oxford:
Wiley-Blackwell, 2005: 132–135.
3. Miller WH Jr, Griffin CE, Campbell KL. Miscellaneous skin dis-
eases. In: Muller and Kirk’s Small Animal Dermatology 7th edi-
tion. Missouri, MO: Elsevier 2013; 709–710.
4. Su WPD, Davis MDP, Weenig RH et al. Pyoderma gangreno-
sum: clinicopathologic correlation and proposed diagnostic crite-
ria. Int J Dermatol 2004; 43: 790–800.
5. Powell FC, Collins S. Pyoderma gangrenosum. Clin Dermatol
2000; 18: 283–293.
6. Cohen PR, Kurzrock R. Sweet’s syndrome: a neutrophilic derma-
tosis classically associated with acute onset and fever. Clin Der-
matol 2000; 18: 265–282.
7. Mellor PJ, Roulois AJA, Day MJ et al. Neutrophilic dermatitis
and immune-mediated haematological disorders in a dog: sus-
pected adverse reaction to carprofen. J Small Anim Pract 2005;
46: 237–242.
8. Okada K, Saegusa S, Yamaoka A et al. Febrile neutrophilic der-
matosis in a miniature schnauzer resembling Sweet’s syndrome
in humans. Vet Dermatol 2004; 15(Suppl. 1): 58 (abstract).
9. Ruocco E, Sangiuliano S, Gravina AG et al. Pyoderma gangreno-
sum: an updated review. J Eur Acad Dermatol Venereol 2009;
23: 1008–1017.
10. Powell FC, Schroeter AL, Su WPD et al. Pyoderma gangreno-
sum: a review of 86 patients. Q J Med 1985; 55: 173–186.
11. Powell FC, Su WPD, Perry HO. Pyoderma gangrenosum: classi-
fication and management. J Am Acad Dermatol 1996; 34: 395–
409.
12. Ehling A, Karrer S, Klebl F et al. Therapeutic management of
pyoderma gangrenosum. Arthritis Rheum 2004; 50: 3076–3084.
13. Plumb DC. Plumb’s Veterinary Drug Handbook. 7th edition.
Stockholm, WI: PharmaVet Inc., 2011; 1281–1283.
14. Von den Driesch P. Pyoderma gangrenosum: a report of 44
cases with follow-up. Br J Dermatol 1997; 137: 1000–1005.

Re
sume

Contexte – La pyodermite gangre
neuse (PG) est une maladie rare, qui a e
te

le sujet d’un seul cas clinique

rature ve
dans la litte
te

rinaire avec comite
de relecture.
Hypothe ses/Objectifs – De
crire l’anamne se, les signes cliniques, les re
sultats diagnostiques et la

ponse au traitement de deux cas de PG canines.
re
Sujets – Deux chiens de proprie
taires pre
sente
s 
a une consultation ve
te

rinaire prive
e de re
fe

re

s entre
2008 et 2010 ayant recßu un diagnostic de PG par des dermatologues ve
te

rinaires spe
cialistes.
Me
thodes – Les donne
es me
dicales ont e
te

analyse

es afin de re

cupe
rer les informations pertinentes.
Re
sultats – Les deux chiens e
taient traite

s avec de la prednisolone; celle-ci e
tait associe
e 
a la ciclosporine
dans le cas 1 et a l’azathioprine dans le cas 2. Le cas 2 pre
sentait une re
ponse plus comple te des le
sions
au traitement et un temps de survie plus long apre s le diagnostic (763 jours) que le cas 1 (81 jours).
Conclusions et importance clinique – La pyodermite gangre
neuse est une maladie rare qui se distingue
par une progression rapide d’ulce res cutane
s ne

crotiques et douloureux, avec des bords mal de
limite
s,

guliers et violace
irre
s. L’azathioprine associe
e aux glucocortico€ıdes peut mener  a un meilleur re
sultat que
la ciclosporine associe
e aux glucocortico€ıdes (actuellement le traitement de premie re ligne chez l’homme
et le seul traitement rapporte
chez le chien).

Resumen
Introduccio
n – la pioderma gangrenosa (PG) es una rara enfermedad que so
lo ha sido descrita una vez en
la literatura veterinaria cient
ıfica revisada.
Hipo
tesis/Objetivos – describir la historia, signos cl
ınicos, hallazgos diagno
sticos, tratamiento y resolu-

n de dos casos de PG en perros.
cio
Animales – dos perros de propietarios particulares que se presentaron a una cl
ınica veterinaria de referen-
cia entre 2008 y 2010 con un diagno
stico de PG dado por dermato
logos veterinarios especialistas.
Me
todos – se analizaron los historiales cl
ınicos para obtener la informacio
n de importancia.
Resultados – ambos perros fueron tratados con prednisolona; e
sta fue combinada con ciclosporina en el
caso 1 y con azatioprina en el caso 2. El caso 2 tuvo una respuesta mas completa de las lesiones al tratami-
ento y una supervivencia mas prolongada tras el diagno
stico (763 d
ıas) que el caso 1 (81 d
ıas).
Conclusiones e importancia cl
ınica – la pioderma gangrenosa es una enfermedad rara diferenciada por
una r
apida progresio
n cl
ınica de u

lceras cut

aneas dolorosas y necro
ticas con bordes de color viol
aceo, irreg-
ulares y deprimidos. El tratamiento con azatioprina y glucocorticoides puede dar un mejor resultado que la
ciclosporina con glucocorticoides (actualmente el tratamiento de eleccio
n en humanos y el u
nico tratamien-
to publicado en perros).

Zusammenfassung
Hintergrund – Die Pyoderma gangraenosum (PG) ist eine seltene Erkrankung, sie wird in der Peer-
reviewed Veterin€arliteratur nur einmal in Form eines Fallberichts thematisiert.
Hypothese/Ziele – Die Anamnese, die klinische Symptomatik, die diagnostischen Ergebnisse und den
Ausgang der Behandlung in zwei F€allen von caniner PG zu beschreiben.

© 2013 ESVD and ACVD, Veterinary Dermatology, 24, 552–e132. 555

Simpson et al.

Tiere – Zwei Hunde in Privatbesitz wurden einer privaten tiera €

€rztlichen Uberweisungspraxis zwischen
2008 und 2010 vorgestellt und von veterin€ ardermatologischen Spezialisten mit PG diagnostiziert.
Methoden – Um wichtige Informationen zu erhalten, wurden die Patientenkarteien analysiert.
Ergebnisse – Beide Hunde wurden mit Prednisolon behandelt; dieses wurde im 1. Fall mit Ciclosporin und
im 2. Fall mit Azathioprin kombiniert. Der 2. Fall zeigte eine vollst€
andigere Reaktion der Ver€
anderungen auf
€
die Behandlung und eine l€angere Uberlebensdauer nach der Diagnose (763 Tage) als der 1. Fall (81 Tage).
Schlußfolgerungen und klinische Bedeutung – Pyoderma gangraenosum ist eine seltene Erkrankung,
die sich durch ein rasches Fortschreiten eines schmerzhaften, nekrolytischen Ulkus der Haut mit unreg-
elm€aßigen, violetten unterminierten Abgrenzungen auszeichnet. Azathioprin mit Glukokortikoiden ko €nnte
zu einem besseren Behandlungsergebnis fu €hren als Ciclosporin und Glukokortikoide (momentan die erste
Behandlungsstrategie beim Menschen und die einzig beschriebene Behandlung bei Hunden).

e132 © 2013 ESVD and ACVD, Veterinary Dermatology, 24, 552–e132.

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