Lauren Madigan, MD, discusses highlights from her lecture, Interesting Cases from Inpatient Consults, at the 2nd Annual Elevate-Derm Alliance Summer Conference at the Grand Hyatt Deer Valley in Park City, Utah.

In this video

Speaking with Veronica Richardson, Dr. Madigan frames neutrophilic dermatoses like Sweet syndrome and pyoderma gangrenosum as reactive processes — when you see one, the next question is "what else is going on with this patient?" Because roughly two-thirds of PG patients have an underlying disease (AML, myelodysplasia, VEXAS, inflammatory bowel disease), she stresses it falls to the provider to work these patients up and uncover cryptic malignancy or inflammatory disease. She treats PG as a diagnosis of exclusion and always biopsies with tissue culture, citing the prominent paper in which 20% of suspected cases turned out to be mimics — including a classic-looking IBD patient whose ulcers were actually blastomycosis on immunosuppression. She argues it is far worse to misdiagnose and go down the wrong treatment path than to hesitate over pathology.

Dr. Madigan walks through distinguishing necrotizing PG from necrotizing fasciitis — pausing when cultures stay negative and broad-spectrum antimicrobials aren't working — and describes how a single PG wound can cycle through neutrophilic inflammation, a healing wound needing better wound care, and true secondary infection, demanding a nimble, closely followed approach. Her first-line agents are prednisone, cyclosporine, and infliximab (handy in IBD), with transitions to JAK or IL-12/23 inhibitors for refractory disease. She closes with a game on why "color matters" at the bedside, and emphasizes that representation matters because delayed diagnosis in skin of color carries real morbidity.

  • Neutrophilic dermatoses are reactive — after diagnosing Sweet syndrome or PG, work the patient up for cryptic malignancy, clonal disorders like VEXAS, or inflammatory bowel disease.
  • Always biopsy pyoderma gangrenosum with tissue culture; it's a diagnosis of exclusion, and 20% of suspected cases in a landmark paper were mimics like infection, malignancy, or vasculitis.
  • When a "necrotizing fasciitis" isn't responding to broad-spectrum antimicrobials and cultures stay negative, pause and consider neutrophilic inflammation gone awry.
  • A PG wound can move through three phases — active neutrophilic inflammation, a slow-healing wound, and true secondary infection — so follow closely and adjust; first-line agents include prednisone, cyclosporine, and infliximab for speed of onset.
  • Learn to read color: green suggests chloroma or Pseudomonas, yellow the xanthomas, purple the vascular and lilac interface clues of dermatomyositis, and blue-gray deeper pigment or minocycline deposition — and remember representation matters for timely diagnosis in skin of color.