Postoperative Pyoderma Gangrenosum Following Varicose Vein Surgery: Recognizing a Rare Surgical Mimic Before Extensive Tissue Loss

Postoperative pyoderma gangrenosum (PG) is a rare neutrophilic dermatosis that frequently masquerades as a surgical site infection. Because its clinical presentation closely resembles postoperative cellulitis or even necrotizing soft tissue infection, diagnosis is often delayed. Misdiagnosis may result in unnecessary antibiotic escalation, repeated surgical interventions, and progressive tissue destruction due to pathergy. This case highlights the importance of early recognition of PG and serves as a reminder for surgeons to consider this uncommon diagnosis when postoperative wounds fail to respond to conventional treatment. A 75-year-old woman underwent elective open varicose vein surgery (ligation of neocrosse veins and phlebectomies) for recurrent symptomatic varicose veins of the left lower limb. One week postoperatively, she developed a painful erythematous wound that was initially diagnosed as a surgical site infection. Despite drainage, repeated wound care, and escalation from oral to broad-spectrum intravenous antibiotic therapy, the lesion rapidly progressed into an extensive necrotic ulcer. Repeated wound cultures and blood cultures remained sterile, while computed tomography scans demonstrated inflammatory changes without evidence of a drainable collection or necrotizing soft tissue infection. Following dermatological consultation, postoperative PG was suspected and confirmed by skin biopsy. High-dose systemic corticosteroid therapy was initiated, resulting in rapid clinical improvement, cessation of ulcer progression, and subsequent wound healing. This case illustrates the diagnostic challenge of postoperative PG and emphasizes several clinical features that should prompt reconsideration of a presumed surgical site infection, including disproportionate pain, rapidly progressive ulceration, sterile cultures, failure of appropriate antimicrobial therapy, and inconclusive imaging findings. Early recognition is essential, as surgical manipulation may exacerbate disease progression through pathergy. Postoperative PG should be considered in any patient presenting with a rapidly progressive postoperative wound that fails to improve despite appropriate antimicrobial treatment. Increased awareness among surgeons may facilitate earlier diagnosis, prevent unnecessary surgical procedures, and reduce the risk of extensive tissue loss.