Facial Ulceration in a Patient With Crohn's Disease


Question: A 55-year-old woman with longstanding ileocolonic Crohn's disease presented with a facial lesion. She had previously undergone a total proctocolectomy and end-ileostomy for disease that was refractory to prednisone, 6-mercaptopurine, infliximab, and adalimumab. In 2010, she developed an ulcerating lesion on her face, between the left naris and left upper lip. A biopsy showed dermal neutrophilic infiltration (Figure A), and wound cultures did not demonstrate infection. The lesion worsened despite treatment with certolizumab pegol, topical tacrolimus, and intralesional steroids. The patient was admitted for severe facial pain associated with worsening of the ulcerating lesion. She had no gastrointestinal symptoms. On physical examination, there was a 2 × 2-cm ulcer superior to the left upper lip with a full-thickness defect, through which a tooth could be seen (Figure B). The borders of the ulcer had a raised, violaceous edge overhanging the ulcer bed.

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