incidence of the disease is ~5/1,000,000.1 inflammatory bowel diseases , hematological malignancies , or rheumatologic diseases have been diagnosed in majority of patients.24 myelodysplastic syndromes ( mdss ) may be associated with pg.35 the mechanism of pg is not yet fully understood ; however , disorders of immune system seem to have an important role.5 small traumas may aggregate pg . thalidomide may be used as a treatment option in some patients.4,7,8 herein , we aimed to report a patient who was diagnosed as pg with mds and responded well to thalidomide treatment . a 61-year - old man with painless ecchymotic lesions in his right upper extremity was admitted to the hospital in isparta , turkey , in january 2015 . abdominal tomography was performed , which revealed lesions as 3222 mm in liver and 35 mm diameter in spleen that were considered as abscess . because immature myeloid cells were seen in blood film , he was referred to our hospital in april 2015 . in his anamnesis , it was found that he was diagnosed as mds 6 years ago and had been treated with cyclosporine at 2100 mg for 5 years , which was stopped in january 2015 . on admission , the laboratory tests showed : hemoglobin , 9.2 g / dl ; white blood cells , 5.110/l ; and thrombocytes , 1010/l . aspiration from liver lesion revealed the presence of mycobacterium tuberculosis , so antituberculosis treatment was started . bone marrow investigation revealed mds - refractory anemia with excess blasts ( 7% ) . for lesions in bilateral upper extremities , lesions began to regress , and the patient tolerated thalidomide well , so the dose was increased to 100 mg / d . after 1 month from the initiation of thalidomide treatment , the lesions in upper extremities had disappeared ( figure 2 ) . all of the ethical considerations were strictly handled in accordance with the helsinki declaration . as a standard of care / action of the hospitals of hacettepe medical school , it was confirmed based on patient records that the study participant gave written informed consent at the time of hospitalization and relevant diagnostic / therapeutic standards of care . first - line treatment in pg often contains high - dose steroids , and if there is resistance to steroids , many immunosuppressive agents , such as cyclophosphamide , cyclosporine a , clofazamine , azathioprine , and chlorambucil , could also be used.9 in the literature , there are some reports of patients with pg who were successfully treated with thalidomide . a 3-year - old refractory pg patient was successfully treated with thalidomide 100 mg / d.10 the time required to achieve treatment response could be different between cases . for example , in one case , pg was treated with thalidomide after 6 months of initiation of therapy.11 however , a refractory pg patient with penis involvement just healed in 5 days after the initiation of thalidomide with 100 mg / d.12 another pg patient responded to treatment after 10 weeks of thalidomide usage . in addition , thalidomide is effective against rheumatic diseases associated with pg . two patients with behcet s syndrome and pg were successfully treated with thalidomide.13,14 an important concern about thalidomide usage in pg is the duration of treatment . in a pg patient , excellent treatment response was observed for 2 years with thalidomide 100 mg / d ; however , after discontinuation of drug , relapse occurred.15 there are several reports on pg in the english literature.16,17 the thalidomide activity mechanism is still not fully understood , but it is known that the result of usage of thalidomide exposes antiangiogenic effect and increases the oxidative stress.18 thalidomide increases the levels of interleukin ( il ) 2 , il-4 , and il-5 ; however , it decreases the levels of tumor necrosis factor  , il-6 , il-10 , and il-12.19 it also modifies the secretion of interferon .19 thalidomide promotes proliferation and migration functions of keratinocytes . thus , it is a very useful agent in skin lesions because it enhances reepithelialization.20 thalidomide could also be used as a treatment option for mds.21 our patient is a complicated case who simultaneously has mds , pg , and tuberculosis infection . the reason for thalidomide usage in our patient was the need of immune modulation without immune suppression . so , thalidomide was considered as the best option in our patient . unlike previous cases , we have started the thalidomide treatment with 50 mg / d , and 1 week later , we have increased the dose to 100 mg / d . our patient has tolerated the drug well , and excellent response was obtained after 1 month of initiation of thalidomide treatment . the plan for our patient is to continue the drug as long as the patient tolerates because there is a risk of relapse in case of discontinuation . to conclude , thalidomide is a very effective drug acting as an immune modulator , which is useful in the clinical management of both mds and pg .
thalidomide may be used as a treatment option for pyoderma gangrenosum ( pg ) and myelodysplastic syndrome ( mds ) . herein , we aimed to report a patient who was treated well with thalidomide and whose diagnosis was pg with mds . a 61-year - old man with painless ecchymotic lesions in his right upper extremity 
 was admitted to the hospital in isparta , turkey , in january 2015 . 
 the lesions were diagnosed as pg . in his anamnesis , it was found that he was diagnosed with mds 6 years ago and had been treated with cyclosporine at 2100 mg for 5 years , which was stopped in january 2015 . 
 aspiration from liver lesion revealed the presence of mycobacterium tuberculosis , so antituberculosis treatment was started . 
 bone marrow investigation revealed mds - refractory anemia with excess blasts ( 7% ) . for lesions in bilateral upper extremities , 
 thalidomide treatment was started at 50 mg / d . 
 after 1 month from the initiation of thalidomide treatment , the lesions in upper extremities had disappeared . in the literature , there are some reports of patients with pg who were successfully treated with thalidomide . 
 our patient is a complicated case who simultaneously has mds , pg , and tuberculosis infection . 
 the reason for thalidomide usage in our patient was the need of immune modulation without immune suppression . 
 our patient has tolerated the drug well , and excellent response was obtained after 1 month of initiation of thalidomide treatment . 
 to conclude , thalidomide is a very effective drug acting as an immune modulator , which is useful in the clinical management of both mds and pg .