Vascular insufficiency resulting in need for amputation

Based on my review of the available medical records, pathology, and clinical photographs, I do not find a deviation from the standard of care by dermatology in the management of this 71-year-old male with a left lower extremity pretibial ulcer. The lesion had reportedly been present for approximately four months when he was first evaluated on 01/23/2025. At that visit, the dermatologist appropriately performed a punch biopsy and considered a reasonable differential diagnosis, including neoplasm of uncertain behavior, chronic non-healing ulcer, pyoderma gangrenosum, and infection. Empiric treatment with mupirocin, clobetasol, and doxycycline was also reasonable pending tissue diagnosis. The pathology report from 01/30/2025 was positive for pyoderma gangrenosum, and the clinical appearance in the photographs reviewed was consistent with pyoderma gangrenosum. In that setting, the continued dermatologic management at the follow-up visit on 02/13/2025 with topical corticosteroid therapy and doxycycline was medically appropriate. Pyoderma gangrenosum is an inflammatory ulcerative dermatosis and is not primarily a vascular diagnosis. Importantly, biopsy confirmation together with the clinical morphology supported that the pretibial ulcer was being managed as pyoderma gangrenosum rather than as an ischemic ulcer. A history of peripheral vascular disease alone does not automatically require immediate vascular surgery referral for every lower extremity ulcer when the lesion’s appearance, biopsy findings, and clinical impression support an alternative dermatologic diagnosis. There is also no indication from the dermatology records provided that, during the earlier visits, the pretibial lesion was clearly presenting as acute limb ischemia, gangrene, or another vascular emergency requiring urgent vascular surgical intervention. Rather, the dermatologist investigated the lesion, obtained tissue diagnosis, and treated in accordance with the biopsy result and clinical presentation. When additional lower extremity ulcerations on the feet were later noted on 04/24/2025, referral to podiatry was made. That was a reasonable step based on the findings documented at that visit. The patient’s later vascular deterioration, hospitalization in June 2025, CTA findings showing occlusion of a prior left femoral artery graft, subsequent bypass, debridement, metatarsal amputations, and eventual left above-knee amputation reflect progression of severe underlying peripheral arterial disease. However, those later events do not establish that the dermatologist breached the standard of care months earlier. Dermatology was evaluating and treating a pretibial lesion that was biopsy-proven and clinically consistent with pyoderma gangrenosum. On the information provided, there is not sufficient basis to conclude that an earlier vascular surgery referral by dermatology was mandated, nor that failure to make such a referral at the January or February visits constituted medical negligence. In summary, the dermatology care appears medically reasonable and within the standard of care. The lesion was appropriately biopsied, the pathology supported pyoderma gangrenosum, the clinical photographs were consistent with that diagnosis, and treatment followed accordingly. The subsequent severe vascular complications appear attributable to the patient’s advanced peripheral arterial disease rather than to any clear error in dermatologic management

To a reasonable degree of medical probability, the dermatology care at issue was not the cause of this patient’s eventual limb loss. The patient had significant preexisting vascular disease, including peripheral vascular disease/peripheral arterial disease and a history of bilateral lower extremity stents, and later was found to have occlusion of a prior left femoral artery graft. Those underlying vascular abnormalities are the medically significant causes of the progression to foot necrosis, gangrene, need for bypass surgery, transmetatarsal-level amputations, and ultimate left above-knee amputation. In contrast, dermatology appropriately evaluated the pretibial lesion, obtained a biopsy, and treated it in accordance with pathology and the clinical impression of pyoderma gangrenosum. Nothing in the records provided supports that the dermatologic management caused the vascular occlusion or substantially contributed to the eventual amputation.