patients with ibd should be periodically examined regarding their dermatologic conditions . in a previous report from iran ,
the prevalence of dermatological manifestations was reported to be 5.9% in patients with ibd with a higher rate in crohn s disease ( 7.29% ) compared with patients with ulcerative colitis ( 4.07% ) .
they were more common in women ( 52% ) than in men ( 48% ) .
one of the rare dermatological manifestations in patients with ibd is pyoderma gangrenosum . which is more common in patients with ulcerative colitis .
since pyoderma gangrenosum is a rare occurrence , its explicit prevalence is unknown , but generally it has been estimated to occur in 3 - 10 million patients annually . in iran , the prevalence of pyoderma gangrenosum in patients with ulcerative colitis has been reported to be 1.4% .
the diagnosis of pyoderma gangrenosum is based on physical examination , and examining the lesions regarding its type , number , size , and location as well as associated symptoms of ulcerative colitis .
most pustular lesions in patients with ibd should be considered as pyoderma gangrenosum variants and be treated accordingly .
even though histopathologic examination is not deemed diagnostic for pyoderma gangrenosum , skin biopsy should be performed to rule out other conditions simulating pyoderma gangrenosum .
pyoderma vegetans is a sign of ibd , but rarely occurs in iranian patients . in case of facing pyoderma vegetans in a patient without significant medical history ,
the mean age for the onset of dermatological manifestations in iranian patients with ibd is 31 years . 


 the patient is a known case of ulcerative colitis limited to her left colon for 15 years under irregular treatments .
she was receiving unknown herbal medications for a long time and discontinued her standard treatments in the past three years .
she had intermittently developed skin lesions diagnosed as pyoderma gangrenosum in her shoulder , thigh , and genital areas during the past 4 years ( figure 1 ) .
( a ) pyoderma gangrenosum on the right thigh , 
 ( b ) pyoderma gangrenosum on the shoulder , 
 ( c ) pyoderma gangrenosum on the genital area 
 
 six months before admission to our center , she developed a small mucosal lesion in her nose .
she was referred to shariati hospital gastrointestinal clinic because of the rapid growth of the lesions and unresponsiveness to local treatments used by her dermatologist .
the only remarkable findings were old skin scars on her extremities and genital area and a lobular dermato - mucosal lesion measured 345 cm in her left nasal lumen ( figure 2 ) . 
  
( a ) the dermato - mucosal lesion in her nose in the first month , ( b ) the dermato - mucosal nasal lesion in month 6 , ( c ) scar of the skin lesion after surgery 
 laboratory assays showed white blood count ( wbc)=6,300/mm , hemoglobin=10.6gr / dlit , platelet count=405,000/mm , esr=61 mm 1st hr , crp=37mg / l with normal stool smear and culture . during the preceding 6 months
, the dermatologist who referred the patient had injected corticosteroids into the lesion several times .
oral cyclosporine followed by dapsone was administered by the dermatologist with no significant effect on her nasal lesion . since the lesion was large and patient complained of respiratory difficulty , surgical intervention was done and the lesion was excised completely .
( a , b ) microscopic features of the verrucous plaques are acanthotis and papillomatous hyperplasia of epidermis along with multiple micro - abscesses ( pustules ) in dermis ( h&e stain , original magnification 60x ) , ( c , d ) higher power view of the lesion shows acanthotic papillomatous epidermis and subepidermal micro - abscess ( pustule ) ( h&e stain , original magnification 150x ) . 

no evidence was detected in favor of cytomegalovirus or clostridium difficile on laboratory or pathological examination .
after initial evaluation and ruling out latent infections such as tuberculosis , intravenous infliximab ( 300 mg ) was started on weeks 0 , 2 , and 6 and then every 8 weeks .
simultaneously oral asacol ( 4.8 grams per day ) was started and she underwent regular monitoring every 8 weeks until week 48 of injection .
after 2 months , the clinical symptoms improved significantly and in a 1-year follow - up no recurrence of the nasal lesion was found .

 in case of simultaneous pyoderma gangrenosum and ulcerative colitis , treatments are delivered directly targeting the skin lesions as well as systemic agents to control ulcerative colitis .
topical therapeutics include highly potent steroids , calcineurin inhibitors ( tacrolimus , pimecrolimus ) , human platelet releasing growth factor , and intralesional injection of cyclosporine .
systemic treatment for pyoderma gangrenosum involves cyclosporine ( 3 - 5 mg / kg / day ) which is effective for extensive pyoderma gangrenosum and is usually administered with steroids . in most cases , cyclosporine could be applied instead of steroids .
dapsone ( maximum dose of 200 mg / day ) is effective in mild cases .
when the patient does not respond to routine treatments , infliximab which is a chimeric anti - tumor necrosis factor alpha antibody is an appropriate option .
however , it is mandatory that the patient be evaluated regarding latent / active infections such as tuberculosis and be monitored during treatment with infliximab in terms of appearance of infective signs . despite various treatments reported in the literature , an exact treatment guideline does not exist for pyoderma gangrenosum . in the presented patient , in view of the presence of active colitis ( evident in colonoscopy ) and mucosal lesion of pyoderma vegetans in her nose associated with other dermatologic manifestations of pyoderma gangrenosum , intravenous infliximab ( 300 mg , 5 mg / kg ) with oral asacol ( 4.8 gr per day ) was initiated . after 2 months , complete resolution of symptoms as well as improvement in macroscopic and microscopic views in colonoscopy was observed . in a one - year follow - up ,
it seems that infliximab was effective not only for her ulcerative colitis signs , but also on extra - intestinal manifestation ( i.e. , pyoderma vegetans ) . 

 some dermatologic manifestations are common in ulcerative colitis ( uc ) . herein , we present a 36-year - old woman with ulcerative colitis and uncommon nasal mucosa pyoderma vegetans . 
 the patient presented to our hospital with symptoms of active colitis and a concomitant 345 cm dermato - mucosal lesion in her left nasal lumen . 
 after surgery of the mucosal lesion , the treatment for her active colitis was initiated with intravenous infliximab and oral asacol . after a 1-year follow - up , no sign of recurrence favoring mucosal lesion was noted and symptoms of ulcerative colitis were managed properly . 
INTRODUCTION
CASE REPORT
DISCUSSION
CONFLICT OF INTEREST