It’s likely you have never heard of pyoderma unless you encountered a patient with it, as I did. Pyoderma gangrenosum is a rare skin condition that causes painful blisters and sores that can rapidly expand into ulcers. While treatable, it often leaves significant scarring, which can pose serious challenges when present on a residual limb.
My patient was a 55-year-old man with a right transtibial amputation due to infection related to type 2 diabetes. He had also undergone a skin graft at the distal end of his residual limb. Although I was aware of his history of pyoderma, I initially focused more on the integrity of the graft site, as this was my first experience managing a residual limb with a skin graft.
His first prosthetic fitting took place in January 2025 using a passive suction system with a suspension sleeve and silicone liner. Within two weeks, he developed a blister at the distal end. The blister was treated by wound care, and he was eventually cleared to resume prosthesis use with precautions, including daily liquid bandage application and a reduced wearing schedule.
Nevertheless, another blister formed within a week. At a follow-up wound care visit, a nurse practitioner clarified that the blisters were not forming at the graft site but on skin previously affected by pyoderma. This marked the beginning of an ongoing cycle: prosthesis use, blister formation, healing, and recurrence. This pattern persisted for eight months, despite dermatological care and multiple interventions.
I attempted several solutions, including friction-reducing ointments (AdaptSkin 90) and distal gel cups, without success. I then fabricated a new socket using a Uniprox Softskin Air Liner, designed to allow moisture to escape. I believed trapped sweat was softening already compromised skin and contributing to blister formation. I also discontinued distal gel cups to allow better moisture management. Unfortunately, the problem continued.
During this time, I learned that the pyoderma-affected skin retained only about 3 percent of its normal integrity. Additionally, the patient reported no pain or discomfort during prosthesis use and did not have neuropathy, which made early detection of issues difficult. The longest he could go without developing a blister was one month.
With little available research on prosthetic use in patients with prior pyoderma involvement, I sought advice from the O&P community. One recommendation was to eliminate suction suspension and rely solely on the sleeve. Though initially hesitant due to concerns about pistoning, I implemented this change along with continued use of the Uniprox liner and AdaptSkin ointment.
At his one-month follow-up, the patient had no blisters, though a small distal callus suggested minor pistoning. To address this, I fabricated a supracondylar socket combined with the suspension sleeve. After two months, the patient showed no signs of skin breakdown—no blisters, calluses, or irritation. After nearly a year of trial and error, we had finally achieved a stable, long-term solution.
This case highlights the importance of reconsidering suction suspension in patients with compromised skin integrity. While the supracondylar design played a key role, I believe success resulted from the combined approach, including moisture management with a permeable liner and friction reduction. Clinicians should consider such strategies, especially in patients with fragile or scarred tissue, where sweat and shear forces can significantly increase the risk of skin breakdown.
Gyasi Cooper, CPO, is a part owner of District Amputee Care Center, Washington DC. He can be contacted at gcoop314@gmail.com.
