Upadacitinib for ulcerative colitis and pyoderma gangrenosum in a patient with schizophrenia on long-term risperidone: A case report

BACKGROUND Pyoderma gangrenosum (PG) is one of the most severe extra-intestinal manifestations of ulcerative colitis (UC). The treatment of refractory UC combined with PG is challenging, particularly for patients with schizophrenia (SCZ) with a long-term history of risperidone use, and there have been no successfully treated patients reported in the literature. CASE SUMMARY A 36-year-old woman attended the gastroenterological clinic due to intermittent symptoms of diarrhea and mucous bloody stools. Prior to the emergence of these symptoms, the patient had a history of SCZ for 3 years. She had been receiving long-term risperidone treatment and had stable mental symptoms. In April 2023, she was diagnosed with UC E3 moderate and began taking mesalazine 3 g/day. In March 2024, her intestinal symptoms recurred and approximately 2 months later, PG developed in both lower limbs. Previous treatments with adalimumab and steroids were ineffective for PG and UC, and simultaneously, the patient experienced headache, confusion, and severe sleep disturbances. After switching to upadacitinib (UPA) 45 mg/day, PG lesions showed complete healing and fecal calprotectin was < 10 mu g/g after 7 weeks of treatment. Following approximately 12 weeks of UPA therapy, colonoscopy indicated that the patient had achieved mucosal healing. No adverse events occurred during UPA induction and maintenance therapy for 6 months with risperidone. CONCLUSION UPA treatment led to successful resolution of both intestinal and extra-intestinal manifestations in this patient with new-onset UC who had a history of SCZ. No adverse effects were observed with concurrent UPA and risperidone use.