With the addition of prednisone and azathioprine to her treatment regimen, the ulcer continued to progress. When the patient was seen in our office, her ulcer measured 20 × 12 cm with exposed muscle and tendons (Figure, A). She was admitted to the hospital, and hydroxyurea, prednisone, and azathioprine were permanently removed from her drug regimen. Vascular assessment failed to reveal significantly reduced arterial flow. After undergoing extensive surgical debridement and receiving intravenous antibiotics, she was discharged with a wound vacuum-assisted closure (VAC) device. Three months later, she underwent a split-thickness skin graft closure of the ulcer leading to complete resolution (Figure, B).