Would you offer upfront radiation for a large painful keloid of the chest that has arisen from an irritated pyoderma gangrenosum lesion? 

Radiation therapy is actually used (rarely) for pyoderma gangrenosum that has been unresponsive to medical management via immunosuppression [1]. Single fraction doses of 400 to 800 cGy have been used with slow regression of the lesions. In the case report cited, the lesion started fading after 3 months, and completely cleared in one year after a single fraction of 800 cGy. Poor response to XRT has been blamed on inadequate doses (400 cGy or less).

We have much more literature for radiation therapy in the primary and postoperative treatment of keloids. Although most studies looked at wide local excision followed by XRT (and the literature supports surgery followed by XRT as the most effective treatment [2]), Malaker et al. [3], in a retrospe...