From the Guidelines
Pyoderma gangrenosum should be treated with systemic corticosteroids as the first line of treatment, with anti-TNF treatment, such as infliximab or adalimumab, considered if a rapid response to corticosteroids is not achieved. This approach is based on the most recent evidence from the Journal of Crohn's and Colitis, which recommends corticosteroids as the primary treatment option, with anti-TNF treatment as a secondary option for non-responsive cases 1.
Diagnosis and Treatment Considerations
When diagnosing pyoderma gangrenosum, it is essential to consider the condition's association with inflammatory bowel disease, rheumatoid arthritis, and hematologic malignancies, which are present in up to 50% of cases. The characteristic violaceous, undermined border of the ulcer and the presence of pathergy (worsening with trauma) are critical diagnostic features.
Treatment Options
The treatment options for pyoderma gangrenosum include:
- Systemic corticosteroids, such as prednisone, as the first line of treatment
- Anti-TNF treatment, such as infliximab or adalimumab, for non-responsive cases
- Topical or oral calcineurin inhibitors as an alternative, although dermatological advice is recommended prior to prescription 1
- Local wound care, including gentle cleansing, moisture-retentive dressings, and pain management
Important Considerations
It is crucial to avoid surgical debridement due to the risk of pathergy, which can worsen the condition. Treatment should continue until complete healing occurs, which may take months, followed by a slow taper of immunosuppression to prevent recurrence. Regular monitoring for underlying conditions and adjustment of treatment as needed is also essential.
From the Research
Diagnosis of Pyoderma Gangrenosum
- Pyoderma gangrenosum is a noninfectious neutrophilic dermatosis that usually starts with sterile pustules which rapidly progress to painful ulcers of variable depth and size with undermined violaceous borders 2
- Diagnosis of pyoderma gangrenosum is based on a history of an underlying disease, typical clinical presentation and histopathology, and exclusion of other diseases that would lead to a similar appearance 2
- The disease is often associated with an underlying disease, most commonly inflammatory bowel disease, rheumatological or hematological disease or malignancy, in 17 to 74% of cases 2
Treatment of Pyoderma Gangrenosum
- The treatments with the best clinical evidence are systemic corticosteroids (in the initial phase usually 100 to 200 mg/day) and cyclosporine (mainly as a maintenance treatment) 2
- Combinations of corticosteroids with cytotoxic drugs such as azathioprine, cyclophosphamide or chlorambucil are used in patients with disease that is resistant to corticosteroids 2
- Alternative treatments include local application of granulocyte-macrophage colony-stimulating factor, intravenous immunoglobulins and plasmapheresis 2
- Biologics such as the TNFα inhibitors infliximab, adalimumab, and etanercept; the interleukin (IL) 12/23 antibody ustekinumab; the IL-1 receptor antagonist anakinra; and the IL-1β antibody canakinumab are also used as treatment options 3
- Topical therapy with modern wound dressings is useful to minimize pain and the high risk of secondary infection 2
Management of Pyoderma Gangrenosum
- The management of pyoderma gangrenosum requires a structured approach to establishing diagnosis of the disease and assessment of the patient 4
- Clinical management of active PG lesions should be carried out in coordination with other specialists (such as nurses and pain managers) and often necessitates a flexible, innovative attitude to therapy 4
- The optimal treatment of pyoderma gangrenosum includes a combination of local wound care and systemic medications 5
- Targeted therapy is therefore lacking and currently treatment is largely empirical and consists of corticosteroids and ciclosporin first line 6