Treatment of Pyoderma Gangrenosum
Systemic corticosteroids are the first-line therapy for pyoderma gangrenosum, with anti-TNF agents such as infliximab or adalimumab reserved for cases that do not respond rapidly to corticosteroids. 1
Initial Diagnosis and Assessment
Pyoderma gangrenosum (PG) is a diagnosis of exclusion characterized by:
- Initial pustules that rapidly progress to painful ulcers
- Violaceous undermined borders
- Ulcer size ranging from 2-20 cm in diameter
- Sterile purulent material within ulcers
- Possible exposure of deeper tissues (tendons, muscles)
- Pathergy (development of lesions at trauma sites)
Key diagnostic considerations:
- Exclude other causes of skin ulceration (ecthyma, necrotizing vasculitis, arterial/venous insufficiency)
- Screen for associated conditions, particularly inflammatory bowel disease (IBD)
- Biopsy from periphery of lesion to help exclude other disorders
Treatment Algorithm
First-Line Treatment
- Systemic corticosteroids (100-200 mg/day initially) 1
- Aim for rapid response to prevent extensive tissue damage
- Monitor for steroid-related adverse effects
- Taper once clinical improvement is evident
Second-Line Treatment (if rapid response to corticosteroids not achieved)
- Anti-TNF therapy 1
- Infliximab 5 mg/kg (showed 46% improvement at week 2 vs. 6% with placebo)
- Adalimumab
- Response rates >90% with short duration PG (<12 weeks)
Adjunctive/Refractory Cases
Calcineurin inhibitors 1
- Oral cyclosporine
- Oral or IV tacrolimus
- Topical tacrolimus or pimecrolimus
Other immunosuppressants
- Azathioprine
Wound Care Management
Collaborate with wound care specialists 1
- Use modern wound dressings that minimize pain and risk of secondary infection
- Avoid unnecessary trauma to prevent pathergy
- Gentle cleansing without sharp debridement 2
- Limited topical antibacterial use
- Maintain moist environment to promote epithelial migration
Tailor dressing selection based on wound characteristics: 2
- Superficial vs. deep wounds
- Exudative nature
- Presence of eschar
- Granulation tissue
- Colonization status
Consider compression therapy to decrease edema and overgranulation 2
Monitoring and Follow-up
- Regular assessment of wound healing progress 1
- Monitor for:
- Secondary infection
- Medication side effects
- Disease recurrence (occurs in >25% of cases, often at the same site)
Associated Conditions Management
- If PG is associated with underlying disease (particularly IBD), treat the underlying condition 1
- For peristomal PG in IBD patients, closure of the stoma might lead to resolution 1
Important Caveats
- Dermatology consultation is strongly recommended for management 1
- Avoid surgical debridement due to risk of pathergy (worsening of lesions with trauma) 2
- PG is frequently misdiagnosed, leading to inappropriate treatments and delayed healing 3
- Disease course can be mild or malignant, chronic or relapsing with significant morbidity 4
- Tuberculosis screening should be performed before initiating anti-TNF therapy 1