From the Guidelines
Pyoderma gangrenosum should be treated with systemic corticosteroids, infliximab, or adalimumab, as these have been shown to be effective in rapidly healing the debilitating skin disorder. The treatment of Pyoderma gangrenosum (PG) typically involves a combination of wound care and immunosuppressive therapy. According to the European evidence-based consensus on extra-intestinal manifestations in inflammatory bowel disease 1, the therapeutic goal should be rapid healing, as PG can be a debilitating skin disorder.
Treatment Options
- Systemic corticosteroids are considered first-line treatment for PG, with oral ciclosporin and oral or intravenous tacrolimus reserved for refractory cases.
- Infliximab has been shown to be effective in the treatment of PG, with a multicentre, randomised, placebo-controlled trial demonstrating significant improvement in patients treated with infliximab compared to placebo 1.
- Adalimumab is also a viable treatment option for PG, although the evidence is not as extensive as it is for infliximab.
- Topical or oral calcineurin inhibitors may also be used in the treatment of PG, particularly for mild cases or as an adjunct to systemic therapy.
Wound Care and Management
- Wound care is crucial in the management of PG and should include gentle cleansing, moist dressings, and pain management.
- Surgical debridement should be avoided as it can worsen the condition due to pathergy (development of lesions at sites of trauma).
- Patients should be monitored regularly for response to treatment and potential side effects of immunosuppressive medications.
Diagnosis and Underlying Conditions
- Diagnosis of PG is primarily clinical and involves excluding other causes of ulceration through biopsy and cultures.
- Identifying and treating any underlying disease is essential for comprehensive management, as PG is often associated with underlying conditions like inflammatory bowel disease, rheumatoid arthritis, or blood disorders.
From the Research
Diagnosis of Pyoderma Gangrenosum
- Pyoderma gangrenosum (PG) is a rare, ulcerative inflammatory skin disease that most commonly occurs in patients with inflammatory bowel disease, rheumatologic diseases, or hematologic diseases 2
- The ulcers are exquisitely painful and characteristically have a necrotic centre with irregular overhanging bluish borders 3
- Biopsies of lesions show a predominantly neutrophilic infiltrate, and several aberrant immune processes have been described, with neutrophils and their recruitment to sites of inflammation by cytokines taking an apparently important role 3
Treatment of Pyoderma Gangrenosum
- The optimal treatment of pyoderma gangrenosum includes a combination of local wound care and systemic medications 4
- Oral and pulse intravenous corticosteroids have traditionally been the most commonly recommended first-line systemic therapies 4
- Cyclosporine, with or without corticosteroids, has more recently emerged as a first-line systemic treatment 4
- Topical and systemic therapies are both vital aspects of treatment, and in recent years, immune modulators have been used with increasing success, with an emerging role for anti-tumour necrosis factor alpha agents such as the monoclonal antibody infliximab 3
- Local wound care, avoidance of trauma and the application of local steroid or tacrolimus ointment are the first-line treatments 5
- Surgical therapy is difficult because of pathergy, but after having stopped the inflammation, the ulcers can be treated by split thickness skin grafts and simultaneous immunosuppression 6