Attack Pyoderma Gangrenosum With an Array of Treatment Options

CHICAGO - A multimodal approach is usually necessary to shut down the destructive progress of pyoderma gangrenosum and induce wound healing.

“The primary, No. 1 issue is shutting down the inflammation that causes the wound to continually expand,” Dr. Laura Winterfield said. “Second in importance is pain control. These patients have a very high level of pain, which is sometimes out of proportion to the size of the lesion.”

Once the inflammatory process halts and pain is under control, physicians can address any behaviors or concomitant disorders that might interfere with healing.

A long list of options is available to control inflammation, “which is usually an indication that no one treatment works in everyone all the time,” said Dr. Winterfield a dermatologist at Brigham and Women’s Hospital, Boston. “Corticosteroids and cyclosporine are usually the first lines of therapy, but there are not really any data saying that they are better than anything else.”

A small randomized controlled trial examined the use of infliximab for the treatment of pyoderma gangrenosum. Thirty patients were randomized to infliximab (13) or placebo (17). At week 2, significantly more patients in the infliximab group had improved (46% vs. 6% placebo, respectively). After 2 weeks, nonresponders in the placebo group were offered infliximab; of 29 of the 30 patients being treated with infliximab at 6 weeks, 69% reported improvement. The remission rate at 6 weeks was 21% (Gut 2006; 55:505-9).

In patients with a history of pyoderma gangrenosum, early lesions can sometimes be controlled with topical or intralesional corticosteroids, calcineurin inhibitors, topical cyclosporine in the form of ophthalmic drops, or dapsone gel.

Minocylcine is also a possibility. “We’ve had a fair amount of success in our patients. It’s fairly well-tolerated and is a good choice where immunosuppression is a concern,” she said.

Dapsone gel can also be helpful. “It can be quite useful for patients who are reluctant to use immunosuppressive agents,” said Dr. Winterfield. She cited one patient who responded so well to dapsone gel that she was later able to undergo an autologous skin graft.

Shutting down pain is also critically important. “Dermatologists don’t think about treating pain as often as other specialties, so work with your pain management colleagues on this. Send patients for consult early in therapy. Controlling pain makes them feel you are much more invested in their care.”

After wound inflammation and pain are controlled, nonstick dressings are a necessity. Dry or wet-to-dry dressings can pull on healing tissue and reactive the inflammatory process. Dressing impregnated with silver or iodine can help prevent superinfection of the lesion.

Cyclosporine ophthalmic drops can also help some. “Drip the liquid right into the wound,” she said. Topical tacrolimus and dapsone gel applied to the wound edges are often helpful. “For a wound that’s ‘stuck’ and won’t heal, you can try a topical recombinant human platelet–derived growth factor.”

Although many are hesitant to surgically debride pyoderma lesions, some patients can tolerate gentle curette debridement once inflammation and pain have stabilized. Enzymatic debridement is an option for patients with a thick wound eschar interfering with topical medications. “Collagenase can soften the eschar and help you remove it so those medicines can get in there and work better,” she said.

Skin grafting may be necessary for some wounds, but autologous grafts can set up another pyoderma lesion at the harvest site. Engineered allograft may make more sense for some patients.

Finally, she said, it’s important to address other issues that might interfere with healing—nutritional status, smoking, venous insufficiency, and poorly controlled diabetes. “Sometimes patients in a lot of pain don’t take in adequate calories and protein, which can be a problem. See what you can do about mitigating these other issues, and you may start to see some improvement.”

 Disclosures: Dr. Winterfield said she had no relevant financial conflicts.

CHICAGO - A multimodal approach is usually necessary to shut down the destructive progress of pyoderma gangrenosum and induce wound healing.

“The primary, No. 1 issue is shutting down the inflammation that causes the wound to continually expand,” Dr. Laura Winterfield said. “Second in importance is pain control. These patients have a very high level of pain, which is sometimes out of proportion to the size of the lesion.”

Once the inflammatory process halts and pain is under control, physicians can address any behaviors or concomitant disorders that might interfere with healing.

A long list of options is available to control inflammation, “which is usually an indication that no one treatment works in everyone all the time,” said Dr. Winterfield a dermatologist at Brigham and Women’s Hospital, Boston. “Corticosteroids and cyclosporine are usually the first lines of therapy, but there are not really any data saying that they are better than anything else.”

A small randomized controlled trial examined the use of infliximab for the treatment of pyoderma gangrenosum. Thirty patients were randomized to infliximab (13) or placebo (17). At week 2, significantly more patients in the infliximab group had improved (46% vs. 6% placebo, respectively). After 2 weeks, nonresponders in the placebo group were offered infliximab; of 29 of the 30 patients being treated with infliximab at 6 weeks, 69% reported improvement. The remission rate at 6 weeks was 21% (Gut 2006; 55:505-9).

In patients with a history of pyoderma gangrenosum, early lesions can sometimes be controlled with topical or intralesional corticosteroids, calcineurin inhibitors, topical cyclosporine in the form of ophthalmic drops, or dapsone gel.

Minocylcine is also a possibility. “We’ve had a fair amount of success in our patients. It’s fairly well-tolerated and is a good choice where immunosuppression is a concern,” she said.

Dapsone gel can also be helpful. “It can be quite useful for patients who are reluctant to use immunosuppressive agents,” said Dr. Winterfield. She cited one patient who responded so well to dapsone gel that she was later able to undergo an autologous skin graft.

Shutting down pain is also critically important. “Dermatologists don’t think about treating pain as often as other specialties, so work with your pain management colleagues on this. Send patients for consult early in therapy. Controlling pain makes them feel you are much more invested in their care.”

After wound inflammation and pain are controlled, nonstick dressings are a necessity. Dry or wet-to-dry dressings can pull on healing tissue and reactive the inflammatory process. Dressing impregnated with silver or iodine can help prevent superinfection of the lesion.

Cyclosporine ophthalmic drops can also help some. “Drip the liquid right into the wound,” she said. Topical tacrolimus and dapsone gel applied to the wound edges are often helpful. “For a wound that’s ‘stuck’ and won’t heal, you can try a topical recombinant human platelet–derived growth factor.”

Although many are hesitant to surgically debride pyoderma lesions, some patients can tolerate gentle curette debridement once inflammation and pain have stabilized. Enzymatic debridement is an option for patients with a thick wound eschar interfering with topical medications. “Collagenase can soften the eschar and help you remove it so those medicines can get in there and work better,” she said.

Skin grafting may be necessary for some wounds, but autologous grafts can set up another pyoderma lesion at the harvest site. Engineered allograft may make more sense for some patients.

Finally, she said, it’s important to address other issues that might interfere with healing—nutritional status, smoking, venous insufficiency, and poorly controlled diabetes. “Sometimes patients in a lot of pain don’t take in adequate calories and protein, which can be a problem. See what you can do about mitigating these other issues, and you may start to see some improvement.”

 Disclosures: Dr. Winterfield said she had no relevant financial conflicts.

CHICAGO - A multimodal approach is usually necessary to shut down the destructive progress of pyoderma gangrenosum and induce wound healing.

“The primary, No. 1 issue is shutting down the inflammation that causes the wound to continually expand,” Dr. Laura Winterfield said. “Second in importance is pain control. These patients have a very high level of pain, which is sometimes out of proportion to the size of the lesion.”

Once the inflammatory process halts and pain is under control, physicians can address any behaviors or concomitant disorders that might interfere with healing.

A long list of options is available to control inflammation, “which is usually an indication that no one treatment works in everyone all the time,” said Dr. Winterfield a dermatologist at Brigham and Women’s Hospital, Boston. “Corticosteroids and cyclosporine are usually the first lines of therapy, but there are not really any data saying that they are better than anything else.”

A small randomized controlled trial examined the use of infliximab for the treatment of pyoderma gangrenosum. Thirty patients were randomized to infliximab (13) or placebo (17). At week 2, significantly more patients in the infliximab group had improved (46% vs. 6% placebo, respectively). After 2 weeks, nonresponders in the placebo group were offered infliximab; of 29 of the 30 patients being treated with infliximab at 6 weeks, 69% reported improvement. The remission rate at 6 weeks was 21% (Gut 2006; 55:505-9).

In patients with a history of pyoderma gangrenosum, early lesions can sometimes be controlled with topical or intralesional corticosteroids, calcineurin inhibitors, topical cyclosporine in the form of ophthalmic drops, or dapsone gel.

Minocylcine is also a possibility. “We’ve had a fair amount of success in our patients. It’s fairly well-tolerated and is a good choice where immunosuppression is a concern,” she said.

Dapsone gel can also be helpful. “It can be quite useful for patients who are reluctant to use immunosuppressive agents,” said Dr. Winterfield. She cited one patient who responded so well to dapsone gel that she was later able to undergo an autologous skin graft.

Shutting down pain is also critically important. “Dermatologists don’t think about treating pain as often as other specialties, so work with your pain management colleagues on this. Send patients for consult early in therapy. Controlling pain makes them feel you are much more invested in their care.”

After wound inflammation and pain are controlled, nonstick dressings are a necessity. Dry or wet-to-dry dressings can pull on healing tissue and reactive the inflammatory process. Dressing impregnated with silver or iodine can help prevent superinfection of the lesion.

Cyclosporine ophthalmic drops can also help some. “Drip the liquid right into the wound,” she said. Topical tacrolimus and dapsone gel applied to the wound edges are often helpful. “For a wound that’s ‘stuck’ and won’t heal, you can try a topical recombinant human platelet–derived growth factor.”

Although many are hesitant to surgically debride pyoderma lesions, some patients can tolerate gentle curette debridement once inflammation and pain have stabilized. Enzymatic debridement is an option for patients with a thick wound eschar interfering with topical medications. “Collagenase can soften the eschar and help you remove it so those medicines can get in there and work better,” she said.

Skin grafting may be necessary for some wounds, but autologous grafts can set up another pyoderma lesion at the harvest site. Engineered allograft may make more sense for some patients.

Finally, she said, it’s important to address other issues that might interfere with healing—nutritional status, smoking, venous insufficiency, and poorly controlled diabetes. “Sometimes patients in a lot of pain don’t take in adequate calories and protein, which can be a problem. See what you can do about mitigating these other issues, and you may start to see some improvement.”

 Disclosures: Dr. Winterfield said she had no relevant financial conflicts.