Current therapyManagement of pyoderma gangrenosum☆
Section snippets
Establishing the diagnosis
The diagnosis of PG may be difficult because of its protean morphologic manifestations. It is important to be aware of the clinical circumstances in which this disorder is likely to present. As with many other cutaneous disorders, establishing the diagnosis in PG requires:
- 1.
Recognition of the clinical features
- 2.
Performing a skin biopsy to reveal histologic findings consistent with PG
- 3.
Investigations to rule out other similar cutaneous eruptions.
The four main clinical types of PG are: Ulcerative,
Search for systemic disease
Categorising PG according to its predominant morphologic features is helpful as a guide to the possibility of underlying systemic disease. Thus, it has been shown in many series that the majority of patients (over 70%) with ulcerative PG will have an associated disease. Arthritis, inflammatory bowel disease, monoclonal gammopathy and internal malignancy are the most common associations [7]. As already outlined, eruptive pustular PG occurs almost exclusively in the setting of acute inflammatory
Stabilization of the patient
Patients who present to dermatologists with PG are often experiencing extremely painful and progressive destruction of their skin tissue. In many cases they have previously received inappropriate treatment which has proved to be of no benefit. They are usually frightened, insecure, and may have lost confidence in their medical care. Some may be experiencing adverse effects of previous therapies. Having established the diagnosis with as much certainty as possible, and while instigating the
Wound care
The principle guiding wound care in a patient with PG should be the avoidance of undue trauma or irritation of the wound surface, and the prevention of secondary infection. Local relief of pain using bland cleansing agents or topical steroids and the creation of a suitable milieu or environment to promote tissue growth with wound healing is important. In the initial evaluation of an ulcerative PG lesion it is important to document location, size, outline and depth as indicated earlier. Clinical
Topical and intralesional agents
Therapies used locally in the skin for lesions of PG are listed below:
Hyperbaric oxygen
Benzyl peroxide
Corticosteroids (topically/intralesional)
Disodium chromoglycate (topical)
Nicotine (topical)
Cyclosporin (intralesional)
Tacrolimus (topical/intralesional)
Macrophage colony stimulating factor (intralesional)
Human platelet-derived growth factor
Skin grafts
Cultured allografts/autografts
X-ray therapy
Local agents can be used in isolation in slowly progressive Vegetative PG lesions, or in combination
Systemic treatments
The majority of patients with PG will require systemic treatment to control their disease. This is particularly so in patients with either ulcerative or bullous PG. Patients with the explosive pustular variant of PG often show poor response to systemic treatment and require active intervention in the closely related acute inflammatory bowel disease to achieve control of their cutaneous lesions. Many patients with vegetative PG respond to local wound care, or require some of the milder systemic
Other approaches
Although it is important to have a logical and sequential approach to the management of a patient with PG, the unpredictable nature of this disease and its variation in aggressiveness in individual patients mean that a flexible approach must be adopted. Often more than one therapeutic agent will be required, and improvisation may be necessary if standard approaches fail to bring about satisfactory results. Thus treatments as diverse as plasma exchange, intestinal decontamination and Chinese
References (32)
- et al.
Pyoderma gangrenosum: Classification and management
J Am Acad Dermatol
(1996) - et al.
Pyoderma gangrenosum, polycythemia rubra vera, and the development of leukemia
J Am Acad Dermatol
(1992) - et al.
Superficial granulomatous pyoderma: a localized vegetative form of pyoderma gangrenosum
J Am Acad Dermatol
(1988) - et al.
Pyoderma gangrenosum
Clin Dermatol
(1993) - et al.
Treatment of pyoderma gangrenosum
J Am Acad Dermatol
(1996) - et al.
Pyoderma gangrenosum and its treatment
Lancet
(1997) Pyoderma gangrenosum
Lancet
(1998)- et al.
Recalitrant pyoderma gangrenosum treated with thalidomide
Mayo Clin Proc
(2000) - et al.
Peristomal pyoderma gangrenosum
J Am Acad Dermatol
(1992) - et al.
Pyoderma gangrenosum after aortic valve replacement
Ann Thorac Surg
(2001)
Pyoderma gangrenosum after cesarean delivery
Am J Obstet Gynecol
Pyoderma gangrenosum: A review of 86 patients
Quarterly J Med, New Series 55
Bullous pyoderma gangrenosum and leukaemia
Arch Dermatol
Pyoderma gangrenosum: A case study for pain management in dermatology nursing
Dermatology Nursing
Pyoderma gangrenosum treated with hyperbaric oxygen therapy
Int J Dermatol
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- ☆
Bruce H. Thiers, MD, Consulting Editor