eMedicine Specialties > Dermatology > Reactive & Inflammatory Dermatoses

Pyoderma Gangrenosum: Treatment & Medication

Author: J Mark Jackson, MD, Clinical Professor of Medicine/Dermatology, Division of Dermatology, University of Louisville
Coauthor(s): Jeffrey P Callen, MD, Professor of Medicine, Chief, Division of Dermatology, University of Louisville School of Medicine
Contributor Information and Disclosures

Updated: Dec 8, 2009

Treatment

Medical Care

No specific therapy is uniformly effective for patients with pyoderma gangrenosum (PG). In patients with an associated underlying disease, the effective therapy of the associated condition may be associated with a control of the cutaneous process as well.

  • Topical therapies include local wound care and dressings, superpotent topical corticosteroids,11 cromolyn sodium 2% solution, nitrogen mustard, and 5-aminosalicylic acid. The new topical immune modifiers tacrolimus and pimecrolimus may have some benefit in certain patients.12
  • Systemic therapies include corticosteroids, cyclosporine,13,14,15 mycophenolate mofetil,16,17 azathioprine,18 dapsone, tacrolimus, cyclophosphamide, chlorambucil,19 thalidomide, tumor necrosis factor-alpha (TNF-alpha) inhibitors, and nicotine.
  • Intravenous therapies include pulsed methylprednisolone,20 pulsed cyclophosphamide,21 infliximab,22,23,24 and intravenous immune globulin.25
  • Other therapy includes hyperbaric oxygen.

Surgical Care

  • Surgery should be avoided, if possible, because of the pathergic phenomenon that may occur with surgical manipulation or grafting, resulting in wound enlargement. In some patients, grafting has resulted in the development of pyoderma gangrenosum at the harvest site. In the cases in which surgery is required, the best plan, if possible, is to have the patient on therapy in order to prevent pathergy.
  • Some patients with ulcerative colitis have responded to total colectomy; however, in others, the disease is peristomal and occurs following bowel resection.

Consultations

  • Depending on the findings in the patient, other specialists may be consulted. Working with the primary care physician is wise for all patients.
    • Gastroenterologist or GI surgeon, proctorectal surgeon, or general surgeon in patients with inflammatory bowel disease
    • Rheumatologist for patients with arthritis
    • Ophthalmologist if ocular disease is present
    • Hematologist/oncologist when preleukemia, leukemia, monoclonal gammopathy, or other neoplasm is associated
    • Plastic surgeon or general surgeon when debridement or grafting is deemed necessary

Diet

No special dietary needs are required.

Activity

Patients should maintain their range of motion and perform all activities that they are able to tolerate.

Medication

The goals of pharmacotherapy are to reduce morbidity and to prevent complications.

Glucocorticoids

These agents have anti-inflammatory properties and cause profound and varied metabolic effects. In addition, these agents modify the body's immune response to diverse stimuli.


Prednisone (Deltasone, Sterapred, Orasone)

DOC; may decrease inflammation by reversing increased capillary permeability and suppressing PMN activity. Methylprednisolone IV may be used in some patients.

Adult

0.5-2 mg/kg/d PO; taper as condition improves; single morning dose is safer for long-term use, but divided doses have more anti-inflammatory effect

Pediatric

4-5 mg/m2/d PO; alternatively, 0.05-2 mg/kg PO divided bid/qid; taper over 2 wk as symptoms resolve

Coadministration with estrogens may decrease clearance; when used with digoxin, digitalis toxicity secondary to hypokalemia may increase; phenobarbital, phenytoin, and rifampin may increase metabolism of glucocorticoids (consider increasing maintenance dose); monitor for hypokalemia with coadministration of diuretics

Documented hypersensitivity; viral, fungal, connective tissue, or tubercular skin infections; peptic ulcer disease; hepatic dysfunction; GI disease

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Closely monitor blood sugar levels in patients with diabetes; patients with potentially long course of therapy should have a PPD placed and read prior to therapy or within first 2 wk of therapy; routinely check blood pressure in patients with high blood pressure; caution in history of tuberculosis, osteoporosis, peptic ulcer disease, and psychological problems; aseptic necrosis may occur

Immunosuppressives

These agents have immunomodulatory effects.


Cyclosporine (Sandimmune, Neoral)

Demonstrated to be helpful in a variety of skin disorders. Most effective steroid-sparing agent. Also used as primary therapy in some patients.

Adult

3-5 mg/kg/d PO/IV, sometimes initial loading therapy at 10-12 mg/kg/d is useful for first 3-5 d

Pediatric

Administer as in adults

Carbamazepine, phenytoin, isoniazid, rifampin, and phenobarbital may decrease concentrations; azithromycin, itraconazole, nicardipine, ketoconazole, fluconazole, erythromycin, verapamil, grapefruit juice, diltiazem, aminoglycosides, acyclovir, amphotericin B, and clarithromycin may increase toxicity; acute renal failure, rhabdomyolysis, myositis, and myalgias increase when taken concurrently with lovastatin; high-dose methylprednisolone may increase risk of seizures when used concomitantly; concomitant use of ACE inhibitors and cyclosporine may decrease renal function

Documented hypersensitivity; uncontrolled hypertension or malignancies; do not administer concomitantly with PUVA or UV-B radiation in psoriasis because it may increase risk of cancer

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Main adverse effects include, anaphylaxis (with IV use), hypertension, hepatotoxicity, nephrotoxicity, malignancy (lymphoproliferative type), gingival hyperplasia, hypomagnesemia, hyperkalemia, and hypertrichosis; check blood pressure at least monthly; monitor renal function by measuring serum creatinine levels at least monthly; reserve IV use only for patients who cannot take PO; infectious disease, pancreatitis, and paresthesia may occur; associated with arteriopathy and Raynaud phenomenon; vasoconstriction leading to mesenteric ischemia may occur
Optic disc edema, including papilledema, with possible visual impairment secondary to intracranial hypertension, has been reported in transplant patients (product information for Sandimmune oral soft gelatin cap, oral solution, injection for infusion, 2005)


Azathioprine (Imuran)

Another drug that may be effective as a steroid-sparing agent. Antagonizes purine metabolism and inhibits synthesis of DNA, RNA, and proteins. May decrease proliferation of immune cells, which results in lower autoimmune activity.

Adult

1-2 mg/kg/d (50-200 mg) PO

Pediatric

Administer as in adults

Toxicity increases with allopurinol; concurrent use with ACE inhibitors may induce severe leukopenia; may increase levels of methotrexate metabolites and decrease effects of anticoagulants, neuromuscular blockers, and cyclosporine; live virus vaccines may have a greater systemic effect; coadministration with other immunosuppressive agents may increase bone marrow suppression; increases in uric acid levels reported when administered concomitantly with tacrolimus

Documented hypersensitivity; low levels of serum TPMT; history of treatment with alkylating agents

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Reduce dose in patients with low TPMT levels; bone marrow suppression may occur; nausea and vomiting are commonly noted; may increase risk of lymphoproliferative disorders in patients treated with long-term therapy; cancer, hepatotoxicity, infectious disease, leukopenia, megaloblastic anemia, pancreatitis, and thrombocytopenia may occur


Mycophenolate (CellCept)

Inhibits purine synthesis and proliferation of human lymphocytes. May be used as steroid-sparing agent or as primary agent in patients that do not respond to first-line agents.

Adult

1-2 g/d PO

Pediatric

Not established

May elevate acyclovir and ganciclovir levels; antacids and cholestyramine decreases absorption, reducing levels (do not administer together); probenecid may increase levels; salicylates may increase toxicity

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Risk of lymphoma may increase in patients on long-term therapy; slightly higher rate of viral and bacterial infections is present while on therapy; GI disturbance and dose-related hematologic effects, including leukopenia, may occur; CellCept brand of oral susp contains aspartame, which is metabolized to phenylalanine (care should be taken if administered to patients with phenylketonuria)


Cyclophosphamide (Cytoxan)

Alkylating agent that depresses B-cell and T-cell function. Chemically related to nitrogen mustards. As an alkylating agent, the mechanism of action of the active metabolites may involve cross-linking of DNA, which may interfere with growth of normal and neoplastic cells.

Adult

1-2 mg/kg/d PO

Pediatric

Administer as in adults

Allopurinol may increase risk of bleeding or infection and enhance myelosuppressive effects; may potentiate doxorubicin-induced cardiotoxicity; may reduce digoxin serum levels and antimicrobial effects of quinolones; chloramphenicol may increase half-life of cyclophosphamide while decreasing metabolite concentrations; may increase effect of anticoagulants; coadministration with high doses of phenobarbital may increase rate of metabolism and leukopenic activity; thiazide diuretics may prolong cyclophosphamide-induced leukopenia and neuromuscular blockade by inhibiting cholinesterase activity

Documented hypersensitivity; severely depressed bone marrow function; pregnancy

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

GI upset and oral stomatitis may occur in up to 70% of patients; hemorrhagic cystitis possible, particularly if drug is given without hydration; azoospermia or anovulation may occur after prolonged therapy; alopecia and hyperpigmentation of nails and skin may occur; perform routine CBC counts and urinalysis; cardiomyopathy, infectious disease, interstitial pneumonia, Stevens-Johnson syndrome, and toxic epidermal necrolysis may occur; possibility of increased toxicity in adrenalectomized patients; be aware of possibility of cross-sensitivity with other alkylating agents
Patients with moderate renal failure (glomerular filtration rate [GFR] 10-50 mL/min) should receive 75% of normal dose given at usual dosage interval and patients with severe renal failure (GFR <10 mL/min) receive 50% of normal dose given at usual dosage interval (no dosage reduction required for mild renal failure (GFR >50 mL/min), although dosing interval should be increased to q12h; dosage may also be adjusted by increasing dosing interval as follows: GFR >10 mL/min, increase interval to >12 h; GFR <10 mL/min, increase interval to q18-24h; data show that patients with hepatic failure develop more toxicity with cyclophosphamide as opposed to patients with normal hepatic function


Chlorambucil (Leukeran)

Alkylates and cross-links strands of DNA, inhibiting DNA replication and RNA transcription. Used as primary or steroid-sparing agent.

Adult

4-6 mg/d PO

Pediatric

Not established

Additive effect with other immunosuppressive agents

Documented hypersensitivity; previous resistance to this medication; pregnancy

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Decreases immune response to live viral vaccines; lymphopenia and neutropenia may occur (monitor CBC counts regularly); metabolism is decreased in patients with impaired hepatic function; hepatotoxicity; infertility, leukemia, myelosuppression, pancytopenia, peripheral neuropathy, pneumonitis, and secondary malignant neoplastic disease may occur; avoid administration of live vaccines to immunocompromised persons; do not administer full dosage within 4 wk of completion of full course of radiation therapy or chemotherapy (risk of bone marrow damage)


Tacrolimus (Prograf)

Suppresses humoral immunity (T-lymphocyte) activity.

Adult

0.05 mg/kg/d IV or 0.15-0.30 mg/kg/d PO divided bid

Pediatric

0.1 mg/kg/d IV or 0.3 mg/kg/d PO

Diltiazem, nicardipine, clotrimazole, verapamil, erythromycin, ketoconazole, itraconazole, fluconazole, bromocriptine, grapefruit juice, metoclopramide, methylprednisolone, danazol, cyclosporine, cimetidine, and clarithromycin may increase levels; coadministration of rifabutin, rifampin, phenobarbital, phenytoin, and carbamazepine may reduce levels

Documented hypersensitivity; hypersensitivity to tacrolimus products or hydrogenated castor oil (if IV formulation used)

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Do not administer simultaneously with cyclosporine (tonic clonic seizures may occur); cardiomegaly, diabetes mellitus, hyperglycemia, hyperkalemia, hypertension, hypomagnesemia, prolonged QT interval, and malignant lymphoma may occur

Blood products

These agents are used to improve the clinical and immunologic aspects of the disease. They may decrease autoantibody production and increase solubilization and removal of immune complexes.


Immune globulins intravenous (Sandoglobulin, Gammagard, Gamimune)

Neutralize circulating myelin antibodies through anti-idiotypic antibodies; down-regulates proinflammatory cytokines, including INF-gamma; blocks Fc receptors on macrophages; suppresses inducer T and B cells and augments suppressor T cells; blocks complement cascade; and promotes remyelination. May increase CSF IgG (10%).

Adult

2 g/kg IV over 2-5 d

Pediatric

Administer as in adults

Increases toxicity of live virus vaccine (MMR) (do not administer within 3 mo of vaccine)

Documented hypersensitivity; IgA deficiency; anti-IgE/IgG antibodies

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Check serum IgA before IVIG (use an IgA-depleted product, eg, Gammagard S/D); infusions may increase serum viscosity and thromboembolic events; infusions may increase risk of migraine attacks, aseptic meningitis (10%), urticaria, pruritus, or petechiae (2-30 d postinfusion); increases risk of renal tubular necrosis in elderly patients and in patients with diabetes, volume depletion, and preexisting kidney disease; laboratory result changes associated with infusions include elevated antiviral or antibacterial antibody titers for 1 mo, 6-fold increase in ESR for 2-3 wk, and apparent hyponatremia

Immunomodulators

These agents have effects on the activity of the immune system.


Thalidomide (Thalomid)

Immunomodulatory agent that may suppress excessive production of TNF-alpha and may down-regulate selected cell-surface adhesion molecules involved in leukocyte migration. In patients <50 kg (110 lb), start at low end of dose regimen.

Adult

50-300 mg/d PO qd with water, preferably hs and at least 1 h pc; 50-200 mg usually yields results

Pediatric

Not established

May increase sedation of alcohol, barbiturates, chlorpromazine, and reserpine; because of teratogenic effects, women must use 2 additional methods of contraception or abstain from intercourse

Documented hypersensitivity; sexually active males not using latex condom (risk to fetus from semen of patients taking thalidomide unknown), women of childbearing potential not using 2 forms of contraception

Pregnancy

X - Contraindicated; benefit does not outweigh risk

Precautions

May cause sedation and an increase in vasoocclusive events; perform pregnancy test within 24-h period prior to initiating therapy (qwk during first month, followed by qmo tests in women with regular menstrual cycles or q2wk with irregular menstrual cycles); bradycardia may occur; use protective measures (eg, sunscreens, protective clothing) against exposure to sunlight or UV light (eg, tanning beds); prescribing physician must register with the "System for Thalomid Education and Prescribing Safety " (STEPS) program established by manufacturer; aplastic anemia, pancytopenia, anemia, leukopenia, neutropenia, thrombocytopenia, cancer, tuberculosis recurrence, and optic neuritis may occur


Etanercept (Enbrel)

Soluble p75 TNF receptor fusion protein (sTNFR-Ig). Inhibits TNF binding to cell surface receptors, thereby, decreasing inflammatory and immune responses.

Adult

50-100 mg SC qwk

Pediatric

0.4 mg/kg SC qwk

Documented hypersensitivity, sepsis, concurrent live vaccination, active granulomatous infection, heart failure, patients with demyelinating diseases

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Serious infections may develop and therapy should be discontinued if they occur; possible adverse effects include injection site pain, redness and swelling at injection site, and headaches; rare cases of lupuslike symptoms and heart failure reported (discontinue treatment if symptoms develop)


Infliximab (Remicade)

Chimeric IgG1k monoclonal antibody that neutralizes cytokine TNF-alpha and inhibits its binding to TNF-alpha receptor. Reduces infiltration of inflammatory cells and TNF-alpha production in inflamed areas

Adult

3-5 mg/kg IV infusion over 2-4 h
Initial induction dose then repeat at week 2, then week 6, then q6-8wk
May increase to 10 mg/kg IV q8wk for patients who respond, then lose their response; discontinue treatment in those who do not response by week 14

Pediatric

Administer as in adults

Crohn disease patients (adolescent and young adult) on concomitant treatment with azathioprine or 6-mercaptopurine have developed fatal hepatosplenic T-cell lymphomas; concomitant immunosuppressive therapy (risk of serious infection, including sepsis and pneumonia [some fatal cases]); concomitant use of infliximab and anakinra not recommended (increased risk for serious infection)

Documented hypersensitivity, congestive heart failure, active granulomatous disease, patients with history of tuberculosis or positive PPD test and are untreated, sepsis

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

TNF-alpha modulates cellular immune responses; anti-TNF therapies (eg, infliximab) may adversely affect normal immune responses and allow development of superinfections; more cases of lymphoma were observed in TNF-alpha blockers compared with control groups; may increase risk of reactivation of tuberculosis in patients with particular granulomatous infections; has been associated with lupus erythematosus; acute coronary syndrome, congestive heart failure, demyelinating disease of CNS or seizure disorder, hepatotoxicity, leukopenia, neutropenia, thrombocytopenia, and pancytopenia may occur; serum sickness – like reactions may occur upon reinstitution of infliximab therapy after extended period without therapy


Adalimumab (Humira)

TNF-alpha inhibitor. Fully human inhibitor of TNF-alpha administered by SC injection.

Adult

40 mg SC qwk or every other wk

Pediatric

Not established

Concomitant use of adalimumab and anakinra not recommended (serious infections have occurred with concomitant use); risk for severe infection with concurrent immunosuppressive therapy (live vaccines should not be given concurrently)

Documented hypersensitivity; rheumatoid arthritis, ulcerative colitis, psoriatic arthritis

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Aplastic anemia, cancer, demyelinating disease of CNS, erythrocytosis, formation of autoantibodies; systemic lupus – like syndrome, infectious disease, leukopenia, malignant lymphoma, pancytopenia, tuberculosis recurrence, paresthesia, and subdural hematoma may occur


Clofazimine (Lamprene)

Inhibits mycobacterial growth, binds preferentially to mycobacterial DNA. Has antimicrobial properties, but mechanism of action is unknown.

Adult

200-400 mg/d PO qd

Pediatric

1 mg/kg/d PO qd

Dapsone may inhibit anti-inflammatory activity; coadministration with antacids can result in reduced clofazimine bioavailability; may increase phenytoin clearance

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Severe abdominal symptoms may require exploratory laparotomies; caution in patients with GI problems (eg, abdominal pain, diarrhea); skin discoloration due to drug may result in depression or suicide; apply oil to skin for dryness and ichthyosis

More on Pyoderma Gangrenosum

Overview: Pyoderma Gangrenosum
Differential Diagnoses & Workup: Pyoderma Gangrenosum
Treatment & Medication: Pyoderma Gangrenosum
Follow-up: Pyoderma Gangrenosum
Multimedia: Pyoderma Gangrenosum
References
[ CLOSE WINDOW ]

References

  1. Brown TS, Marshall GS, Callen JP. Cavitating pulmonary infiltrate in an adolescent with pyoderma gangrenosum: a rarely recognized extracutaneous manifestation of a neutrophilic dermatosis. J Am Acad Dermatol. Jul 2000;43(1 Pt 1):108-12. [Medline].

  2. Ayyala RS, Armstrong S. Corneal melting and scleromalacia perforans in a patient with pyoderma gangrenosum and acute myeloid leukemia. Ophthalmic Surg Lasers. Apr 1998;29(4):328-31. [Medline].

  3. Happle R, Schiffer HP, Kövary PM. Ocular involvement in pyoderma gangrenosum. Arch Dermatol. Nov 1977;113(11):1612. [Medline].

  4. Graham JA, Hansen KK, Rabinowitz LG, Esterly NB. Pyoderma gangrenosum in infants and children. Pediatr Dermatol. Mar 1994;11(1):10-7. [Medline].

  5. Branagan NM, Higgins SP, Halim SA, Le TH. Systemic polyarteritis nodosa mimicking pyoderma gangrenosum in a rare association with small lymphocytic leukaemia/chronic lymphocytic leukaemia. Clin Exp Dermatol. Jul 2009;34(5):e127-9. [Medline].

  6. Namazi MR, Kerchner KR, Pichardo RO. Essential type II mixed cryoglobulinemia causing pyoderma gangrenosum-like ulcers. ScientificWorldJournal. 2008;8:228. [Medline].

  7. Vadillo M, Jucgla A, Podzamczer D, Rufi G, Domingo A. Pyoderma gangrenosum with liver, spleen and bone involvement in a patient with chronic myelomonocytic leukaemia. Br J Dermatol. Sep 1999;141(3):541-3. [Medline].

  8. Ahmad K, Ramsay B. Pyoderma gangrenosum associated with subcorneal pustular dermatosis and IgA myeloma. Clin Exp Dermatol. Jan 2009;34(1):46-8. [Medline].

  9. McCalmont CS, Leshin B, White WL, Greiss FC Jr, Jorizzo JL. Vulvar pyoderma gangrenosum. Int J Gynaecol Obstet. Jun 1991;35(2):175-8. [Medline].

  10. Brown TS, Marshall GS, Callen JP. Cavitating pulmonary infiltrate in an adolescent with pyoderma gangrenosum: a rarely recognized extracutaneous manifestation of a neutrophilic dermatosis. J Am Acad Dermatol. Jul 2000;43(1 Pt 1):108-12. [Medline].

  11. Nybaek H, Olsen AG, Karlsmark T, Jemec GB. Topical therapy for peristomal pyoderma gangrenosum. J Cutan Med Surg. Jul-Aug 2004;8(4):220-3. [Medline].

  12. Jackson JM. TNF- alpha inhibitors. Dermatol Ther. Jul-Aug 2007;20(4):251-64. [Medline].

  13. Fedi MC, Quercetani R, Lotti T. Recalcitrant pyoderma gangrenosum responsive to cyclosporine. Int J Dermatol. Feb 1993;32(2):119. [Medline].

  14. Matis WL, Ellis CN, Griffiths CE, Lazarus GS. Treatment of pyoderma gangrenosum with cyclosporine. Arch Dermatol. Aug 1992;128(8):1060-4. [Medline].

  15. Wilson DM, John GR, Callen JP. Peripheral ulcerative keratitis--an extracutaneous neutrophilic disorder:report of a patient with rheumatoid arthritis, pustular vasculitis,pyoderma gangrenosum, and Sweet''s syndrome with an excellent response tocyclosporine therapy. J Am Acad Dermatol. Feb 1999;40(2 Pt 2):331-4. [Medline].

  16. Daniels NH, Callen JP. Mycophenolate mofetil is an effective treatment for peristomal pyoderma gangrenosum. Arch Dermatol. Dec 2004;140(12):1427-9. [Medline].

  17. Eaton PA, Callen JP. Mycophenolate mofetil as therapy for pyoderma gangrenosum. Arch Dermatol. Jul 2009;145(7):781-5. [Medline].

  18. August PJ, Wells GC. Pyoderma gangrenosum treated with azathioprine and prednisolone. Br J Dermatol. 1974;91:80-2.

  19. Burruss JB, Farmer ER, Callen JP. Chlorambucil is an effective corticosteroid-sparing agent for recalcitrant pyoderma gangrenosum. J Am Acad Dermatol. Nov 1996;35(5 Pt 1):720-4. [Medline].

  20. Johnson RB, Lazarus GS. Pulse therapy. Therapeutic efficacy in the treatment of pyoderma gangrenosum. Arch Dermatol. Feb 1982;118(2):76-84. [Medline].

  21. Zonana-Nacach A, Jiménez-Balderas FJ, Martínez-Osuna P, Mintz G. Intravenous cyclophosphamide pulses in the treatment of pyoderma gangrenosum associated with rheumatoid arthritis: report of 2 cases and review of the literature. J Rheumatol. Jul 1994;21(7):1352-6. [Medline].

  22. Brooklyn TN, Dunnill MG, Shetty A, Bowden JJ, Williams JD, Griffiths CE, et al. Infliximab for the treatment of pyoderma gangrenosum: a randomised, double blind, placebo controlled trial. Gut. Apr 2006;55(4):505-9. [Medline].

  23. Kaur MR, Lewis HM. Severe recalcitrant pyoderma gangrenosum treated with infliximab. Br J Dermatol. Sep 2005;153(3):689-91. [Medline].

  24. Fernández A, Velasco A, Prieto V, Canueto J, Alvarez A, Rodríguez A. Response to Infliximab in Atypical Pyoderma Gangrenosum Associated With Ulcerative Colitis. Am J Gastroenterol. Aug 27 2008;[Medline].

  25. Cummins DL, Anhalt GJ, Monahan T, Meyerle JH. Treatment of pyoderma gangrenosum with intravenous immunoglobulin. Br J Dermatol. Dec 2007;157(6):1235-9. [Medline].

  26. Aractingi S, Mallet V, Pinquier L, Chosidow O, Vignon-Pennamen MD, Degos L, et al. Neutrophilic dermatoses during granulocytopenia. Arch Dermatol. Oct 1995;131(10):1141-5. [Medline].

  27. Bennett ML, Jackson JM, Jorizzo JL, Fleischer AB Jr, White WL, Callen JP. Pyoderma gangrenosum. A comparison of typical and atypical forms with an emphasis on time to remission. Case review of 86 patients from 2 institutions. Medicine (Baltimore). Jan 2000;79(1):37-46. [Medline].

  28. Cairns BA, Herbst CA, Sartor BR, Briggaman RA, Koruda MJ. Peristomal pyoderma gangrenosum and inflammatory bowel disease. Arch Surg. Jul 1994;129(7):769-72. [Medline].

  29. Callen JP. Pyoderma gangrenosum and related disorders. Med Clin North Am. Sep 1989;73(5):1247-61. [Medline].

  30. Callen JP. Pyoderma gangrenosum. Lancet. Feb 21 1998;351(9102):581-5. [Medline].

  31. Callen JP, Jackson JM. Pyoderma gangrenosum: an update. Rheum Dis Clin North Am. Nov 2007;33(4):787-802, vi. [Medline].

  32. Charles CA, Bialy TL, Falabella AF, Eaglstein WH, Kerdel FA, Kirsner RS. Poor prognosis of arthritis-associated pyoderma gangrenosum. Arch Dermatol. Jul 2004;140(7):861-4. [Medline].

  33. Chow RK, Ho VC. Treatment of pyoderma gangrenosum. J Am Acad Dermatol. Jun 1996;34(6):1047-60. [Medline].

  34. Dourmishev AL, Miteva I, Schwartz RA. Pyoderma gangrenosum in childhood. Cutis. Oct 1996;58(4):257-62. [Medline].

  35. Gettler S, Rothe M, Grin C, Grant-Kels J. Optimal treatment of pyoderma gangrenosum. Am J Clin Dermatol. 2003;4(9):597-608. [Medline].

  36. Goldstein F, Krain R, Thornton JJ. Intralesional steroid therapy of pyoderma gangrenosum. J Clin Gastroenterol. Dec 1985;7(6):499-501. [Medline].

  37. Hay CR, Messenger AG, Cotton DW, Bleehen SS, Winfield DA. Atypical bullous pyoderma gangrenosum associated with myeloid malignancies. J Clin Pathol. Apr 1987;40(4):387-92. [Medline].

  38. Hayani A, Steuber CP, Mahoney DH Jr, Levy ML. Pyoderma gangrenosum in childhood leukemia. Pediatr Dermatol. Dec 1990;7(4):296-8. [Medline].

  39. Holt PJ, Davies MG, Saunders KC, Nuki G. Pyoderma gangrenosum: clinical and laboratory findings in 15 patients with special reference to polyarthritis. Medicine (Baltimore). Mar 1980;59(2):114-33. [Medline].

  40. Hughes AP, Jackson JM, Callen JP. Clinical features and treatment of peristomal pyoderma gangrenosum. JAMA. Sep 27 2000;284(12):1546-8. [Medline].

  41. Hurwitz RM, Haseman JH. The evolution of pyoderma gangrenosum. A clinicopathologic correlation. Am J Dermatopathol. Feb 1993;15(1):28-33. [Medline].

  42. Jorizzo JL, Solomon AR, Zanolli MD, Leshin B. Neutrophilic vascular reactions. J Am Acad Dermatol. Dec 1988;19(6):983-1005. [Medline].

  43. Kaplan B, Trau H, Sofer E, Feinstein A, Schewach-Millet M. Treatment of pyoderma gangrenosum with clofazimine. Int J Dermatol. Aug 1992;31(8):591-3. [Medline].

  44. Keltz M, Lebwohl M, Bishop S. Peristomal pyoderma gangrenosum. J Am Acad Dermatol. 1993;27:360-64.

  45. Ko CB, Walton S, Wyatt EH. Pyoderma gangrenosum: associations revisited. Int J Dermatol. Aug 1992;31(8):574-7. [Medline].

  46. Koester G, Tarnower A, Levisohn D, Burgdorf W. Bullous pyoderma gangrenosum. J Am Acad Dermatol. Nov 1993;29(5 Pt 2):875-8. [Medline].

  47. McCulloch AJ, McEvoy A, Jackson JD, Jarvis EH. Severe steroid responsive pneumonitis associated with pyoderma gangrenosum and ulcerative colitis. Thorax. Apr 1985;40(4):314-5. [Medline].

  48. Powell FC, Schroeter AL, Su WP, Perry HO. Pyoderma gangrenosum: a review of 86 patients. Q J Med. May 1985;55(217):173-86. [Medline].

  49. Powell FC, Su WP, Perry HO. Pyoderma gangrenosum: classification and management. J Am Acad Dermatol. Mar 1996;34(3):395-409; quiz 410-2. [Medline].

  50. Prystowsky JH, Kahn SN, Lazarus GS. Present status of pyoderma gangrenosum. Review of 21 cases. Arch Dermatol. Jan 1989;125(1):57-64. [Medline].

  51. Rand RP, Olerud JE, Verrier ED. Pyoderma gangrenosum after coronary artery bypass grafting. Ann Thorac Surg. Apr 1993;55(4):1016-8. [Medline].

  52. Su WP, Davis MD, Weenig RH, Powell FC, Perry HO. Pyoderma gangrenosum: clinicopathologic correlation and proposed diagnostic criteria. Int J Dermatol. Nov 2004;43(11):790-800. [Medline].

  53. Takeuchi K, Kyoko H, Hachiya M, Ohara A, Tsukimoto I, Kanto H, et al. Pyoderma gangrenosum of the skin and respiratory tract in a 5-year-old girl. Eur J Pediatr. May 2003;162(5):344-5. [Medline].

  54. Tjandra JJ, Hughes LE. Parastomal pyoderma gangrenosum in inflammatory bowel disease. Dis Colon Rectum. Sep 1994;37(9):938-42. [Medline].

  55. Urano S, Kodama H, Kato K, Nogura K. Pyoderma gangrenosum with systemic involvement. J Dermatol. Jul 1995;22(7):515-9. [Medline].

  56. Urano S, Kodama H, Kato K, Nogura K. Pyoderma gangrenosum with systemic involvement. J Dermatol. Jul 1995;22(7):515-9. [Medline].

  57. Vidal D, Puig L, Gilaberte M, Alomar A. Review of 26 cases of classical pyoderma gangrenosum: clinical and therapeutic features. J Dermatolog Treat. Jun 2004;15(3):146-52. [Medline].

  58. Vignon-Pennamen MD, Wallach D. Neutrophilic disease: a review of extracutaneous manifestations. Eur J Dermatol. 1995;5:449-55.

  59. von den Driesch P. Pyoderma gangrenosum: a report of 44 cases with follow-up. Br J Dermatol. Dec 1997;137(6):1000-5. [Medline].

  60. Yoshida C, Kojima H, Ishigaki T, Katsura Y, Kaneko S, Suzukawa K, et al. Association of pyoderma gangrenosum and sterile osteomyelitis in a patient having myelodysplastic syndrome with der(1;7)(q10;q10). Eur J Haematol. Feb 2004;72(2):149-53. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

pyoderma gangrenosum, PG, classic PG, classic pyoderma gangrenosum, atypical PG, atypical pyoderma gangrenosum, pyostomatitis vegetans, vulvar pyoderma gangrenosum, penile pyoderma gangrenosum, peristomal pyoderma gangrenosum

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

J Mark Jackson, MD, Clinical Professor of Medicine/Dermatology, Division of Dermatology, University of Louisville
J Mark Jackson, MD is a member of the following medical societies: American Academy of Dermatology, American Acne and Rosacea Society, American Medical Association, Kentucky Medical Association, and Texas Medical Association
Disclosure: Nothing to disclose.

Coauthor(s)

Jeffrey P Callen, MD, Professor of Medicine, Chief, Division of Dermatology, University of Louisville School of Medicine
Jeffrey P Callen, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American College of Physicians, and American College of Rheumatology
Disclosure: Amgen Honoraria Consulting; Abbott Honoraria Consulting; Electrical Optical Sciences Honoraria Consulting; Centocor Honoraria Consulting; Medicis Honoraria Consulting; Celgene Honoraria Consulting

Medical Editor

David P Fivenson, MD, Associate Director, St Joseph Mercy Hospital Dermatology Program, Ann Arbor, Michigan
David P Fivenson, MD is a member of the following medical societies: American Academy of Dermatology, Medical Dermatology Society, Michigan Dermatological Society, Michigan State Medical Society, Photomedicine Society, Society for Investigative Dermatology, and Wound Healing Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Michael J Wells, MD, Associate Professor, Department of Dermatology, Texas Tech University Health Sciences Center
Michael J Wells, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, and Texas Medical Association
Disclosure: Nothing to disclose.

Managing Editor

Warren R Heymann, MD, Head, Division of Dermatology, Professor, Department of Internal Medicine, University of Medicine and Dentistry of New Jersey
Warren R Heymann, MD is a member of the following medical societies: American Academy of Dermatology, American Society of Dermatopathology, and Society for Investigative Dermatology
Disclosure: Nothing to disclose.

CME Editor

Joel M Gelfand, MD, MSCE, Medical Director, Clinical Studies Unit, Assistant Professor, Department of Dermatology, Associate Scholar, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania
Joel M Gelfand, MD, MSCE is a member of the following medical societies: Society for Investigative Dermatology
Disclosure: AMGEN Consulting fee Consulting; AMGEN Grant/research funds Investigator; Genentech Grant/research funds investigator; Centocor Consulting fee Consulting; Abbott Grant/research funds investigator; Abbott Consulting fee Consulting; Novartis  investigator; Pfizer Grant/research funds investigator; Celgene Consulting fee DMC Chair; NIAMS and NHLBI Grant/research funds investigator

Chief Editor

Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center
Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.