Pyoderma Gangrenosum Treatment & Management

Updated: Sep 05, 2018
  • Author: J Mark Jackson, MD; Chief Editor: William D James, MD  more...
  • Print
Treatment

Approach Considerations

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

Topical therapies include gentle local wound care and dressings, superpotent topical corticosteroids, [20] cromolyn sodium 2% solution, nitrogen mustard, and 5-aminosalicylic acid. The topical immune modifiers tacrolimus and pimecrolimus may have some benefit in certain patients. [21]

Systemic therapies include corticosteroids, cyclosporine, [22, 23, 24] mycophenolate mofetil, [25, 26, 27] azathioprine, [28] dapsone, tacrolimus, cyclophosphamide, chlorambucil, [29] thalidomide, tumor necrosis factor-alpha (TNF-alpha) inhibitors (eg, thalidomide, etanercept, infliximab, adalimumab, [30] clofazimine [31] ), and nicotine.

Intravenous (IV) therapies include pulsed methylprednisolone, [32] pulsed cyclophosphamide, [33] infliximab, [34, 35, 36, 37] IV immunoglobulin, [38] and ustekinumab. [39] Other therapies include hyperbaric oxygen. [40]

Canakinumab proved effective in a patient with concomitant hidradenitis suppurativa. [41]

Other new biologic agents are currently in early trials and may be helpful for treating pyoderma gangrenosum along with other inflammatory conditions.

Surgery

Surgery should be avoided, if possible, because of the pathergic phenomenon that may occur with surgical manipulation or grafting, resulting in wound enlargement. [42] Pathergy is seen in about 30% of cases. In some patients, grafting has resulted in the development of pyoderma gangrenosum at the harvest site. In cases in which surgery is required, the best plan, if possible, is to have the patient on therapy, and active disease under control, in order to prevent pathergy.

Some patients with ulcerative colitis have responded to total colectomy; in other patients, however, the disease is peristomal and occurs following bowel resection.

Transfer

Care of the patient with pyoderma gangrenosum is often referred from the general dermatologist to tertiary centers where such patients are seen more frequently.

Follow-up

Patients with pyoderma gangrenosum should receive follow-up care on a regular basis to monitor drug therapy and to measure the size of the lesion or lesions. Multiple methods of wound care are available.

Activity

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

Next:

Consultations

Working with the primary care physician is wise for all patients. Depending on patient findings, however, other specialists may need to be consulted, including the following:

  • Gastroenterologist or GI surgeon, proctorectal surgeon, or general surgeon - For 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

Previous