Pioderma Gangrenoso
R
EVIEWS
Pyoderma gangrenosum: A review and update
on new therapies
Jeremiah Miller, MD,
a Brad A. Yentzer, MD,a Adele Clark, PA-C,a Joseph L. Jorizzo, MD,
a
and Steven R. Feldman, MD, PhD
a,b,c
Winston-Salem, North Carolina
Pyoderma gangrenosum is a rare and often painful skin disease that can be unpredictable in its response to
treatment. There is currently no gold standard of treatment or published algorithm for choice of therapy.
The majority of data comes from case studies that lack a standard protocol not only for treatment
administration but also for the objective assessment of lesion response to a specific therapy. This review
provides an update to the treatment of pyoderma gangrenosum with a particular focus on new systemic
therapies. ( J Am Acad Dermatol 2010;62:646-54.)
Key words:
adalimumab; alefacept; clinical trials; efalizumab; etanercept; infliximab.
P
yoderma gangrenosum (PG) is a rare ulcerative
disorder of the skin that can cause pain,
disfigurement, and even death. PG is generally
classified into 4 types: classic (ulcerative), bullous,
pustular, and vegetative.
1
Diagnosis can be difficult,
and the biopsy specimen does not provide any
pathognomonic information.
2
The key in diagnosing
PG is excluding other causes of cutaneous ulcers
through biopsy, culture, and clinical acumen. Once
diagnosed, treatment should target any underlying
disease that is present (inflammatory bowel disease,
monoclonal gammopathy, hematologic malignancy
or paraproteinemia, Behc¸et disease, Sweet syndrome,
hepatitis, HIV, systemic lupus erythematosus,
pregnancy, and Takayasu arteritis).
1,3-5
Various drug regimens have been implemented
with success in PG. These often include complicated
combinations of steroids and other medications that
inhibit some component of the immune system. The
goal of this review is to provide an update on treating
PG in an effective and safe manner. Information was
gathered from textbooks, a PubMed and Ovid literature
search, and expert opinion. The PubMed and
Ovid searches were performed using a variety of
combined search terms including ‘‘pyoderma gangrenosum,’’
‘‘treatments,’’ ‘‘topical,’’ ‘‘biologics,’’
‘‘therapy,’’ ‘‘infliximab,’’ ‘‘etanercept,’’ ‘‘alefacept,’’
‘‘efalizumab,’’ and ‘‘adalimumab.’’
LOCAL WOUND MANAGEMENT
Effective management of PG ulcers is an objective
evaluation of the ulcers so that wound management
can be planned. At each visit, objective measurements
including depth, length, and width of the ulcer
should be recorded.
6
These measurements in
combination with sequential photography can then
serve as a gauge for wound management success.
The inflammatory component of PG is assessed by
the border elevation and lesion expansion. When the
border flattens, anti-inflammatory medications can
be slowly tapered.
Once a system for monitoring the lesions is in
place, a decision regarding wound dressing must be
made. Moisture-retentive dressings appear to be
superior to desiccative gauzes in that they provide
better pain control, induce collagen production,
facilitate autolytic debridement, and promote angiogenesis.
6
Furthermore, these occlusive dressings are
less permeable to external infection than gauze.
6
Creating a barrier to infection is particularly relevant
in PG as many of its systemic treatments (eg, steroids,
From the Departments of Dermatology,
a Pathology,b
and Public
Health Sciences,
c
Center for Dermatology Research, Wake
Forest University School of Medicine.
Astellas Pharma Global Development Inc provided support for the
preparation of this review. The Center for Dermatology Research
is supported by an unrestricted educational grant from
Galderma Laboratories LP.
Disclosure: Dr Feldman has received research, speaking, and/or
consulting support from Abbott Labs, American Society for
Dermatologic Surgery, Amgen, Astellas, Aventis Pharmaceuticals,
Biogen, Centocor, Connetics, Galderma, Genentech, Novartis,
and Roche. Dr Jorizzo has received speaking and/or
consulting support from Amgen. Dr Miller, Dr Yentzer, and Ms
Clark have no conflicts of interest to declare.
Reprints not available from the authors.
Correspondence to: Steven R. Feldman, MD, PhD, Department of
Dermatology, Wake Forest University School of Medicine,
Medical Center Blvd, Winston-Salem, NC 27157-1071. E-mail:
sfeldman@wfubmc.edu
.
0190-9622/$36.00
ª
2009 by the American Academy of Dermatology, Inc.
doi:10.1016/j.jaad.2009.05.030
646