EVIEWS

Pyoderma gangrenosum: A review and update

on new therapies

a Brad A. Yentzer, MD,a Adele Clark, PA-C,a Joseph L. Jorizzo, MD,

a

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.)

adalimumab; alefacept; clinical trials; efalizumab; etanercept; infliximab.

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,

1

Diagnosis can be difficult,

and the biopsy specimen does not provide any

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,

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

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.

Furthermore, these occlusive dressings are

6

Creating a barrier to infection is particularly relevant

in PG as many of its systemic treatments (eg, steroids,

a Pathology,b

and Public

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:

.

0190-9622/$36.00

2009 by the American Academy of Dermatology, Inc.

doi:10.1016/j.jaad.2009.05.030

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