Cath Lab Digest

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Index: Ostomy Wound Manage. 2012;58(9):44–48.

Abstract

  Pyoderma gangrenosum (PG), an uncommon inflammatory and ulcerative skin disease, typically is treated medically with a combination of immunosuppression and local wound care, but evidence to guide care is limited. PG wounds can be difficult to heal. A 76-year-old male patient presented with a history of rheumatoid arthritis and recalcitrant PG. After 9 months of treatment with local wound care, steroids, and topical tacrolimus, the wound had increased in size from 1.8 cm x 1.5 cm to 7.2 cm x 5.6 cm. At that time, he was started on a regimen of five applications of a bioengineered cell-based product (one application every 2 weeks for a total of five applications) with twice-weekly mechanically powered negative pressure device changes. The latter was started at 75 mm Hg and changed to 125 mm Hg after 4 weeks. Oral corticosteroid therapy was initially started at 40 mg of prednisone, then slowly tapered to 20 mg, but could not be completely discontinued due to a flare in the patient’s rheumatoid symptoms. The wound was completely healed after 16 weeks. Research to ascertain the effectiveness of protocols of PG care, including the combination treatment described, is needed to help clinicians provide evidence-based care for these challenging wounds.

Keywords: case report, pyoderma gangrenosum, negative-pressure wound therapy, artificial skin, wounds

Potential Conflicts of Interest: This material is the result of work supported with resources from and the use of facilities at the Southern Arizona VA Medical Center.

Introduction

  Pyoderma gangrenosum (PG) is an uncommon inflammatory and ulcerative skin disease.¹ The disease is classified as a neutrophilic dermatosis; approximately 50% of patients who develop PG have systemic diseases, including inflammatory bowel disease, hematologic malignancies, and arthritis.² Typical PG lesions begin with folliculocentric pustules or fluctuant nodules with an inflammatory halo that expands peripherally to form an ulcer with sharply circumscribed violaceous raised edges, usually affecting the lower extremities and trunk.³ These lesions are typically painful and tender because the patient usually does not have neuropathy.² Diagnosis is based on a clinical-histological approach to exclude other ulcerative processes involving dermal neutrophilia.²

  The current mainstay of PG empirical treatment is long-term immunosuppression with high doses of corticosteroids or low doses of cyclosporine.^4,5 Surgical management of PG is controversial because of the phenomenon of pathergy, which results in the emergence of new PG lesions or the rapid expansion of existing ulcerative PG in response to any type of trauma, such as surgery. When pathergy occurs, PG can mimic postsurgical wound ulceration or spontaneous dehiscence.⁶

Negative Pressure in Wound Healing

  Negative pressure wound therapy (NPWT) is now commonly used in the management of large, complex, acute, and chronic skin ulcers from a wide variety of causes.⁵ At least three randomized controlled trials demonstrate the efficacy of NPWT as a primary treatment for nonhealing skin ulcers.^7-10 In 1997, Argenta and Morykwas⁷ reported that of 300 chronic, subacute, and acute wounds treated, 296 responded “favorably to subatmospheric pressure” and had increased granulation tissue.