Pyoderma Gangrenosum Treatment: A Steroid-Free Option
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Pyoderma gangrenosum (PG), a rare clinical lesion, is a morpholic description of an inflammatory response presenting as a reaction pattern in the skin. The lesions usually present on the lower extremities but also may appear on the trunk, upper extremities, face, and mouth. The papules, pustules, and plaques can evolve and resolve without passing through an ulcerative stage. Before ulceration, aspiration from these lesions shows no bacterial growth; the role of bacteria cultured from ulcerated lesions is that of secondary invaders or colonizers. Salient clinical features of PG are the rapid development of a necrotizing ulceration, pain, ulcer borders that are undermined and boggy and surrounded by bluish-red areola, and a waffled wound bed appearance. The ulcers heal with a cribriform type of scar. The clinical diagnosis characteristically involves histopathology as opposed to being pathogenic, with no specific laboratory changes.1
Pyoderma gangrenosum is associated with patients with ulcerative colitis, but recent findings have expanded the association to other systemic diseases. Only about 50% of patients with PG have ulcerative colitis; PG has been associated with other bowel diseases such as Crohn’s disease, active chronic hepatitis, and diverticulitis. It also can be a cutaneous manifestation of a variety of different systemic diseases in association with myeloproliferative disorders, polyarthritis, rheumatoid arthritis, paraproteinemia (including multiple myeloma), drug reactions, and delayed altered hypersensitivity. In some cases, patients have no associated systemic disease.2
Until recently, determining the etiology of the lesions associated with PG was accomplished through a diagnosis of exclusion, wound biopsy, tissue culture to assess for secondary infection, and complete, detailed patient history. Treatment included control of the underlying disease process, standard local wound care, providing a clean, moist wound environment without debridement, and the use of corticosteroids, cyclosporins, and sulfones to prevent secondary infection.3 The use of high-dose corticosteroid therapy has many untoward effects/complications, including but not limited to central nervous system affects (eg, euphoria, insomnia, seizures, cerebrovascular); alteration of prothrombin time [PT] and international normalized ratio [INR]; heart failure, arrhythmias, thromboembolism; endocrine dysfunction (eg, cushingoid state and increased blood glucose levels that could lead to the onset of diabetes); gastro-intestinal effects (eg, peptic ulceration); delayed wound healing; acute adrenal insufficiency; and infection. After prolonged use of corticosteroids, sudden withdrawal can be fatal.4
As part of a clinical trial, the authors began using Hydrofera Blue™ (Hydrofera, Willimantic, Conn.), a PVA sponge with methylene blue and gentian violet bound to the foam (components that have been used for more than 50 years), on Wound Care Center patients. As the clinical trial began, some remarkable, almost immediate results were noted, including the flattening of rolled wound edges, decreased inflammation, decreased pain (by 50% to 75%) within the first week of treatment, decreased (from 100% to less than 20%) fibrin covering the wound bed, and the presence of beefy red granulation tissue. The new epithelialization appeared from week to week, noted by the slightly blue hue noted in the new epithelial cells.
Within the first 2 weeks of the initial study, the authors decided to try the product on Ms. K.
1. Bennett ML, Jackson JM, Jorizzo JL, et al. Pyoderma gangrenosum. A comparison of typical and atypical forms with emphasis on time to remission. Case review of 86 patients from 2 institutions. Medicine (Baltimore). 2000;79(1):37–46
2. Falabella A, Falanga V. Uncommon causes of ulcers. Pyoderma gangrenosum. Clinics in Plastic Surgery. 1998;25(3):473–474.
3. Hall WL. Jr. Curative Health Services Clinical Conference. Maximum Impact, Clinical Pathway/Assessment by Etiology. Dallas, Tex.: March 2003.
4. Corticosteroids. Nursing 99 Drug Handbook. 1999;673–679