Notes on Practice: Pyoderma Gangrenosum Treatment: A Steroid-Free Option

Background

   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.

Case Study 1: History/Diagnosis

   Ms. K is a 65-year-old female with multiple long-standing chronic ulcers. Ms K’s comorbidities include rheumatoid arthritis, multiple drug allergies, hypertension, and chronic pain. Before her treatment at the Wound Care Center, Ms. K’s ulcer care had included many treatment modalities over the previous 3 years: Silvadine (Monarch, Bristol, Tenn.); hydrogel dressings, Vaseline gauze (Tyco HealthCare/Kendall, Mansfield, Mass.); wet-to-dry dressings; and antibiotic ointment. She had endured the ulcers for more than 12 months before becoming a patient of the Wound Care Center. At this time, a diagnosis of Pyoderma gangrenosum was made by biopsy (see Figure 1).

Treatment

   Clinicians began treating Ms. K with the foam wound dressing on September 25, 2002. Within 24 hours of beginning treatment, epibole edges had flattened, and after 1 week of treatment, Ms. K’s pain (as measured on a numeric pain scale) was reduced by 50%. By November 20, 2002, the wound had converted to two smaller wounds, with visible new epithelialization (see Figure 2). The blue hue noted is from the pigments in the dressing. By this point in the treatment, Ms. K’s pain was almost gone. She was declared healed on January 22, 2003 (see Figure 3).

Prognosis/Conclusion

   Because Ms. K fared so well with this product alone, the authors initiated adjunctive studies on PG patients across the country, utilizing the same wound dressing. In their initial 20-week follow-up study at the Wound Care Center, 20 patients (some with multiple wounds) completed the study; 16 experienced complete healing and four patients who healed 10 out of their 16 wounds. All of the patients reported a pain reduction of at least 50% (as measured on a numeric pain scale) within the first week and no adverse reactions were noted.

   In another study conducted over 24 weeks, of the 10 initial patients with 23 wounds, eight patients (19 wounds) healed, and two patients did not heal but made great progress toward healing. All patients noted a 50% to 75% pain reduction in the first week with no adverse reactions noted during this study.

Case Study 2: History/Diagnosis

   An insect bit Miss B., a healthy 3-year-old female, during a trip to the Philippines. Miss B developed large wounds on all extremities. She was admitted to the hospital and all wounds were debrided. Miss B had used a variety of products, including a number of the silver dressings. A biopsy was performed and a diagnosis of Pyoderma gangrenosum was made. Miss B was placed on steroids and saw a total of 11 specialists but the wounds continued to worsen. Miss B’s father began researching Pyoderma on the Internet and found Hydrofera’s website, where success using the product for Pyoderma was noted. Miss B’s father contacted the company, which provided her physician with the dressings to treat Miss B. The Wound Care Center, working long-distance with photos taken by her father, lab reports that showed heavy growth of Pseudomonas, and wound documentation, assisted in Miss B’s treatment.

Treatment

   Miss B began using the foam wound dressings in November 2003 (see Figure 4). At the same time, Miss B also was started on antibiotic therapy to treat the Pseudomonas infection. In January 2004 (see Figure 5), Miss B was 70% healed, and in February 2004 Miss B was completely healed (see Figure 6).

Conclusion

   From the authors’ experience and observation, the wound dressing appears to have helped heal multiple cases of PG without the use of steroids and healed a variety of wounds including venous stasis, pilonidal cyst, trauma, and diabetic foot wounds, as well as heal necrotizing fasciitis. The authors now also are using the product on wounds infected with MRSA, VRE, and Candida albicans. Further study is encouraged and warranted.

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