Materiały źródłowe

• #1 Pyoderma gangrenosum: Treatment and prognosis – UpToDate

  https://www.uptodate.com/contents/pyoderma-gangrenosum-treatment-and-prognosis

  Pyoderma gangrenosum: Treatment and prognosis […] Although multiple local and systemic therapies have been utilized for PG, high-quality efficacy studies are lacking for most interventions. Topical corticosteroids, systemic corticosteroids, and cyclosporine are common initial therapies (algorithm 1). […] In general, after the diagnosis of PG is made, patients are managed with a combination of pharmacologic therapies that suppress the inflammatory process and wound care measures that optimize the environment for wound healing. […] Major principles of treatment include:

• #2 Diagnosis and treatment of pyoderma gangrenosum

  https://pmc.ncbi.nlm.nih.gov/articles/PMC1513476/

  Pyoderma gangrenosum is a rare but serious ulcerating skin disease, the treatment of which is mostly empirical. […] The mainstay of treatment is long term immunosuppression, often with high doses of corticosteroids or low doses of ciclosporin. Recently, good outcomes have been reported for treatments based on anti-tumour necrosis factor, and infliximab proved effective in a randomised controlled trial. […] No single, specific treatment exists and few controlled trials of treatment have been done. Most clinicians use a stepwise approach and both topical and systemic treatments. Immunosuppression is the mainstay of treatment, and the most commonly used drugs are corticosteroids and ciclosporin. […] Highly potent topical corticosteroids (occasionally underneath occlusive dressings) may be sufficient to induce remission. Triamcinolone 40 mg/ml may be injected into the ulcer edge, either alone or as an adjunct to systemic treatment. Recently, topical tacrolimus has been shown to be effective in patients with peristomal disease.

• #2 Pyoderma gangrenosum: Treatment and prognosis – UpToDate

  https://www.uptodate.com/contents/pyoderma-gangrenosum-treatment-and-prognosis/print

  Pyoderma gangrenosum (PG) is an uncommon inflammatory and ulcerative skin disorder characterized histopathologically by the accumulation of neutrophils in the skin. […] Although multiple local and systemic therapies have been utilized for PG, high-quality efficacy studies are lacking for most interventions. Topical corticosteroids, systemic corticosteroids, and cyclosporine are common initial therapies. […] In general, after the diagnosis of PG is made, patients are managed with a combination of pharmacologic therapies that suppress the inflammatory process and wound care measures that optimize the environment for wound healing. […] Major principles of treatment include:

• #3 Pyoderma Gangrenosum Treatment & Management: Approach Considerations, Medical Care, Surgical Care

  https://emedicine.medscape.com/article/1123821-treatment

  No specific therapy is uniformly effective for patients with pyoderma gangrenosum. Therapy for pyoderma gangrenosum involves the use of anti-inflammatory agents, including antibiotics, corticosteroids, immunosuppressive agents, and biologic agents. […] Although surgical management should generally be avoided if possible, it is sometimes warranted. In patients with an associated underlying disease, effective therapy for the associated condition may be linked to a control of the cutaneous process as well. […] Topical therapies include gentle local wound care and dressings, superpotent topical corticosteroids, cromolyn sodium 2% solution, nitrogen mustard, and 5-aminosalicylic acid (5-ASA). The topical immune modifiers tacrolimus and pimecrolimus may have some benefit in certain patients. […] A systematic review suggested that corticosteroid powder (from capsules or crushed tablets) could be a useful topical treatment in cases of peristomal pyoderma gangrenosum, in that it (unlike lotions or ointments) does not reduce pouch adhesion; however, further study would be needed to confirm this.

• #4

  https://woundreference.com/app/topic?id=pyoderma-gangrenosum-treatment

  Currently, there is no definitive guideline or gold standard in management of pyoderma gangrenosum, as data from controlled clinical trials are scarce. As a result, management is guided primarily by small non-randomized controlled studies, and clinical experience. […] An adequate treatment plan aims to: Treat the cause: Aberrant inflammatory response is managed with therapeutic agents and avoidance of triggers. See topical and systemic therapies. […] Pain management is crucial to relieve patient’s anxiety and avoid depression, decreased quality of life and wound healing impairment. See pain management. […] The role of wound care in the management of pyoderma gangrenosum follows the rational path that patients receive traditional wound care after they have been successfully immunosuppressed.

• #5 Pyoderma gangrenosum | Beacon Health System

  https://www.beaconhealthsystem.org/library/diseases-and-conditions/pyoderma-gangrenosum?content_id=CON-20154762

  Treatment of pyoderma gangrenosum is aimed at reducing swelling, controlling pain and helping skin sores heal. Medicines are the most common treatment. Treatment also might involve wound care and surgery. Your treatment depends on your health, how many sores you have, how deep they are and how fast they’re growing. […] Some people respond well to treatment with a combination of medicine taken by mouth, creams and injections. Sores can take weeks or months to heal, and it’s common for new ones to develop. […] The most common treatment for pyoderma gangrenosum is daily doses of corticosteroids. These drugs may be applied to the skin, injected into the wound or taken by mouth. The pill form is called prednisone. Using corticosteroids for a long time or in high doses may cause severe side effects. To avoid these side effects, steroids may be used only for short periods of time to control the sores. And other medicines that target the immune system may be used long term to control the disease. These are called steroid-sparing medicines or steroid-sparing drugs.

• #6

  https://link.springer.com/article/10.1007/s40265-023-01931-3

  Systemic therapy with corticosteroids and/or cyclosporine remains the treatment of choice for most patients with pyoderma gangrenosum. […] Based on new data, systemic therapies with biologics are gaining importance as alternative or first-line therapy in patients with inflammatory comorbidities. […] Concomitant topical therapy can be given with classic immunosuppressants, e.g. corticosteroids or calcineurin inhibitors. […] There should always be a special focus on pain management. […] Once the diagnosis of PG has been established, the objective clinical features of severity for PG such as ulcer size, depth, number and location can guide the next steps. […] Patients with PG often present to clinicians at a late stage with ulceration, and the focus is placed on systemic therapies to gain rapid control of the inflammation.

• #7

  https://link.springer.com/article/10.1007/s40265-023-01931-3

  However, a subset of patients might present with early and small ulcerations, e.g. patients who are having a recurrence, and be in a position to start local treatment early in the course of the disease. […] Based on our experience, small PG ulcers (4 cm2 or less) without compromise of the deep structures (e.g. muscle/tendon) might be ideal for trying local or intra-lesional immunosuppressants. […] The two most commonly used local therapies are super potent corticosteroids and calcineurin antagonists. […] Local corticosteroid therapies can cause skin atrophy but have a much lower rate of other significant side effects and therefore, in our opinion, may contribute to reducing systemic immunosuppression. […] The largest study of topical therapies was conducted as a substudy of the STOPGAP study and recruited 66 patients who investigators felt had PG that would be amenable to local treatment.

• #8 Pyoderma Gangrenosum: Symptoms, Causes, and Treatment — DermNet

  https://dermnetnz.org/topics/pyoderma-gangrenosum

  Treatment of pyoderma gangrenosum is mainly non-surgical. The necrotic tissue should be gently removed. Wide surgical debridement should be avoided during the active stage of pyoderma gangrenosum because it may result in enlargement of the ulcer. Skin grafting and other surgical procedures may be performed when the active disease phase has settled, with care to minimise trauma. […] Often conventional antibiotics such as flucloxacillin are prescribed before making the correct diagnosis. These may be continued if bacteria are cultured in the wound (secondary wound infection) or there is surrounding cellulitis (red hot, painful skin), but they are not helpful for uncomplicated pyoderma gangrenosum. […] Small ulcers are often treated with: potent topical steroid ointment, tacrolimus ointment, intralesional steroid injections into the ulcer edge, ciclosporin solution, special dressings, oral anti-inflammatory antibiotics such as doxycycline or minocycline, and if tolerated, careful compression bandaging to reduce swelling.

• #9 Topical treatment of pyoderma gangrenosum: A systematic review – Indian Journal of Dermatology, Venereology and Leprology

  https://ijdvl.com/topical-treatment-of-pyoderma-gangrenosum-a-systematic-review/

  Systemic immunosuppressants are the mainstay of treatment for pyoderma gangrenosum (PG), but they generally have significant side effects which may be avoided by limiting treatment to topical therapy. This review aimed to assess the efficacy and safety of topical treatments for PG. […] The greatest weight of the current evidence for topical therapy favours either corticosteroids or calcineurin inhibitors. According to our review, both these options appear well tolerated with a few side effects and may have similar efficacy in speeding up the resolution of PG ulcers. Topical therapy could be considered for use in combination with systemic treatment. There may also be a role for isolated topical monotherapy in selected patients with PG, especially those with early or mild disease and those with idiopathic PG. However further research is needed to confirm this and establish optimal treatment approaches for this condition.

• #10 Diagnosis and treatment of pyoderma gangrenosum

  https://pmc.ncbi.nlm.nih.gov/articles/PMC1513476/

  Pyoderma gangrenosum is a rare but serious ulcerating skin disease, the treatment of which is mostly empirical. […] The mainstay of treatment is long term immunosuppression, often with high doses of corticosteroids or low doses of ciclosporin. Recently, good outcomes have been reported for treatments based on anti-tumour necrosis factor, and infliximab proved effective in a randomised controlled trial. […] No single, specific treatment exists and few controlled trials of treatment have been done. Most clinicians use a stepwise approach and both topical and systemic treatments. Immunosuppression is the mainstay of treatment, and the most commonly used drugs are corticosteroids and ciclosporin. […] Highly potent topical corticosteroids (occasionally underneath occlusive dressings) may be sufficient to induce remission. Triamcinolone 40 mg/ml may be injected into the ulcer edge, either alone or as an adjunct to systemic treatment. Recently, topical tacrolimus has been shown to be effective in patients with peristomal disease.

• #11

  https://link.springer.com/article/10.1007/s40265-023-01931-3

  However, a subset of patients might present with early and small ulcerations, e.g. patients who are having a recurrence, and be in a position to start local treatment early in the course of the disease. […] Based on our experience, small PG ulcers (4 cm2 or less) without compromise of the deep structures (e.g. muscle/tendon) might be ideal for trying local or intra-lesional immunosuppressants. […] The two most commonly used local therapies are super potent corticosteroids and calcineurin antagonists. […] Local corticosteroid therapies can cause skin atrophy but have a much lower rate of other significant side effects and therefore, in our opinion, may contribute to reducing systemic immunosuppression. […] The largest study of topical therapies was conducted as a substudy of the STOPGAP study and recruited 66 patients who investigators felt had PG that would be amenable to local treatment.

• #12 Topical treatment of pyoderma gangrenosum: A systematic review – Indian Journal of Dermatology, Venereology and Leprology

  https://ijdvl.com/topical-treatment-of-pyoderma-gangrenosum-a-systematic-review/

  Systemic immunosuppressants are the mainstay of treatment for pyoderma gangrenosum (PG), but they generally have significant side effects which may be avoided by limiting treatment to topical therapy. This review aimed to assess the efficacy and safety of topical treatments for PG. […] The greatest weight of the current evidence for topical therapy favours either corticosteroids or calcineurin inhibitors. According to our review, both these options appear well tolerated with a few side effects and may have similar efficacy in speeding up the resolution of PG ulcers. Topical therapy could be considered for use in combination with systemic treatment. There may also be a role for isolated topical monotherapy in selected patients with PG, especially those with early or mild disease and those with idiopathic PG. However further research is needed to confirm this and establish optimal treatment approaches for this condition.

• #13 Pyoderma Gangrenosum: Treatment Options

  https://pmc.ncbi.nlm.nih.gov/articles/PMC10511384/

  Concomitant topical therapy can be given with classic immunosuppressants, e.g. corticosteroids or calcineurin inhibitors. […] There should always be a special focus on pain management. […] Once the diagnosis of PG has been established, the objective clinical features of severity for PG such as ulcer size, depth, number and location can guide the next steps. […] Patients with PG often present to clinicians at a late stage with ulceration, and the focus is placed on systemic therapies to gain rapid control of the inflammation. […] However, a subset of patients might present with early and small ulcerations, e.g. patients who are having a recurrence, and be in a position to start local treatment early in the course of the disease. […] The two most commonly used local therapies are super potent corticosteroids and calcineurin antagonists.

• #14 Diagnosis and treatment of pyoderma gangrenosum

  https://pmc.ncbi.nlm.nih.gov/articles/PMC1513476/

  Pyoderma gangrenosum is a rare but serious ulcerating skin disease, the treatment of which is mostly empirical. […] The mainstay of treatment is long term immunosuppression, often with high doses of corticosteroids or low doses of ciclosporin. Recently, good outcomes have been reported for treatments based on anti-tumour necrosis factor, and infliximab proved effective in a randomised controlled trial. […] No single, specific treatment exists and few controlled trials of treatment have been done. Most clinicians use a stepwise approach and both topical and systemic treatments. Immunosuppression is the mainstay of treatment, and the most commonly used drugs are corticosteroids and ciclosporin. […] Highly potent topical corticosteroids (occasionally underneath occlusive dressings) may be sufficient to induce remission. Triamcinolone 40 mg/ml may be injected into the ulcer edge, either alone or as an adjunct to systemic treatment. Recently, topical tacrolimus has been shown to be effective in patients with peristomal disease.

• #15 Pyoderma gangrenosum – BAD Patient Hub

  https://www.skinhealthinfo.org.uk/condition/pyoderma-gangrenosum/

  Pyoderma gangrenosum is often difficult to treat and may take some time to heal. More than one treatment may need to be tried. Skin grafts and surgery are not treatment options as they often fail and may cause enlargement of the ulcer. […] Treatment depends on the severity of the disease. Mild disease is treated with topical creams or ointments, including corticosteroids and calcineurin inhibitors (such as tacrolimus). More severe disease is often managed with oral or injection therapies. […] Systemic treatments include antibiotics such as dapsone or minocycline, steroid tablets (e.g. prednisolone), immunosuppressive medicines such as Mycophenolate mofetil, Ciclosporin or Azathioprine, and targeted therapies such as infliximab. […] In very severe cases your doctor may consider other stronger, immunosuppressive medicines including cyclophosphamide, intravenous steroids or immunoglobulins.

• #16 Pyoderma Gangrenosum: Symptoms, Causes, and Treatment — DermNet

  https://dermnetnz.org/topics/pyoderma-gangrenosum

  Treatment of pyoderma gangrenosum is mainly non-surgical. The necrotic tissue should be gently removed. Wide surgical debridement should be avoided during the active stage of pyoderma gangrenosum because it may result in enlargement of the ulcer. Skin grafting and other surgical procedures may be performed when the active disease phase has settled, with care to minimise trauma. […] Often conventional antibiotics such as flucloxacillin are prescribed before making the correct diagnosis. These may be continued if bacteria are cultured in the wound (secondary wound infection) or there is surrounding cellulitis (red hot, painful skin), but they are not helpful for uncomplicated pyoderma gangrenosum. […] Small ulcers are often treated with: potent topical steroid ointment, tacrolimus ointment, intralesional steroid injections into the ulcer edge, ciclosporin solution, special dressings, oral anti-inflammatory antibiotics such as doxycycline or minocycline, and if tolerated, careful compression bandaging to reduce swelling.

• #17 How to promote healing in ulcers secondary to pyoderma gangrenosum?

  https://elenaconde.com/en/how-to-promote-healing-in-ulcers-secondary-to-pyoderma-gangrenosum/

  If I had to choose a single sentence to answer this question, it would undoubtedly be with an adequate anti-inflammatory strategy and, if necessary, with an invasive approach. […] Treatment with systemic and topical corticosteroids is the first choice in these patients. […] The aim of this post is to explain and underline the interest of a holistic approach to the patient with an ulcer secondary to pyoderma gangrenosum, beyond the use of immunosuppressive agents. […] The choice of dressing type and frequency of dressing changes will depend on the characteristics of the wound bed and perilesional skin. Topical corticosteroids, like the systemic corticosteroids, is the etiological treatment of choice for pyoderma gangrenosum. Topical calcineurin inhibitors (tacrolimus) are an effective and safe alternative.

• #18

  https://link.springer.com/article/10.1007/s40265-023-01931-3

  The use of intra-lesional steroid injections for PG is widely reported in case reports and case series, often in the context of peristomal disease. […] A wide variety of other treatments have been reported. […] Future alternatives will most likely include topical Janus kinase (JAK) inhibitors such as tofacitinib or ruxolitinib. […] While the main therapeutic options for classic PG remain those listed by Maronese et al., evidence from a large, multi-centre, retrospective cohort study as well as an expert survey study shows that PG patients receive an average of two different systemic agents. […] Combination treatment has not been defined but based on our experience, overlapping classic immunosuppressants and corticosteroid sparing agents for at least 4 weeks throughout the course of the disease is becoming standard of care in clinical practice when patient require systemic treatments.

• #19 Management of pyoderma gangrenosum – An update – Indian Journal of Dermatology, Venereology and Leprology

  https://ijdvl.com/management-of-pyoderma-gangrenosum-an-update/

  It is essential to exclude other diagnoses such as infectious diseases before therapy is initiated as corticosteroid and immunosuppressant therapy is the mainstay in the treatment of PG. […] The treatment of the underlying disease may aid in healing the ulcer. […] Local therapy is an important adjunct to systemic therapy and may provide relief from symptoms. […] Various agents that have been used for local therapy include topical and intralesional corticosteroids, topical 5-aminosalicylic acid, benzoyl peroxide, topical sodium cromoglycate, intralesional cyclosporine and topical nitrogen mustard. […] For early and localized lesions, intralesional corticosteroid injections with triamcinolone acetonide may halt progression and induce healing. […] Topical tacrolimus (0.5% solution) can be used as an add-on and follow-up medication in the treatment of PG.

• #20 Pyoderma Gangrenosum Treatment & Management: Approach Considerations, Medical Care, Surgical Care

  https://emedicine.medscape.com/article/1123821-treatment

  No specific therapy is uniformly effective for patients with pyoderma gangrenosum. Therapy for pyoderma gangrenosum involves the use of anti-inflammatory agents, including antibiotics, corticosteroids, immunosuppressive agents, and biologic agents. […] Although surgical management should generally be avoided if possible, it is sometimes warranted. In patients with an associated underlying disease, effective therapy for the associated condition may be linked to a control of the cutaneous process as well. […] Topical therapies include gentle local wound care and dressings, superpotent topical corticosteroids, cromolyn sodium 2% solution, nitrogen mustard, and 5-aminosalicylic acid (5-ASA). The topical immune modifiers tacrolimus and pimecrolimus may have some benefit in certain patients. […] A systematic review suggested that corticosteroid powder (from capsules or crushed tablets) could be a useful topical treatment in cases of peristomal pyoderma gangrenosum, in that it (unlike lotions or ointments) does not reduce pouch adhesion; however, further study would be needed to confirm this.

• #21

  https://link.springer.com/article/10.1007/s40265-023-01931-3

  When PG occurs on the lower legs, compression bandages should be applied to support anti-inflammatory activity by reducing oedema. […] It has been demonstrated that a PG significantly limits patients quality of life, mental health and ability to work. […] From our experience, local pharmacologic therapy only can be attempted when there are single small ( 4 cm2) PG skin lesions with or without ulceration. […] Systemic therapy should be considered when an ulcer is large ( 4 cm2) or if there are numerous or PG ulcers. […] However, the healing rate is less than 50% at 6 months and classical side effects associated with each type of medication determine which patient might benefit from one or the other. […] Biologics can already be used as first choice drugs in patients with inflammatory comorbidities such as IBD and inflammatory arthritis.

• #22 Diagnosis and treatment of pyoderma gangrenosum

  https://pmc.ncbi.nlm.nih.gov/articles/PMC1513476/

  Pyoderma gangrenosum is a rare but serious ulcerating skin disease, the treatment of which is mostly empirical. […] The mainstay of treatment is long term immunosuppression, often with high doses of corticosteroids or low doses of ciclosporin. Recently, good outcomes have been reported for treatments based on anti-tumour necrosis factor, and infliximab proved effective in a randomised controlled trial. […] No single, specific treatment exists and few controlled trials of treatment have been done. Most clinicians use a stepwise approach and both topical and systemic treatments. Immunosuppression is the mainstay of treatment, and the most commonly used drugs are corticosteroids and ciclosporin. […] Highly potent topical corticosteroids (occasionally underneath occlusive dressings) may be sufficient to induce remission. Triamcinolone 40 mg/ml may be injected into the ulcer edge, either alone or as an adjunct to systemic treatment. Recently, topical tacrolimus has been shown to be effective in patients with peristomal disease.

• #23

  https://link.springer.com/article/10.1007/s40265-023-01931-3

  Corticosteroids are the first-line immunosuppressant for PG worldwide. […] Treatment with systemic corticosteroids (CS) at a dosage of 0.51 mg/kg/day induces a clinical response in up to half of PG cases but it has heterogeneous response rates. […] It is recommended that systemic CS be combined with other immunosuppressants or immunomodulatory agents, the most common agent being cyclosporine. […] Mycophenolate mofetil (MMF) is an immunosuppressive drug which inhibits T- and B-cell proliferation by blocking the production of guanosine nucleotides required for DNA synthesis. […] Dapsone is a sulfone with anti-inflammatory as well as antibacterial and antibiotic properties. […] There are case reports, case series and systematic reviews on the treatment of PG with IVIG with doses from 0.5 to 2.0 g/kg.

• #24 Pyoderma Gangrenosum: Treatment Options

  https://pmc.ncbi.nlm.nih.gov/articles/PMC10511384/

  Pyoderma gangrenosum is a rare neutrophilic dermatosis that leads to exceedingly painful ulcerations of the skin. […] Various immunosuppressive and immunomodulatory therapies are available for the treatment of affected patients. […] Corticosteroids and/or cyclosporine remain the systemic therapeutics of choice for most patients. […] In recent years, there has been an increasing number of studies on the positive effects of biologic therapies such as inhibitors of tumour necrosis factor-; interleukin-1, interleukin-17, interleukin-23 or complement factor C5a. […] Systemic therapy with corticosteroids and/or cyclosporine remains the treatment of choice for most patients with pyoderma gangrenosum. […] Based on new data, systemic therapies with biologics are gaining importance as alternative or first-line therapy in patients with inflammatory comorbidities.

• #25 Pyoderma Gangrenosum – Dermatologic Disorders – Merck Manual Professional Edition

  https://www.merckmanuals.com/professional/dermatologic-disorders/hypersensitivity-and-reactive-skin-disorders/pyoderma-gangrenosum

  Treatment includes wound care and, based on severity, anti-inflammatory medications or immunosuppressants. […] Wound care […] Corticosteroids […] Tumor necrosis factor (TNF)-alpha inhibitors […] Sometimes other anti-inflammatory medications or immunosuppressants […] Avoidance of surgical debridement. […] Wound healing can be promoted with moisture-retaining occlusive dressings for less exudative plaques and absorptive dressings for highly exudative plaques. […] Topical therapy with high-potency corticosteroids or tacrolimus can help with superficial and early lesions. […] For more severe manifestations, prednisone 60 to 80 mg orally once a day is a common first-line therapy. […] TNF-alpha inhibitors (eg, infliximab, adalimumab, etanercept) are effective, particularly in patients who have inflammatory bowel disease.

• #26 Diagnosis and treatment of pyoderma gangrenosum

  https://pmc.ncbi.nlm.nih.gov/articles/PMC1513476/

  Most patients need systemic treatment to induce remission and doctors often start patients on oral corticosteroids at an early stage. Prednisolone is the drug of choice and is usually started at high doses (60-120 mg). […] When corticosteroids fail, the most widely used alternative is ciclosporin. Several case reports and small case series have demonstrated a good clinical response to low dose ciclosporin. […] Pyoderma has been reported to respond to infliximab, a monoclonal antibody against tumour necrosis factor. More recently, pyoderma gangrenosum was reported to resolve after treatment with etanercept, a recombinant protein that neutralises the soluble factor. […] We recommend oral corticosteroids (with or without minocycline) as first line treatment. If patients do not respond promptly, we then use infliximab as this has fewer recognised side effects than ciclosporin and has been used widely in inflammatory bowel disease and rheumatoid arthritis.

• #27

  https://link.springer.com/article/10.1007/s40265-023-01931-3

  Corticosteroids are the first-line immunosuppressant for PG worldwide. […] Treatment with systemic corticosteroids (CS) at a dosage of 0.51 mg/kg/day induces a clinical response in up to half of PG cases but it has heterogeneous response rates. […] It is recommended that systemic CS be combined with other immunosuppressants or immunomodulatory agents, the most common agent being cyclosporine. […] Mycophenolate mofetil (MMF) is an immunosuppressive drug which inhibits T- and B-cell proliferation by blocking the production of guanosine nucleotides required for DNA synthesis. […] Dapsone is a sulfone with anti-inflammatory as well as antibacterial and antibiotic properties. […] There are case reports, case series and systematic reviews on the treatment of PG with IVIG with doses from 0.5 to 2.0 g/kg.

• #28 Pyoderma gangrenosum – a review | Orphanet Journal of Rare Diseases | Full Text

  https://ojrd.biomedcentral.com/articles/10.1186/1750-1172-2-19

  Ciclosporin A is an inhibitor of T-lymphocyte activation. Immunosuppressive therapy with ciclosporin A has become an accepted treatment for widespread PG after initial steroids or in combination with steroids. In many cases, steroids can be completely replaced by ciclosporin A. Doses of 2 to 3 mg ciclosporin A/kg body weight and day show efficacy in PG. During therapy with ciclosporin A it is necessary to control blood pressure and creatinine. The drug induces an early response but has no impact on the incidence of recurrences. Therefore, combination with other drugs can become necessary even after initial response to ciclosporine A monotherapy. […] Sulfa drugs are useful in milder cases of PG. The combination of steroids with diaminodiphenylsulfone (dapsone) up to 200 mg daily (only for patients with a normal glucose-6-phosphate dehydrogenase level) is the most popular. Dapsone inhibits neutrophil migration and production of reactive oxygen species and exerts a variety of other anti-inflammatory activities. Formation of met-hemoglobin needs regular monitoring during this treatment.

• #29 Pyoderma Gangrenosum – Dermatologic Disorders – Merck Manual Professional Edition

  https://www.merckmanuals.com/professional/dermatologic-disorders/hypersensitivity-and-reactive-skin-disorders/pyoderma-gangrenosum

  Cyclosporine 3 mg/kg orally once a day is also quite effective, particularly in rapidly progressive disease. […] Dapsone, azathioprine, cyclophosphamide, methotrexate, clofazimine, thalidomide, and mycophenolate mofetil have also been used successfully. […] Antimicrobials such as minocycline have also been used for vegetative (superficial) pyoderma gangrenosum. […] Surgical treatments are avoided because of the risk of wound extension. […] Optimize wound care and avoid surgical debridement. […] Use potent topical corticosteroids or tacrolimus to treat early lesions and use systemic corticosteroids, tumor necrosis factor (TNF)-alpha inhibitors, or other anti-inflammatories or immunosuppressants to treat more severe manifestations.

• #30 Management of pyoderma gangrenosum – An update – Indian Journal of Dermatology, Venereology and Leprology

  https://ijdvl.com/management-of-pyoderma-gangrenosum-an-update/

  Cyclosporine, which does not cause significant myelosuppression, is one of the most promising immunosuppressants for the treatment of PG. […] Tacrolimus, a novel macrolide antibiotic with immunosuppressive properties, has recently been used as a steroid-sparing or replacing agent in the treatment of PG. […] Mycophenolate mofetil has been found useful as a relatively well tolerated immunosuppressive agent in various immune-mediated inflammatory dermatological diseases including PG. […] Recently, infliximab has shown promising results in the treatment of PG, with complete healing of skin lesions reported in a series of 13 cases. […] Plasma exchange, intravenous immunoglobulin, hyperbaric oxygen therapy, thalidomide, nicotine, and potassium iodide have also been used with varying success in the management of PG. […] Thalidomide 400 mg/day in a patient with Behets disease and PG has been reported to have shown a dramatic response. […] Nicotine gum 6 mg/day was reported to be effective in clearing the skin lesions of one patient with intractable PG within 3 weeks.

• #31 Pyoderma Gangrenosum Treatment & Management: Approach Considerations, Medical Care, Surgical Care

  https://emedicine.medscape.com/article/1123821-treatment

  Systemic therapies include corticosteroids, cyclosporine, mycophenolate mofetil, azathioprine, dapsone, tacrolimus, cyclophosphamide, chlorambucil, thalidomide, tumor necrosis factor (TNF)- inhibitors (eg, thalidomide, etanercept, infliximab, adalimumab, certolizumab, golimumab, and clofazimine), and nicotine. […] Intravenous (IV) therapies include pulsed methylprednisolone, pulsed cyclophosphamide, infliximab, IV immunoglobulin (IVIG), and ustekinumab. […] Often, a corticosteroid (eg, prednisone) is prescribed initially. An immunosuppressive agent is also sometimes initiated, either simultaneously or subsequently; this is particularly the case in patients for whom high-dose long-term therapy is anticipated. Some physicians select cyclosporine as the initial therapy; azathioprine, mycophenolate, cyclophosphamide, chlorambucil, and tacrolimus have also been used.

• #32 Pyoderma Gangrenosum – Dermatologic Disorders – Merck Manual Professional Edition

  https://www.merckmanuals.com/professional/dermatologic-disorders/hypersensitivity-and-reactive-skin-disorders/pyoderma-gangrenosum

  Cyclosporine 3 mg/kg orally once a day is also quite effective, particularly in rapidly progressive disease. […] Dapsone, azathioprine, cyclophosphamide, methotrexate, clofazimine, thalidomide, and mycophenolate mofetil have also been used successfully. […] Antimicrobials such as minocycline have also been used for vegetative (superficial) pyoderma gangrenosum. […] Surgical treatments are avoided because of the risk of wound extension. […] Optimize wound care and avoid surgical debridement. […] Use potent topical corticosteroids or tacrolimus to treat early lesions and use systemic corticosteroids, tumor necrosis factor (TNF)-alpha inhibitors, or other anti-inflammatories or immunosuppressants to treat more severe manifestations.

• #33 Management of pyoderma gangrenosum – An update – Indian Journal of Dermatology, Venereology and Leprology

  https://ijdvl.com/management-of-pyoderma-gangrenosum-an-update/

  Systemic corticosteroids are considered as the drug of choice for the treatment of PG and are particularly effective in treating the acute, rapidly progressive form of this disease. […] Sulfasalazine, sulfapyridine and sulfamethoxy-pyridazine have been successfully used in the management of PG. […] Dapsone has also been shown to be effective in the treatment of PG. […] Clofazimine, an imino phenazine dye mainly used in the treatment of leprosy and other mycobacterial diseases, is reported to be effective in the treatment of PG. […] Minocycline is another antimicrobial agent with possible beneficial effects in PG. […] Immunosuppressive agents like azathioprine, mercaptopurine, cyclophosphamide, arabinoside, chlorambucil, colchicine and daunorubicin have been used as an adjunctive or alternative therapy to systemic corticosteroids with varying success in PG.

• #34

  https://link.springer.com/article/10.1007/s40265-023-01931-3

  Corticosteroids are the first-line immunosuppressant for PG worldwide. […] Treatment with systemic corticosteroids (CS) at a dosage of 0.51 mg/kg/day induces a clinical response in up to half of PG cases but it has heterogeneous response rates. […] It is recommended that systemic CS be combined with other immunosuppressants or immunomodulatory agents, the most common agent being cyclosporine. […] Mycophenolate mofetil (MMF) is an immunosuppressive drug which inhibits T- and B-cell proliferation by blocking the production of guanosine nucleotides required for DNA synthesis. […] Dapsone is a sulfone with anti-inflammatory as well as antibacterial and antibiotic properties. […] There are case reports, case series and systematic reviews on the treatment of PG with IVIG with doses from 0.5 to 2.0 g/kg.

• #35 Pyoderma gangrenosum – a review | Orphanet Journal of Rare Diseases | Full Text

  https://ojrd.biomedcentral.com/articles/10.1186/1750-1172-2-19

  Ciclosporin A is an inhibitor of T-lymphocyte activation. Immunosuppressive therapy with ciclosporin A has become an accepted treatment for widespread PG after initial steroids or in combination with steroids. In many cases, steroids can be completely replaced by ciclosporin A. Doses of 2 to 3 mg ciclosporin A/kg body weight and day show efficacy in PG. During therapy with ciclosporin A it is necessary to control blood pressure and creatinine. The drug induces an early response but has no impact on the incidence of recurrences. Therefore, combination with other drugs can become necessary even after initial response to ciclosporine A monotherapy. […] Sulfa drugs are useful in milder cases of PG. The combination of steroids with diaminodiphenylsulfone (dapsone) up to 200 mg daily (only for patients with a normal glucose-6-phosphate dehydrogenase level) is the most popular. Dapsone inhibits neutrophil migration and production of reactive oxygen species and exerts a variety of other anti-inflammatory activities. Formation of met-hemoglobin needs regular monitoring during this treatment.

• #36 Pyoderma Gangrenosum: Symptoms, Causes, and Treatment — DermNet

  https://dermnetnz.org/topics/pyoderma-gangrenosum

  Treatment of pyoderma gangrenosum is mainly non-surgical. The necrotic tissue should be gently removed. Wide surgical debridement should be avoided during the active stage of pyoderma gangrenosum because it may result in enlargement of the ulcer. Skin grafting and other surgical procedures may be performed when the active disease phase has settled, with care to minimise trauma. […] Often conventional antibiotics such as flucloxacillin are prescribed before making the correct diagnosis. These may be continued if bacteria are cultured in the wound (secondary wound infection) or there is surrounding cellulitis (red hot, painful skin), but they are not helpful for uncomplicated pyoderma gangrenosum. […] Small ulcers are often treated with: potent topical steroid ointment, tacrolimus ointment, intralesional steroid injections into the ulcer edge, ciclosporin solution, special dressings, oral anti-inflammatory antibiotics such as doxycycline or minocycline, and if tolerated, careful compression bandaging to reduce swelling.

• #37 Management of pyoderma gangrenosum – An update – Indian Journal of Dermatology, Venereology and Leprology

  https://ijdvl.com/management-of-pyoderma-gangrenosum-an-update/

  Systemic corticosteroids are considered as the drug of choice for the treatment of PG and are particularly effective in treating the acute, rapidly progressive form of this disease. […] Sulfasalazine, sulfapyridine and sulfamethoxy-pyridazine have been successfully used in the management of PG. […] Dapsone has also been shown to be effective in the treatment of PG. […] Clofazimine, an imino phenazine dye mainly used in the treatment of leprosy and other mycobacterial diseases, is reported to be effective in the treatment of PG. […] Minocycline is another antimicrobial agent with possible beneficial effects in PG. […] Immunosuppressive agents like azathioprine, mercaptopurine, cyclophosphamide, arabinoside, chlorambucil, colchicine and daunorubicin have been used as an adjunctive or alternative therapy to systemic corticosteroids with varying success in PG.

• #38 Successful Treatment of Pyoderma Gangrenosum with Potassium Iodide | HTML | Acta Dermato-Venereologica

  https://www.medicaljournals.se/acta/content/html/10.1080/00015555-0006

  Pyoderma gangrenosum (PG) is an uncommon, non-infectious, inflammatory skin disease characterized by progressive ulcer formation with undermined borders and a necrotic purulent base. It usually follows a chronic course, and there is no specific and uniformly effective treatment. Here, we present a patient with PG with recurrent ulcers on her extremities. Although her condition was refractory to conventional treatments, potassium iodide (KI), not routinely used in this disease, was found to be very effective in inducing remission. […] PG is often difficult to manage because of its recurrent nature and poor responsiveness to therapy. Although local wound care and topical agents may be sufficient to control the disease process in mild cases, a combination with systemic therapy is usually necessary. For systemic therapy, oral corticosteroids offer the best results and remain the mainstay of treatment. Dapsone and minocycline are most frequently subscribed as steroid-sparing agents or as useful monotherapies in less aggressive cases.

• #39 Pyoderma Gangrenosum: Treatment Options

  https://pmc.ncbi.nlm.nih.gov/articles/PMC10511384/

  Pyoderma gangrenosum is a rare neutrophilic dermatosis that leads to exceedingly painful ulcerations of the skin. […] Various immunosuppressive and immunomodulatory therapies are available for the treatment of affected patients. […] Corticosteroids and/or cyclosporine remain the systemic therapeutics of choice for most patients. […] In recent years, there has been an increasing number of studies on the positive effects of biologic therapies such as inhibitors of tumour necrosis factor-; interleukin-1, interleukin-17, interleukin-23 or complement factor C5a. […] Systemic therapy with corticosteroids and/or cyclosporine remains the treatment of choice for most patients with pyoderma gangrenosum. […] Based on new data, systemic therapies with biologics are gaining importance as alternative or first-line therapy in patients with inflammatory comorbidities.

• #40

  https://link.springer.com/article/10.1007/s40265-023-01931-3

  When PG occurs on the lower legs, compression bandages should be applied to support anti-inflammatory activity by reducing oedema. […] It has been demonstrated that a PG significantly limits patients quality of life, mental health and ability to work. […] From our experience, local pharmacologic therapy only can be attempted when there are single small ( 4 cm2) PG skin lesions with or without ulceration. […] Systemic therapy should be considered when an ulcer is large ( 4 cm2) or if there are numerous or PG ulcers. […] However, the healing rate is less than 50% at 6 months and classical side effects associated with each type of medication determine which patient might benefit from one or the other. […] Biologics can already be used as first choice drugs in patients with inflammatory comorbidities such as IBD and inflammatory arthritis.

• #41

  https://link.springer.com/article/10.1007/s40265-023-01931-3

  A semi-systematic review found that 238 out of 356 (67%) patients had healed while on TNF- inhibitors. […] In a semi-systematic review, ustekinumab proved effective in 71% of patients treated with this biologic. […] The IL-1 inhibitors used for the treatment of PG include anakinra (IL-1 receptor antagonist that blocks IL-1 and IL-1) and canakinumab (IL-1 inhibitor). […] Sparse reports have described successful PG treatment with interleukin IL-17 inhibitors, including secukinumab (anti-IL-17A). […] Vilobelimab (IFX-1) is a chimeric monoclonal antibody that inhibits neutrophil activation, chemotaxis, reduces inflammatory signalling and complement driven tissue damage in various diseases such as hidradenitis suppurativa. […] The principles of modern moist wound therapy also apply to PG.

• #42 Infliximab for the treatment of pyoderma gangrenosum: a randomised, double blind, placebo controlled trial | Gut

  https://gut.bmj.com/content/55/4/505

  Pyoderma gangrenosum (PG) is a chronic ulcerating skin condition that often occurs in association with inflammatory bowel disease. There have been a number of reports of PG responding to infliximab, a monoclonal antibody against tumour necrosis factor. […] In the first randomised placebo controlled trial of any drug for the treatment of PG, we have studied the role of infliximab in this disorder. […] The mainstay of treatment of PG remains immunosuppression and the most commonly used drugs are corticosteroids and ciclosporin. A variety of other immunosuppressive agents have also been used with varied results, but treatment is largely empirical with the choice of treatment often dependent on local experience. […] This study has demonstrated that infliximab at a dose of 5 mg/kg is superior to placebo in the treatment of PG. Open label treatment with infliximab also produced promising results. Infliximab treatment should be considered in patients with PG.

• #43 Pyoderma gangrenosum – a review | Orphanet Journal of Rare Diseases | Full Text

  https://ojrd.biomedcentral.com/articles/10.1186/1750-1172-2-19

  Tumour necrosis alpha inhibitor infliximab was reported to be effective in PG associated with inflammatory bowel disease at a dosage of 5 mg/kg body weight. Infliximab is given by infusion at weeks 0, 2 and 6, and every 8 weeks thereafter. The chimeric antibody is usually combined with low-dose methotrexate for Crohn’s disease. In a small series including 4 patients with fistulating Crohn’s disease and PG infliximab was given either as a single infusion or a series of three infusions at a dosage of 5 mg per kg body weight/day. All patients demonstrated a rapid healing of PG within 4 weeks after starting the treatment. Healing was complete and relapses were not observed. […] The positive effect on PG has also seen with another tumour-necrosis factor alpha antagonist etanercept, a fusion protein. Etanercept is applied by subcutaneous injections of 50 mg twice weekly. Because there is a risk of reactivation of tuberculosis during anti-tumour necrosis alpha therapy patients have to be screened for tuberculosis before and during treatment.

• #44 Pyoderma Gangrenosum: Symptoms, Causes, and Treatment — DermNet

  https://dermnetnz.org/topics/pyoderma-gangrenosum

  Systemic treatment for larger ulcers due to pyoderma gangrenosum may include: oral prednisone for several weeks or longer, or intermittent intravenous methylprednisolone for 35 days, ciclosporin, which is as effective as prednisone and has differing adverse effects and risks, biologic agents: There is a growing body of evidence for success with the anti-TNF agents infliximab, adalimumab, etanercept; there are case reports of success with other biologic agents including ustekinumab, guselkumab, spesolimab, canakinumab, and anakinra. […] Other therapies may include: mycophenolate mofetil, dapsone, azathioprine, a tetracycline such as minocycline, potassium iodide solution, methotrexate, cyclophosphamide, chlorambucil, intravenous immunoglobulins and plasmapheresis. […] Expert wound care and pain management are essential. Once the disease is stable and inactive, surgical repair may be considered using a skin flap, skin graft, negative pressure wound therapy, and cultured skin. […] Systemic therapy should be tapered slowly over several months.

• #45

  https://link.springer.com/article/10.1007/s40265-023-01931-3

  A semi-systematic review found that 238 out of 356 (67%) patients had healed while on TNF- inhibitors. […] In a semi-systematic review, ustekinumab proved effective in 71% of patients treated with this biologic. […] The IL-1 inhibitors used for the treatment of PG include anakinra (IL-1 receptor antagonist that blocks IL-1 and IL-1) and canakinumab (IL-1 inhibitor). […] Sparse reports have described successful PG treatment with interleukin IL-17 inhibitors, including secukinumab (anti-IL-17A). […] Vilobelimab (IFX-1) is a chimeric monoclonal antibody that inhibits neutrophil activation, chemotaxis, reduces inflammatory signalling and complement driven tissue damage in various diseases such as hidradenitis suppurativa. […] The principles of modern moist wound therapy also apply to PG.

• #46 The Pathophysiology and Treatment of Pyoderma Gangrenosum—Current Options and New Perspectives

  https://www.mdpi.com/1422-0067/25/4/2440

  Several antibiotics, besides their antimicrobial properties, present anti-inflammatory effects. […] The favorable safety profile of intravenous immunoglobulin (IVIG) renders it an attractive therapeutic alternative for individuals with severe PG who cannot endure the adverse effects of conventional immunosuppressive agents or are already significantly immunocompromised. […] Infliximab is a chimeric mouse/human monoclonal IgG1 antibody against TNF-α. […] Adalimumab is a fully human monoclonal antibody against TNF-α. […] Ustekinumab is an IL-12/IL-23 antagonist that can be used in PG management. […] IL-1 antagonists utilized in PG treatment include canakinumab and anakinra. […] IL-17 inhibitors are a group of novel biological drugs that inhibit the activity of IL-17. […] The future of PG treatment lies in targeted therapies. Ongoing research on the pathogenesis of the disease and emerging insights into the pathomechanisms provide hope for the integration of both existing and novel molecules in the treatment paradigm. […] Janus Kinase inhibitors (JAKi) may be the future of the treatment of PG.

• #47 Pyoderma Gangrenosum: Symptoms, Causes, and Treatment — DermNet

  https://dermnetnz.org/topics/pyoderma-gangrenosum

  Systemic treatment for larger ulcers due to pyoderma gangrenosum may include: oral prednisone for several weeks or longer, or intermittent intravenous methylprednisolone for 35 days, ciclosporin, which is as effective as prednisone and has differing adverse effects and risks, biologic agents: There is a growing body of evidence for success with the anti-TNF agents infliximab, adalimumab, etanercept; there are case reports of success with other biologic agents including ustekinumab, guselkumab, spesolimab, canakinumab, and anakinra. […] Other therapies may include: mycophenolate mofetil, dapsone, azathioprine, a tetracycline such as minocycline, potassium iodide solution, methotrexate, cyclophosphamide, chlorambucil, intravenous immunoglobulins and plasmapheresis. […] Expert wound care and pain management are essential. Once the disease is stable and inactive, surgical repair may be considered using a skin flap, skin graft, negative pressure wound therapy, and cultured skin. […] Systemic therapy should be tapered slowly over several months.

• #48 Pyoderma gangrenosum: a review of the clinical, mechanistic and therapeutic landscape :: Cambridge Media Journals

  https://journals.cambridgemedia.com.au/wpr/volume-30-number-1/pyoderma-gangrenosum-review-clinical-mechanistic-and-therapeutic-landscape

  IL23 inhibitors, including ustekinumab (IL12/IL23p40) and guselkumab, as well as IL17 inhibitors, including brodalumab, have also demonstrated effectiveness in PG ulcer healing. […] JAK-STAT inhibitors, including tofacitinib, may represent a new and effective treatment option for PG as they are able to downregulate the production of multiple associated cytokines including IL23R, IL12R, and IL10R.

• #49 The Pathophysiology and Treatment of Pyoderma Gangrenosum—Current Options and New Perspectives

  https://www.mdpi.com/1422-0067/25/4/2440

  Several antibiotics, besides their antimicrobial properties, present anti-inflammatory effects. […] The favorable safety profile of intravenous immunoglobulin (IVIG) renders it an attractive therapeutic alternative for individuals with severe PG who cannot endure the adverse effects of conventional immunosuppressive agents or are already significantly immunocompromised. […] Infliximab is a chimeric mouse/human monoclonal IgG1 antibody against TNF-α. […] Adalimumab is a fully human monoclonal antibody against TNF-α. […] Ustekinumab is an IL-12/IL-23 antagonist that can be used in PG management. […] IL-1 antagonists utilized in PG treatment include canakinumab and anakinra. […] IL-17 inhibitors are a group of novel biological drugs that inhibit the activity of IL-17. […] The future of PG treatment lies in targeted therapies. Ongoing research on the pathogenesis of the disease and emerging insights into the pathomechanisms provide hope for the integration of both existing and novel molecules in the treatment paradigm. […] Janus Kinase inhibitors (JAKi) may be the future of the treatment of PG.

• #50 Effective New Therapy for Pyoderma Gangrenosumlogo-32logo-40logo-60NEJM Journal WatchnejmJW_1L_RGB-b

  https://www.jwatch.org/na47962/2018/11/27/effective-new-therapy-pyoderma-gangrenosum

  Effective New Therapy for Pyoderma Gangrenosum […] Tofacitinib produces promising results for refractory pyoderma. […] Oral tofacitinib 5 mg twice daily resulted in significant improvement, if not complete healing, in all three patients by 12 weeks. […] In these patients, tofacitinib was well tolerated and showed an effect in a short amount of time. […] More patients will need to be treated to show true effectiveness, but this drug is a potentially much safer agent to use in this clinical scenario.

• #51 Pyoderma Gangrenosum: Background, Epidemiology, Prognosis

  https://emedicine.medscape.com/article/1123821-overview

  Tofacitinib for the Treatment of Pyoderma Gangrenosum. […] Successful Outcome Treating Pyoderma Gangrenosum and Pouchitis With Upadacitinib. […] Intravenous immunoglobulin as adjunct therapy for refractory pyoderma gangrenosum: systematic review of cases and case series. […] A retrospective study of 12 cases of pyoderma gangrenosum: why we should avoid surgical intervention and what therapy to apply. […] Perioperative management of pyoderma gangrenosum.

• #52 Pyoderma gangrenosum: a review of the clinical, mechanistic and therapeutic landscape :: Cambridge Media Journals

  https://journals.cambridgemedia.com.au/wpr/volume-30-number-1/pyoderma-gangrenosum-review-clinical-mechanistic-and-therapeutic-landscape

  IL23 inhibitors, including ustekinumab (IL12/IL23p40) and guselkumab, as well as IL17 inhibitors, including brodalumab, have also demonstrated effectiveness in PG ulcer healing. […] JAK-STAT inhibitors, including tofacitinib, may represent a new and effective treatment option for PG as they are able to downregulate the production of multiple associated cytokines including IL23R, IL12R, and IL10R.

• #53

  https://link.springer.com/article/10.1007/s40265-023-01931-3

  Corticosteroids are the first-line immunosuppressant for PG worldwide. […] Treatment with systemic corticosteroids (CS) at a dosage of 0.51 mg/kg/day induces a clinical response in up to half of PG cases but it has heterogeneous response rates. […] It is recommended that systemic CS be combined with other immunosuppressants or immunomodulatory agents, the most common agent being cyclosporine. […] Mycophenolate mofetil (MMF) is an immunosuppressive drug which inhibits T- and B-cell proliferation by blocking the production of guanosine nucleotides required for DNA synthesis. […] Dapsone is a sulfone with anti-inflammatory as well as antibacterial and antibiotic properties. […] There are case reports, case series and systematic reviews on the treatment of PG with IVIG with doses from 0.5 to 2.0 g/kg.

• #54

  https://link.springer.com/article/10.1007/s40257-024-00904-w

  Pyoderma gangrenosum (PG) is rare neutrophil skin disease causing painful, progressively enlarging ulcers. Among the treatment options, intravenous immunoglobulin (IVIG) is a therapy of first choice for paraneoplastic PG. Otherwise, it is used in therapy-refractory courses. […] This multicentre retrospective study shows the important role of adjunctive IVIG therapy in patients with PG with recalcitrant courses. Identifying subgroups with a higher probability of response could improve future response rates and save patients from ineffective treatment and potential adverse events. […] IVIG is one of those options, most commonly used as adjunct therapy. […] In patients with associated malignancy, IVIG is considered as first-line therapy in the German guidelines, although it is not approved for the treatment of PG.

• #55 Pyoderma Gangrenosum: Background, Epidemiology, Prognosis

  https://emedicine.medscape.com/article/1123821-overview

  Severe recalcitrant pyoderma gangrenosum treated with infliximab. […] Response to infliximab in atypical pyoderma gangrenosum associated with ulcerative colitis. […] Six patients with pyoderma gangrenosum successfully treated with infliximab. […] Intravenous Immunoglobulin Therapy for Pyoderma Gangrenosum: A Multicenter Retrospective Analysis in 81 Patients. […] Treatment of pyoderma gangrenosum with intravenous immunoglobulin. […] Interleukin 23 expression in pyoderma gangrenosum and targeted therapy with ustekinumab. […] Hyperbaric oxygen therapy as an adjuvant treatment for pyoderma gangrenosum. […] Pyoderma gangrenosum and concomitant hidradenitis suppurativa–rapid response to canakinumab (anti-IL-1). […] The Clinical and Molecular Response of Pyoderma Gangrenosum to Interleukin 23 Blockade: Result from a proof-of-concept open-label clinical trial.

• #56 Pyoderma Gangrenosum – Dermatology – Diseases – McMaster Textbook of Internal Medicine

  https://empendium.com/mcmtextbook/chapter/B31.II.856.5.

  IV pulsed methylprednisolone (1000 mg/d) may be used in severe and recalcitrant disease. […] High-dose IV immunoglobulin (IVIG) (2 g/kg) over 2 to 3 consecutive days per month for 6 months may be used as an adjuvant treatment in recalcitrant disease, for solitary PG lesions, or when trying to prevent repetitive superinfections. […] Targeted therapies include biologic agents that antagonize proinflammatory mediators in PG, such as tumor necrosis factor (TNF), IL-1 beta, and IL-6 antagonists; however, most biologic agents have been used off label for PG, with only limited and anecdotal evidence. […] TNF antagonists: Adalimumab is a potential treatment in therapy-resistant PG that has shown some clinical improvement or incomplete resolution with a good safety profile; more clinical evidence is required, as investigations are limited to small case series.

• #57 Pyoderma gangrenosum – a review | Orphanet Journal of Rare Diseases | Full Text

  https://ojrd.biomedcentral.com/articles/10.1186/1750-1172-2-19

  Since PG is a neutrophilic disease, removal of activated neutrophiles should improve the symptoms. Leukocytapheresis, where white blood cells are removed extracorporeal, and granulocyte adsorptive apheresis, a more selective procedure, have been used in single cases with success. These methods have been used in single cases unresponsive to systemic standard therapy with success. […] Topical treatment is important in any case when ulcers have developed. Moist wound management is a cornerstone of wound management. Since most ulcers show heavy exudates, foam dressings or laminate dressings composed of different layers are recommended. In case of sloughy or purulent covered lesions, semiocclusive dressings are contraindicated. In such cases, wet compresses with sterile saline solution or Ringer-lactate solution and alginate dressings are useful. Pain relief and improvement of odor have also been observed with compresses.

• #58 Treatment-resistant pyoderma gangrenosum managed with maggot debridement therapy and hyperbaric oxygen therapy: a case study – Wounds UK

  https://wounds-uk.com/journal-articles/treatment-resistant-pyoderma-gangrenosum-managed-with-maggot-debridement-therapy-and-hyperbaric-oxygen-therapy-a-case-study/

  Here we discuss the case of a patient with treatment-resistant pyoderma gangrenosum. […] The case of a 69-year-old female with an extremely painful multitreatment resistant pyoderma gangrenosum of the left shin, which clinically improved in both appearance and pain levels following maggot debridement and hyperbaric oxygen therapy. […] A decision was made to first trial maggot debridement therapy followed by hyperbaric oxygen therapy (HBOT) to assist wound healing, pain reduction and to aid as an adjuvant to further immunosuppressive therapy. […] Following this trial our patients pain was noted to have reduced from 9/10 on VAS to 6/10, and removal of non-viable tissue was significant. […] Then, 20 sessions of HBOT were undertaken. Further reductions in pain levels were noted, with a decrease from 6/10 to 4/10 on VAS following HBOT.

• #59 New Published Case Report: HBOT as treatment for Pyoderma Gangrenosum

  https://www.hyperbaricmedicalsolutions.com/blog/new-published-hms-research-on-hbot-role-in-treatment-of-pyoderma-gangrenosum

  Pyoderma gangrenosum is an uncommon, inflammatory skin disorder. Traditional treatment plans for Pyoderma gangrenosum patients include taking oral steroids and other medications that suppress the immune system, like tumor necrosis factor blockers. Wound care is provided to these patients, but Pyoderma gangrenosum-associated wounds do not respond well to surgical treatments. A case report prepared in part by HMS Medical Director, Alan Katz MD, FUHM, FACEP, FAAEM, and Research Coordinator, Kristin Thomson, DHSc., PA-C, was published in the International Journal of Research in Dermatology describing patients who used hyperbaric oxygen therapy (HBOT) as an adjunctive treatment for Pyoderma gangrenosum. Hyperbaric oxygen therapy was added into their traditional plan, and both patients responded well to treatments. The closure of the wounds after hyperbaric oxygen therapy reduced their pain which impacted their quality of life. […] Hyperbaric oxygen therapy has been well established in treating select problem wounds, like certain diabetic and surgical wounds.

• #60 Pyoderma Gangrenosum: Background, Epidemiology, Prognosis

  https://emedicine.medscape.com/article/1123821-overview

  Severe recalcitrant pyoderma gangrenosum treated with infliximab. […] Response to infliximab in atypical pyoderma gangrenosum associated with ulcerative colitis. […] Six patients with pyoderma gangrenosum successfully treated with infliximab. […] Intravenous Immunoglobulin Therapy for Pyoderma Gangrenosum: A Multicenter Retrospective Analysis in 81 Patients. […] Treatment of pyoderma gangrenosum with intravenous immunoglobulin. […] Interleukin 23 expression in pyoderma gangrenosum and targeted therapy with ustekinumab. […] Hyperbaric oxygen therapy as an adjuvant treatment for pyoderma gangrenosum. […] Pyoderma gangrenosum and concomitant hidradenitis suppurativa–rapid response to canakinumab (anti-IL-1). […] The Clinical and Molecular Response of Pyoderma Gangrenosum to Interleukin 23 Blockade: Result from a proof-of-concept open-label clinical trial.

• #61 Pyoderma gangrenosum | Beacon Health System

  https://www.beaconhealthsystem.org/library/diseases-and-conditions/pyoderma-gangrenosum?content_id=CON-20154762

  Because pyoderma gangrenosum can be made worse by cuts to the skin, surgery to remove dead tissue is not usually considered a good treatment option. Trauma to the skin may worsen existing sores or bring on new ones. […] If sores are large and aren’t healing, a skin graft may be an option. In this procedure, the surgeon attaches a piece of skin from somewhere else on your body over the open sores.

• #62 Pyoderma Gangrenosum: Symptoms, Causes, and Treatment — DermNet

  https://dermnetnz.org/topics/pyoderma-gangrenosum

  Treatment of pyoderma gangrenosum is mainly non-surgical. The necrotic tissue should be gently removed. Wide surgical debridement should be avoided during the active stage of pyoderma gangrenosum because it may result in enlargement of the ulcer. Skin grafting and other surgical procedures may be performed when the active disease phase has settled, with care to minimise trauma. […] Often conventional antibiotics such as flucloxacillin are prescribed before making the correct diagnosis. These may be continued if bacteria are cultured in the wound (secondary wound infection) or there is surrounding cellulitis (red hot, painful skin), but they are not helpful for uncomplicated pyoderma gangrenosum. […] Small ulcers are often treated with: potent topical steroid ointment, tacrolimus ointment, intralesional steroid injections into the ulcer edge, ciclosporin solution, special dressings, oral anti-inflammatory antibiotics such as doxycycline or minocycline, and if tolerated, careful compression bandaging to reduce swelling.

• #63 Pyoderma Gangrenosum: A Diagnostic Challenge for the Surgical Consultant | ACS

  https://www.facs.org/for-medical-professionals/news-publications/journals/case-reviews/issues/v4n1/harrington-pyoderma-gangrenosum/

  Pyoderma gangrenosum (PG) is a rare, sterile, neutrophilic dermatosis occurring in 0.3-1.0 per 100,000 persons. Treatment is multimodal, involving wound care, topical therapies, and immunosuppression, and wound resolution occurs slowly, with an average of 20.37 weeks to complete healing. […] Treatment of PG focuses on reducing ongoing inflammation, limiting pain, and preventing infection and often includes a mix of wound care, topical therapies, and systemic immunosuppressive therapies. Given the frequency with which pathergy is associated with PG, wound care must avoid adherent dressings and irritating solutions. Further, any unnecessary manipulation of the ulcer bed should be avoided. Topical therapy, such as steroid application, is often a useful adjunct and inter-lesion injections such as Kenalog also facilitate healing in these complex wounds. Systemic immunosuppressive therapy with oral corticosteroids or cyclosporine is commonly employed as first-line therapy. However, tumor necrosis factor (TNF) inhibitors, including infliximab, adalimumab, and enteracept, have all been reported to demonstrate greater than 85% response rate and nearly 70% complete response rate leading some to suggest their use early in the treatment of PG.

• #64 Pyoderma gangrenosum – a review | Orphanet Journal of Rare Diseases | Full Text

  https://ojrd.biomedcentral.com/articles/10.1186/1750-1172-2-19

  For small flat lesions without secondary infection, topical high potent corticosteroids are in use. They are rarely capable of inducing remissions except in peristomal PG. Topical calcineurin inhibitors like tacrolimus or pimecrolimus were used in some cases with success. Dramatic improvement has been observed in particular in peristomal PG. […] Surgery has to be used with caution since it can be trigger PG. Any surgical procedure has to be done as an adjunct to immunosuppression only in patients with stable disease or partial remission. Autologous split-skin grafts have been used with variable outcome. A significant disadvantage of split-skin grafts is the necessity to create a new wound at the donor site. New developments include the use of bioengineered skin, like the dermal regeneration template Integra, hair follicle stem cell-derived autologous keratinocyte sheets Epidex or hyaluronic acid-based autologous keratinocyte delivery system.

• #65

  https://woundreference.com/app/topic?id=pyoderma-gangrenosum-treatment

  For peristomal pyoderma gangrenosum, restoring bowel continuity when possible is the best approach. […] If pyoderma gangrenosus response to immunosuppressants (corticosteroids, tacrolimus, cyclosporine) is suboptimal, second-line therapy with TNF blockers may be considered. […] The potential benefit of Negative Pressure Wound Therapy as well as Hyperbaric Oxygen Therapy as adjunctive therapy has been mentioned in several small case studies and individual case reports but sufficient wider trials are necessary to support endorsement of these therapies.

• #66 Pyoderma Gangrenosum – Dermatology – Diseases – McMaster Textbook of Internal Medicine

  https://empendium.com/mcmtextbook/chapter/B31.II.856.5.

  Anakinra is a recombinant, nonglycosylated IL-1 receptor antagonist, typically used in rheumatoid arthritis and cryopyrinopathies, that has shown substantial improvement or complete resolution of PG. […] Canakinumab has been shown to reduce wound size and improve quality of life in patients with glucocorticoid-refractory PG. […] Tocilizumab has been shown to improve PG in a patient with coexisting rheumatoid arthritis. […] Systemic glucocorticoids are the mainstay of treatment for ocular PG. […] Improving kidney function in conjunction with topical or intralesional and systemic glucocorticoid therapy should improve the PG ulcers. […] Systemic glucocorticoids are the treatment of choice for both cutaneous and skeletal manifestations. […] Systemic immunotherapy (systemic glucocorticoids with or without systemic cyclosporine) may be used to treat splenic involvement.

• #67

  https://link.springer.com/article/10.1007/s40265-023-01931-3

  A semi-systematic review found that 238 out of 356 (67%) patients had healed while on TNF- inhibitors. […] In a semi-systematic review, ustekinumab proved effective in 71% of patients treated with this biologic. […] The IL-1 inhibitors used for the treatment of PG include anakinra (IL-1 receptor antagonist that blocks IL-1 and IL-1) and canakinumab (IL-1 inhibitor). […] Sparse reports have described successful PG treatment with interleukin IL-17 inhibitors, including secukinumab (anti-IL-17A). […] Vilobelimab (IFX-1) is a chimeric monoclonal antibody that inhibits neutrophil activation, chemotaxis, reduces inflammatory signalling and complement driven tissue damage in various diseases such as hidradenitis suppurativa. […] The principles of modern moist wound therapy also apply to PG.

• #68 How to promote healing in ulcers secondary to pyoderma gangrenosum?

  https://elenaconde.com/en/how-to-promote-healing-in-ulcers-secondary-to-pyoderma-gangrenosum/

  If I had to choose a single sentence to answer this question, it would undoubtedly be with an adequate anti-inflammatory strategy and, if necessary, with an invasive approach. […] Treatment with systemic and topical corticosteroids is the first choice in these patients. […] The aim of this post is to explain and underline the interest of a holistic approach to the patient with an ulcer secondary to pyoderma gangrenosum, beyond the use of immunosuppressive agents. […] The choice of dressing type and frequency of dressing changes will depend on the characteristics of the wound bed and perilesional skin. Topical corticosteroids, like the systemic corticosteroids, is the etiological treatment of choice for pyoderma gangrenosum. Topical calcineurin inhibitors (tacrolimus) are an effective and safe alternative.

• #69 Pyoderma gangrenosum – a review | Orphanet Journal of Rare Diseases | Full Text

  https://ojrd.biomedcentral.com/articles/10.1186/1750-1172-2-19

  Since PG is a neutrophilic disease, removal of activated neutrophiles should improve the symptoms. Leukocytapheresis, where white blood cells are removed extracorporeal, and granulocyte adsorptive apheresis, a more selective procedure, have been used in single cases with success. These methods have been used in single cases unresponsive to systemic standard therapy with success. […] Topical treatment is important in any case when ulcers have developed. Moist wound management is a cornerstone of wound management. Since most ulcers show heavy exudates, foam dressings or laminate dressings composed of different layers are recommended. In case of sloughy or purulent covered lesions, semiocclusive dressings are contraindicated. In such cases, wet compresses with sterile saline solution or Ringer-lactate solution and alginate dressings are useful. Pain relief and improvement of odor have also been observed with compresses.

• #70 The challenges of managing patients with pyoderma gangrenosum: three case reports :: Cambridge Media Journals

  https://journals.cambridgemedia.com.au/wpr/volume-24-no-1/challenges-managing-patients-pyoderma-gangrenosum-three-case-reports

  Pyoderma gangrenosum (PG) remains challenging for clinicians. There are no specific guidelines for the diagnosis and treatment of PG. The aim of this paper is to provide an overview of the challenges faced by the clinician in diagnosing and managing patients with PG. […] The disease process in poorly understood and treatment is based predominately on clinical experience. Approach to treatment should be multidisciplinary, including dermatology, rheumatology, wound care specialists, pain specialists and pathologists. Treatment aim is to reduce the inflammation, minimise pain, promote wound healing, and control underlying disorders. If the patient has any underlying systemic disease, control of this often results in the control of skin lesions. […] At each presentation the lesions should have a comprehensive assessment of the wound bed and the wound border, paying attention in particular to the type of tissue at the wound bed, amount and type of exudate, evidence of violaceous wound margins and the level of pain the patient is experiencing.

• #71

  https://link.springer.com/article/10.1007/s40265-023-01931-3

  When PG occurs on the lower legs, compression bandages should be applied to support anti-inflammatory activity by reducing oedema. […] It has been demonstrated that a PG significantly limits patients quality of life, mental health and ability to work. […] From our experience, local pharmacologic therapy only can be attempted when there are single small ( 4 cm2) PG skin lesions with or without ulceration. […] Systemic therapy should be considered when an ulcer is large ( 4 cm2) or if there are numerous or PG ulcers. […] However, the healing rate is less than 50% at 6 months and classical side effects associated with each type of medication determine which patient might benefit from one or the other. […] Biologics can already be used as first choice drugs in patients with inflammatory comorbidities such as IBD and inflammatory arthritis.

• #72 Causes, Symptoms & Treatment of Pyoderma Gangrenosum

  https://legsmatter.org/information-and-support/skin-concerns/pyoderma-gangrenosum/

  Compression is an essential part of the treatment if you have PG on your legs or feet and this important fact is often missed. Medical management may not be enough on its own to control this condition or any associated swelling. Even if the leg is not very swollen the compression bandage or sock will reduce the level of exudate and make the wounds less wet. You may want to start with mild compression, but increase the level of compression as soon as you can so the limb can benefit from the anti-inflammatory properties of the compression therapy.

• #73

  https://link.springer.com/article/10.1007/s40265-023-01931-3

  Systemic therapy with corticosteroids and/or cyclosporine remains the treatment of choice for most patients with pyoderma gangrenosum. […] Based on new data, systemic therapies with biologics are gaining importance as alternative or first-line therapy in patients with inflammatory comorbidities. […] Concomitant topical therapy can be given with classic immunosuppressants, e.g. corticosteroids or calcineurin inhibitors. […] There should always be a special focus on pain management. […] Once the diagnosis of PG has been established, the objective clinical features of severity for PG such as ulcer size, depth, number and location can guide the next steps. […] Patients with PG often present to clinicians at a late stage with ulceration, and the focus is placed on systemic therapies to gain rapid control of the inflammation.

• #74 The challenges of managing patients with pyoderma gangrenosum: three case reports :: Cambridge Media Journals

  https://journals.cambridgemedia.com.au/wpr/volume-24-no-1/challenges-managing-patients-pyoderma-gangrenosum-three-case-reports

  For small lesions, such as superficial pustules or shallow ulcers, treatment can include local application of high-potency corticosteroid lotion, ointment, cream or intralesional injections. Topical agents can also be used in conjunction with systemic therapy for patients with severe PG. […] Systemic therapy is required in patients with all but superficial lesions. Topical agents also do not address systemic disease and as the disease progresses a combination of topical and systemic agents may be required. […] Surgery is not generally recommended due to the risk of pathergy; as a result the ulcers could potentially worsen following surgery. However, there are a few reports in the literature of success following surgical intervention. […] Pain associated with PG can be distressing for the patient. Pain levels should be monitored and as the ulcer improves pain levels should decrease.

• #75 How to promote healing in ulcers secondary to pyoderma gangrenosum?

  https://elenaconde.com/en/how-to-promote-healing-in-ulcers-secondary-to-pyoderma-gangrenosum/

  Complete healing rates with classical immunosuppressive treatments (predominantly oral corticosteroids and cyclosporine) do not reach 50% at 6 months. […] Once the inflammatory activity is controlled, the strategy to facilitate the formation of granulation tissue and promote epithelialization will be similar to that used in wounds of other aetiologies. Therefore, negative pressure therapy and thin split-thickness grafts will be good alternatives, either alone or in combination, to accelerate healing. […] Analgesic control is a key aspect in the treatment of wounds secondary to pyoderma gangrenosum, which are very painful lesions. Topical irrigation of sevoflurane is a very interesting option in these patients. […] Whenever an ulcer diagnosed as pyoderma gangrenosum does not respond to an adequate immunosuppressive treatment, besides considering that the ulcer may be resistant to treatment and could require association or change to other drugs, we should always wonder if is it really an ulcer secondary to pyoderma gangrenosum?

• #76 Pyoderma gangrenosum | Beacon Health System

  https://www.beaconhealthsystem.org/library/diseases-and-conditions/pyoderma-gangrenosum?content_id=CON-20154762

  Some medicines can stop your immune system from attacking healthy tissues. Examples are the the steroid-sparing medicines cyclosporine, mycophenolate (Cellcept), immunoglobulins, dapsone, infliximab (Remicade) and tacrolimus (Protopic). Tacrolimus is a type of medicine called a calcineurin inhibitor. Steroid-sparing medicines might be applied to the wounds, injected or taken by mouth. These medicines also can have severe side effects. […] Depending on the extent of your wounds, you may benefit from pain medicine, especially when your dressings are being changed. […] In addition to applying medicine to your wounds, a healthcare professional may cover them with a moist nonstick dressing and, perhaps, an elasticized wrap. You may be asked to keep the affected area raised. Follow instructions you receive for wound care.

• #77

  https://link.springer.com/article/10.1007/s40265-023-01931-3

  When PG occurs on the lower legs, compression bandages should be applied to support anti-inflammatory activity by reducing oedema. […] It has been demonstrated that a PG significantly limits patients quality of life, mental health and ability to work. […] From our experience, local pharmacologic therapy only can be attempted when there are single small ( 4 cm2) PG skin lesions with or without ulceration. […] Systemic therapy should be considered when an ulcer is large ( 4 cm2) or if there are numerous or PG ulcers. […] However, the healing rate is less than 50% at 6 months and classical side effects associated with each type of medication determine which patient might benefit from one or the other. […] Biologics can already be used as first choice drugs in patients with inflammatory comorbidities such as IBD and inflammatory arthritis.

• #78 Pyoderma gangrenosum: challenges and solutions | CCID

  https://www.dovepress.com/pyoderma-gangrenosum-challenges-and-solutions-peer-reviewed-fulltext-article-CCID

  Treatment is also challenging since, due to its rarity, clinical trials are difficult to perform, and consequently, there is no gold standard therapy. […] Patients frequently require aggressive immunosuppression, often in multidrug regimens that are not standardized. […] Topical and systemic corticosteroids are considered the first therapeutic option, whereas other immunosuppressors and cytostatics can be used as steroid-sparing agents. […] Treatments differ between patients with idiopathic disease and those who have an underlying disorder. […] Anti-inflammatory and immunosuppressive drugs can be effective both in PG and the underlying disease, as the example of the IL1 antagonist anakinra for PG in the context of PAPA syndrome, and of infliximab and other anti-TNF agents in the context of Crohns disease and ulcerative colitis.

• #79

  https://link.springer.com/article/10.1007/s40265-023-01931-3

  When PG occurs on the lower legs, compression bandages should be applied to support anti-inflammatory activity by reducing oedema. […] It has been demonstrated that a PG significantly limits patients quality of life, mental health and ability to work. […] From our experience, local pharmacologic therapy only can be attempted when there are single small ( 4 cm2) PG skin lesions with or without ulceration. […] Systemic therapy should be considered when an ulcer is large ( 4 cm2) or if there are numerous or PG ulcers. […] However, the healing rate is less than 50% at 6 months and classical side effects associated with each type of medication determine which patient might benefit from one or the other. […] Biologics can already be used as first choice drugs in patients with inflammatory comorbidities such as IBD and inflammatory arthritis.

• #80 Pyoderma Gangrenosum: A Diagnostic Challenge for the Surgical Consultant | ACS

  https://www.facs.org/for-medical-professionals/news-publications/journals/case-reviews/issues/v4n1/harrington-pyoderma-gangrenosum/

  Pyoderma gangrenosum (PG) is a rare, sterile, neutrophilic dermatosis occurring in 0.3-1.0 per 100,000 persons. Treatment is multimodal, involving wound care, topical therapies, and immunosuppression, and wound resolution occurs slowly, with an average of 20.37 weeks to complete healing. […] Treatment of PG focuses on reducing ongoing inflammation, limiting pain, and preventing infection and often includes a mix of wound care, topical therapies, and systemic immunosuppressive therapies. Given the frequency with which pathergy is associated with PG, wound care must avoid adherent dressings and irritating solutions. Further, any unnecessary manipulation of the ulcer bed should be avoided. Topical therapy, such as steroid application, is often a useful adjunct and inter-lesion injections such as Kenalog also facilitate healing in these complex wounds. Systemic immunosuppressive therapy with oral corticosteroids or cyclosporine is commonly employed as first-line therapy. However, tumor necrosis factor (TNF) inhibitors, including infliximab, adalimumab, and enteracept, have all been reported to demonstrate greater than 85% response rate and nearly 70% complete response rate leading some to suggest their use early in the treatment of PG.

• #81 Pyoderma Gangrenosum on the Lower Extremity | Consultant360

  https://www.consultant360.com/photoclinic/pyoderma-gangrenosum-lower-extremity

  A 53-year-old woman presented for a dermatology consult for a spreading ulcer on the lateral left calf. […] Given the pertinent history and physical examination, the condition was diagnosed as pyoderma gangrenosum and was treated with 5 g topical clobetasol 0.05% ointment twice daily under nonadherent dressings. Her pain improved significantly after a single day of treatment. After 3 weeks of treatment, the lesion improved significantly. […] Treatment of pyoderma gangrenosum depends on severity. Stable or slowly growing lesions can be treated with compresses with occlusive dressing as pyoderma gangrenosum can spontaneously regress. Potent topical corticosteroids, topical dapsone, or topical tacrolimus can be considered for more persistent lesions. Rapid progression, extensive disease, or facial involvement may necessitate the use of systemic corticosteroids, cyclosporine, or infliximab. If an underlying associated disease is present, treatment of that disorder is recommended and can lead to improvement of the pyoderma gangrenosum. Response to treatment is typically seen in 1 to 2 weeks, but resolution may take months. Caution should be given to prolonged use of high-dose, super-potent topical corticosteroids to avoid potential complications, such as elevated blood glucose level, Cushing syndrome, or adrenal suppression. Limiting the risk of pathergy (eg, by avoiding unnecessary surgical procedures) and good wound care are also vital for resolution. […] First-line treatments include gentle wound care and potent topical corticosteroids with a taper as the lesion improves. When in doubt, consider consulting a dermatologist.

• #82

  https://link.springer.com/article/10.1007/s40265-023-01931-3

  When PG occurs on the lower legs, compression bandages should be applied to support anti-inflammatory activity by reducing oedema. […] It has been demonstrated that a PG significantly limits patients quality of life, mental health and ability to work. […] From our experience, local pharmacologic therapy only can be attempted when there are single small ( 4 cm2) PG skin lesions with or without ulceration. […] Systemic therapy should be considered when an ulcer is large ( 4 cm2) or if there are numerous or PG ulcers. […] However, the healing rate is less than 50% at 6 months and classical side effects associated with each type of medication determine which patient might benefit from one or the other. […] Biologics can already be used as first choice drugs in patients with inflammatory comorbidities such as IBD and inflammatory arthritis.

• #83 Diagnosis and treatment of pyoderma gangrenosum

  https://pmc.ncbi.nlm.nih.gov/articles/PMC1513476/

  Most patients need systemic treatment to induce remission and doctors often start patients on oral corticosteroids at an early stage. Prednisolone is the drug of choice and is usually started at high doses (60-120 mg). […] When corticosteroids fail, the most widely used alternative is ciclosporin. Several case reports and small case series have demonstrated a good clinical response to low dose ciclosporin. […] Pyoderma has been reported to respond to infliximab, a monoclonal antibody against tumour necrosis factor. More recently, pyoderma gangrenosum was reported to resolve after treatment with etanercept, a recombinant protein that neutralises the soluble factor. […] We recommend oral corticosteroids (with or without minocycline) as first line treatment. If patients do not respond promptly, we then use infliximab as this has fewer recognised side effects than ciclosporin and has been used widely in inflammatory bowel disease and rheumatoid arthritis.

• #84

  https://link.springer.com/article/10.1007/s40265-023-01931-3

  Corticosteroids are the first-line immunosuppressant for PG worldwide. […] Treatment with systemic corticosteroids (CS) at a dosage of 0.51 mg/kg/day induces a clinical response in up to half of PG cases but it has heterogeneous response rates. […] It is recommended that systemic CS be combined with other immunosuppressants or immunomodulatory agents, the most common agent being cyclosporine. […] Mycophenolate mofetil (MMF) is an immunosuppressive drug which inhibits T- and B-cell proliferation by blocking the production of guanosine nucleotides required for DNA synthesis. […] Dapsone is a sulfone with anti-inflammatory as well as antibacterial and antibiotic properties. […] There are case reports, case series and systematic reviews on the treatment of PG with IVIG with doses from 0.5 to 2.0 g/kg.

• #85

  https://link.springer.com/article/10.1007/s40265-023-01931-3

  A semi-systematic review found that 238 out of 356 (67%) patients had healed while on TNF- inhibitors. […] In a semi-systematic review, ustekinumab proved effective in 71% of patients treated with this biologic. […] The IL-1 inhibitors used for the treatment of PG include anakinra (IL-1 receptor antagonist that blocks IL-1 and IL-1) and canakinumab (IL-1 inhibitor). […] Sparse reports have described successful PG treatment with interleukin IL-17 inhibitors, including secukinumab (anti-IL-17A). […] Vilobelimab (IFX-1) is a chimeric monoclonal antibody that inhibits neutrophil activation, chemotaxis, reduces inflammatory signalling and complement driven tissue damage in various diseases such as hidradenitis suppurativa. […] The principles of modern moist wound therapy also apply to PG.

• #86 Pyoderma gangrenosum: challenges and solutions | CCID

  https://www.dovepress.com/pyoderma-gangrenosum-challenges-and-solutions-peer-reviewed-fulltext-article-CCID

  Patients with mild disease and, particularly, those with the vegetative/superficial granulomatous form of PG have been reported to respond well to topical therapy and wound dressing. […] Systemic treatment is mandatory for a more widespread or rapidly progressive disease. […] Over the past decade, PG has been reported to respond to many different biologic medications, most commonly, to anti-TNF drugs such as etanercept, adalimumab, certolizumab, and infliximab. […] Although multidrug therapy has not been well described in the literature, it should be considered for refractory disease. […] In case of malignancy, immunosuppression should only be performed at the minimum doses. […] A persistent ulcer does not necessarily mean treatment failure. […] Pain is a major complaint and should be carefully controlled, to improve patients quality of life.

• #87 Effective Strategies for the Management of Pyoderma Gangrenosum: A Comprehensive Review | HTML | Acta Dermato-Venereologica

  https://www.medicaljournals.se/acta/content/html/10.2340/00015555-2008

  Surgery alone has not been shown to be an effective strategy for management of PG. […] Combination therapy for PG has not been highlighted in the literature, but it is important to consider this option for the management of patients with refractory disease. […] Ultimately, a multidrug regimen may be a better strategy than sequentially switching a patient from one immunosuppressive agent to another.

• #88

  https://link.springer.com/article/10.1007/s40265-023-01931-3

  The use of intra-lesional steroid injections for PG is widely reported in case reports and case series, often in the context of peristomal disease. […] A wide variety of other treatments have been reported. […] Future alternatives will most likely include topical Janus kinase (JAK) inhibitors such as tofacitinib or ruxolitinib. […] While the main therapeutic options for classic PG remain those listed by Maronese et al., evidence from a large, multi-centre, retrospective cohort study as well as an expert survey study shows that PG patients receive an average of two different systemic agents. […] Combination treatment has not been defined but based on our experience, overlapping classic immunosuppressants and corticosteroid sparing agents for at least 4 weeks throughout the course of the disease is becoming standard of care in clinical practice when patient require systemic treatments.

• #89

  https://link.springer.com/article/10.1007/s40265-023-01931-3

  When PG occurs on the lower legs, compression bandages should be applied to support anti-inflammatory activity by reducing oedema. […] It has been demonstrated that a PG significantly limits patients quality of life, mental health and ability to work. […] From our experience, local pharmacologic therapy only can be attempted when there are single small ( 4 cm2) PG skin lesions with or without ulceration. […] Systemic therapy should be considered when an ulcer is large ( 4 cm2) or if there are numerous or PG ulcers. […] However, the healing rate is less than 50% at 6 months and classical side effects associated with each type of medication determine which patient might benefit from one or the other. […] Biologics can already be used as first choice drugs in patients with inflammatory comorbidities such as IBD and inflammatory arthritis.

• #90

  https://link.springer.com/article/10.1007/s40265-023-01931-3

  In paraneoplastic PG, there is stronger evidence that treatment of the underlying malignancy may be helpful in treating PG. […] It is always difficult to determine when systemic therapy should be stopped. […] With all forms of therapy, it is very important to clarify in advance whether these treatments are at all feasible for patients who often have underlying illnesses. […] Despite the proposal of new diagnostic frameworks, the impact on the misdiagnosis rate is yet to be seen. […] PG is a rare inflammatory dermatological disease that leads to very painful ulcerations and causes a significantly reduced quality of life. […] Once the diagnosis is confirmed with validated scores, numerous immunosuppressive and immunomodulatory therapies are now available. […] In particular, biologics will play an increasingly important role in the treatment regimens of patients with PG.

• #91 Pyoderma gangrenosum: challenges and solutions | CCID

  https://www.dovepress.com/pyoderma-gangrenosum-challenges-and-solutions-peer-reviewed-fulltext-article-CCID

  Treatment is also challenging since, due to its rarity, clinical trials are difficult to perform, and consequently, there is no gold standard therapy. […] Patients frequently require aggressive immunosuppression, often in multidrug regimens that are not standardized. […] Topical and systemic corticosteroids are considered the first therapeutic option, whereas other immunosuppressors and cytostatics can be used as steroid-sparing agents. […] Treatments differ between patients with idiopathic disease and those who have an underlying disorder. […] Anti-inflammatory and immunosuppressive drugs can be effective both in PG and the underlying disease, as the example of the IL1 antagonist anakinra for PG in the context of PAPA syndrome, and of infliximab and other anti-TNF agents in the context of Crohns disease and ulcerative colitis.

• #92 Pyoderma Gangrenosum in a Patient with Crohn’s Disease Treated with Adalimumab: A Case-Based Review and Systematic Review of the Current Literature

  https://www.mdpi.com/2039-7283/15/3/57

  Adalimumab appears to be a promising therapeutic option, particularly for steroid-resistant PG, though further research is needed to establish standardized treatment protocols. […] In our case, adalimumab has been demonstrated to be an effective therapeutic option for the management of both pyoderma gangrenosum and axial spondyloarthritis, while maintaining CD in remission. […] There is growing evidence that adalimumab is an effective option for the treatment of pyoderma gangrenosum, even in steroid-refractory cases. […] These findings indicate that adalimumab may be an effective treatment option for pyoderma gangrenosum, including patients with underlying inflammatory conditions and IBD. […] Treating PG, especially with CD, requires a multidisciplinary approach with collaboration between dermatologists and gastroenterologists; PG management focuses on suppressing the immune response and controlling inflammation.

• #93

  https://link.springer.com/article/10.1007/s40265-023-01931-3

  In paraneoplastic PG, there is stronger evidence that treatment of the underlying malignancy may be helpful in treating PG. […] It is always difficult to determine when systemic therapy should be stopped. […] With all forms of therapy, it is very important to clarify in advance whether these treatments are at all feasible for patients who often have underlying illnesses. […] Despite the proposal of new diagnostic frameworks, the impact on the misdiagnosis rate is yet to be seen. […] PG is a rare inflammatory dermatological disease that leads to very painful ulcerations and causes a significantly reduced quality of life. […] Once the diagnosis is confirmed with validated scores, numerous immunosuppressive and immunomodulatory therapies are now available. […] In particular, biologics will play an increasingly important role in the treatment regimens of patients with PG.

• #94 Pyoderma Gangrenosum: Background, Epidemiology, Prognosis

  https://emedicine.medscape.com/article/1123821-overview

  Therapy for pyoderma gangrenosum involves the use of anti-inflammatory agents, including antibiotics, corticosteroids, immunosuppressive agents, and biologic agents. […] The prognosis is generally good; however, the disease can recur, and residual scarring is common. […] Most patients with pyoderma gangrenosum improve with initial immunosuppressive therapy and require minimal care afterwards. […] However, many patients follow a refractory course, and multiple therapies may fail. […] Some patients demonstrate pathergy, or the development of pyoderma gangrenosumlike lesions at the site of skin trauma; in such instances, protection of the skin from trauma may prevent a recurrence of the disease. […] Death from pyoderma gangrenosum is rare, but it may occur as a consequence of an associated disease or as a result of therapy.

• #95 Pyoderma Gangrenosum Treatment & Management: Approach Considerations, Medical Care, Surgical Care

  https://emedicine.medscape.com/article/1123821-treatment

  The TNF- inhibitors are close to being first-line agents in the treatment of pyoderma gangrenosum. […] The interleukin (IL)-1 inhibitor canakinumab proved effective in a patient with pyoderma gangrenosum and concomitant hidradenitis suppurativa. […] Surgery should be avoided if possible because of the pathergic phenomenon that may occur with surgical manipulation or grafting, resulting in wound enlargement. […] In cases where surgery or superficial debridement is required, the best plan, if feasible, is to have the patient on therapy, and active disease under control, in order to prevent the development of new pyoderma gangrenosum lesions. […] Patients with pyoderma gangrenosum should receive follow-up care on a regular basis to monitor drug therapy and to measure the size of the lesion or lesions.

• #96

  https://link.springer.com/article/10.1007/s40265-023-01931-3

  In paraneoplastic PG, there is stronger evidence that treatment of the underlying malignancy may be helpful in treating PG. […] It is always difficult to determine when systemic therapy should be stopped. […] With all forms of therapy, it is very important to clarify in advance whether these treatments are at all feasible for patients who often have underlying illnesses. […] Despite the proposal of new diagnostic frameworks, the impact on the misdiagnosis rate is yet to be seen. […] PG is a rare inflammatory dermatological disease that leads to very painful ulcerations and causes a significantly reduced quality of life. […] Once the diagnosis is confirmed with validated scores, numerous immunosuppressive and immunomodulatory therapies are now available. […] In particular, biologics will play an increasingly important role in the treatment regimens of patients with PG.

• #97 Pyoderma gangrenosum – Care at Mayo Clinic – Mayo Clinic

  https://www.mayoclinic.org/diseases-conditions/pyoderma-gangrenosum/care-at-mayo-clinic/mac-20350395

  Pyoderma gangrenosum is a rare condition that can have widespread effects on your body. Proper diagnosis and treatment are key to recovery. Your Mayo Clinic doctors work with you to develop a comprehensive treatment plan that meets your needs and considers the possible side effects of each treatment option. Your care team follows up with you to see how well the treatment is working. […] Based on that, they develop a personalized treatment plan for you. […] You may need treatment for other conditions related to pyoderma gangrenosum, such as chronic pain. Your Mayo Clinic dermatologists can work with other Mayo Clinic specialists and your local healthcare professional to ensure you get the care you need. […] Our physician-scientists research the extent to which pyoderma gangrenosum is misdiagnosed and the types of treatment that work best for the condition.

• #98 Pyoderma gangrenosum: a review of the clinical, mechanistic and therapeutic landscape :: Cambridge Media Journals

  https://journals.cambridgemedia.com.au/wpr/volume-30-number-1/pyoderma-gangrenosum-review-clinical-mechanistic-and-therapeutic-landscape

  Pyoderma gangrenosum (PG) is a neutrophilic dermatosis that is uncommon and can sometimes be associated with systemic diseases. […] PG remains a difficult condition to diagnose, mainly because it was previously seen as a diagnosis of exclusion, although newer diagnostic criteria have been proposed in order to overcome this. Furthermore, many patients do not respond to conventional therapy for PG once diagnosed, and experience persistence or worsening of their condition over time. The advent of immune targeted therapies, however, may represent a new treatment option for these patients. […] Current management involves optimal wound care and topical or systemic steroids or steroid sparing agents. Certain biological agents, including IL23 and IL17 antagonists, as well as JAK-STAT inhibitors, however, may hold promise in the rapid treatment of this condition.

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