Review
Pyoderma gangrenosum: A review and update on new therapies

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Pyoderma gangrenosum is a rare and often painful skin disease that can be unpredictable in its response to treatment. There is currently no gold standard of treatment or published algorithm for choice of therapy. The majority of data comes from case studies that lack a standard protocol not only for treatment administration but also for the objective assessment of lesion response to a specific therapy. This review provides an update to the treatment of pyoderma gangrenosum with a particular focus on new systemic therapies.

Section snippets

Local wound management

Effective management of PG ulcers is an objective evaluation of the ulcers so that wound management can be planned. At each visit, objective measurements including depth, length, and width of the ulcer should be recorded.6 These measurements in combination with sequential photography can then serve as a gauge for wound management success. The inflammatory component of PG is assessed by the border elevation and lesion expansion. When the border flattens, anti-inflammatory medications can be

Pain control

With the exception of the vegetative variant, patients with PG almost universally experience debilitating pain, sometimes described as “stabbing” in quality. The pain can become so severe that amputation has been implemented when systemic therapy is ineffective.7 Although patients with the vegetative variant of PG may have some tenderness, the pain is generally less than that experienced by patients with other types of PG. The source of the pain is multifactorial, but much of it can be

Treatments

There is currently no gold standard of treatment for PG.9 Choice of therapy will depend on multiple factors including size and depth of the lesion, the rapidity of lesion growth and appearance of new lesions, the associated disease (eg, inflammatory bowel disease, arthritis), and general medical status of the patient. Other factors in choice of treatment include associated toxicities of the medications, as up to 50% of patients with classic PG require long-term therapy to maintain remission.9

Clinical trials

Several studies have emerged showing the benefit of using biologics (infliximab, etanercept, efalizumab, adalimumab, and alefacept) for the treatment of PG. Most of the studies used an end point of complete resolution of lesions (Table III). However, this is not the most sensitive method for detecting efficacy, as many biologics may yield significant clinical improvement without complete resolution of lesions or lesions may require more time for complete healing than the constraints of the

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    Astellas Pharma Global Development Inc provided support for the preparation of this review. The Center for Dermatology Research is supported by an unrestricted educational grant from Galderma Laboratories LP.

    Disclosure: Dr Feldman has received research, speaking, and/or consulting support from Abbott Labs, American Society for Dermatologic Surgery, Amgen, Astellas, Aventis Pharmaceuticals, Biogen, Centocor, Connetics, Galderma, Genentech, Novartis, and Roche. Dr Jorizzo has received speaking and/or consulting support from Amgen. Dr Miller, Dr Yentzer, and Ms Clark have no conflicts of interest to declare.

    Reprints not available from the authors.

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