Hi Americo

No specific therapy is uniformly effective for patients with pyoderma gangrenosum. 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,[17] cromolyn sodium 2% solution, nitrogen mustard, and 5-aminosalicylic acid. The topical immune modifiers tacrolimus and pimecrolimus may have some benefit in certain patients.[18]

Systemic therapies include corticosteroids, cyclosporine,[19, 20, 21] mycophenolate mofetil,[22, 23, 24] azathioprine,[25] dapsone, tacrolimus, cyclophosphamide, chlorambucil,[26] thalidomide, tumor necrosis factor-alpha (TNF-alpha) inhibitors (eg, thalidomide, etanercept, infliximab, adalimumab,[27] clofazimine[28] ), and nicotine.

Intravenous (IV) therapies include pulsed methylprednisolone,[29] pulsed cyclophosphamide,[30] infliximab,[31, 32, 33, 34] IV immunoglobulin,[35] and ustekinumab.[36] Other therapies include hyperbaric oxygen.[37]

Canakinumab proved effective in a patient with concomitant hidradenitis suppurativa.[38]

Surgery

Surgery should be avoided, if possible, because of the pathergic phenomenon that may occur with surgical manipulation or grafting, resulting in wound enlargement.[39] In some patients, grafting has resulted in the development of pyoderma gangrenosum at the harvest site. In cases in which surgery is required, the best plan, if possible, is to have the patient on therapy in order to prevent pathergy.

Some patients with ulcerative colitis have responded to total colectomy; in other patients, however, the disease is peristomal and occurs following bowel resection.

Transfer

Care of the patient with pyoderma gangrenosum is often referred from the general dermatologist to tertiary centers where such patients are seen more frequently.

Follow-up

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. Multiple methods of wound care are available.

Activity

Patients should maintain their range of motion and perform all activities that they are able to tolerate.For more please read at the following link

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

Dear Américo,

some papers that may interest you: 

Article Pyoderma gangrenosum treatment: a steroid-free option

Article Recalcitrant pyoderma gangrenosum: Treatment with thalidomide

Article Pyoderma gangrenosum treated with Azathioprine and Prednisolone

I would like to know your own approach and not the revisions of the literature. Do you begin all with systemic corticosteroids ?

 Dear Américo,

P.J. August here on RG have tried different approaches, consult with him. Based on the literature Mercaptopurine is reported as causing a dramatic remission of pyoderma gangrenosum in a child with acute leukaemia (Maldonedo et al., 1968). Other investigators have used cyclophosphamide (Crawford, et al., 1967) and corticosteroids (Hofstad, 1959; Holt & Waddington, 1973) although they did not help this patient. The use of radiotherapy does not seem to have been reported recently. In the case reported, a combination of moderately high doses of steroids and azathioprine was essential. High dose steroids, however, were ineffective and once control was achieved a reduction of steroid dosage was followed by relapse.

Oral  prednisone -1mg/kg/day- until the interruption of  progression of  lesions and  the development of new ones  plus silver sulfadiazine  cream  ; as the inflammatory  component of  PG disappears, the dosage is tapered slowly --10mg/month --to discontinuation after the condition has completely resolved . Silver sulfadiazine cream is replaced by  topical  potent corticoid  in  the tapering phase .

Pyoderma gangrenosum (PG) is a rare noninfectious neutrophilic dermatosis commonly associated with underlying systemic disease. Several clinical variants of PG have been described including ulcerative, pustular, bullous

and vegetative forms. Although the pathogenesis of PG is not fully understood, an immune-mediated process is thought to have an important role. Approximately

50% of patients with PG have an associated systemic disease. Common associations include IBD, arthritis, haematological malignancies and monoclonal gammopathies. Many effective treatment strategies have been reported. Choice of treatment generally depends on disease severity as well as on the presence of associated disease. For early or mild lesions, topical therapy may be sufficient. This includes wet compresses, hydrophilic occlusive dressings, antimicrobial agents and topical corticosteroids. Topical tacrolimus has recently shown

promising results for the treatment of early PG lesions, and intralesional corticosteroids are another therapeutic option of reported benefit. For more severe

disease or for PG resistant to topical therapy, oral corticosteroids have been the mainstay of therapy. Pulsed intravenous corticosteroid therapy has been reported to be effective in some cases refractory to oral corticosteroids; it is recommended in PG refractory to other forms of treatment. Sulphones and other antimicrobials such as dapsone, clofazimine and minocycline have been found to be useful in treating PG. In one case we could detect H. Pylori infection in a high IgG titer in an ulcerative PG recalcitrant case and given triple therapy to respond dramatically with puckering scars skin healing and no skin ulcer relapse for almost 5 years.

We in our institute treat pg with oral prednisolone 1-2 mg/kg body wt initially and add steroid sparing drugs as azathioptine and slowly taper steroids

Dear Dr. Figueiredo,

Pyoderma gangrenosum could be very aggressive disease. In my small period of experience (3 years residency in Cairo University, and fellowship in USA for 2 years) I saw patient with pyoderma gangrenosum  in his hand that progressed to amputation of that hand, and other patient that arise in breasts of female patient after mammoplasty that eventually the patient lost her breasts due to misdiagnosis as wound infection and progression of PG within two weeks.

So systemic treatment from the beginning could be justified to prevent such complications besides control of underlying condition. Prednisone 1mg/kg/day could be started with monitoring the progression of the ulcer (disappearnce of the violaceous hue, arrest of progression of the ulcer size by daily measurement, start of healing, no appearance of new erythematous papules around the previous ulcer which indicate that new lesions are going to happen, and decreased pain). If these previous points were not noticed one could think to switch to cyclosporin 3-5mg/kg/day which I noticed in the patients that we treated very good results. 

Do you use usually only 1mg/Kg/day of prednisolone or more. Anyone have experience with cyclosporin ?

In my experience if there are an indication for cyclosporin in Dermatology this is exactly Pyoderma Gangrenosum in a dose higher than in psoriasis - about 6-8 mg/kg/ day.

I saw very good results from cyclosporin in a lower dose than you have mentioned, but all depends on the response of the patient.

I agree with you, cyclosporin in Dermatology is for pyoderma gangrenosum.

But in Egypt with the high incidence of Hep c in psoriatic patients, cyclosporin is one of the best choices after failure of phototherapy

We know Amira. You have about ten million people with Hep C ? Is this correct ?

Yes about that number. Unfortunately 20% of Egyptian population is HCV positive!

Hello Américo, dear  colleague and friend,

 I have just seen your question now but my answer will not be a review of literature and recent published papers (other colleagues quite completely did it in their replies). As almost all old dermatologists I have seen some cases of pyoderma gangrenosum (in hospital and private practice but referred to the hospital when posible).

 I used many of different known therapies for the disorder, particularly systemic corticosteroids and cyclosporin, with quite acceptable but variable results depending of severity and associated disease (of course we must take into consideration individual characteristics of each patient for indication/contraindications and underlying pathology). In my long term practice systemic treatment was most important and efficient than topical one. But even though I continue half time my private practice, I have not seen PG cases in the recent times.

 I do not believe my comment will be really useful but it is always nice to be in touch with you by this way. 

  Warmest regards from

                                            Jose

Thank you Dear Friend and Master.

Your oppinion is always important for us. This kind of question is to know who uses now cyclosporin or tracolimus. Corticosteroids all we use but what more ?

What have change ?

All of good for you

Américo

The severity of PG influences the approach to treatment. For patients with mild, localized PG (few superficial ulcers or a plaque of vegetative PG), we suggest initial treatment with a high potency or superpotent topical corticosteroid or topical tacrolimus (Grade 2C). Patients with mild PG who fail to improve with local interventions should be treated with systemic therapy. We often attempt treatment with dapsone or minocycline prior to the initiation of more aggressive immunomodulatory therapies.

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

Article Etiology and Management of Pyoderma Gangrenosum

Article Pyoderma Gangrenosum: A review and update on new therapies

Hello Américo,

Just to add one more "off-label" approach: apheresis.

We've had a patient that went through plasma exchange multiple times, very intensive in the beginning, ie, 2-3 times a week for a couple of weeks, and nowadays less intensive with plasma exchange once a month. So far, it has been the only effective treatment for this patient with mild to none secondary/unwanted effects.