Pulse therapy. Therapeutic efficacy in the treatment of pyoderma gangrenosum

Unusual causes of cutaneous ulceration

Skin ulceration is a major source of morbidity and is often difficult to manage. Ulcers caused by an inflammatory cause or microvascular occlusion are particularly challenging in terms of diagnosis and treatment. The management of such ulcers requires careful assessment of associated systemic conditions and a thorough analysis of the ulcer's clinical and histologic findings. In this article, the authors discuss several examples of inflammatory ulcers and the approach to the diagnosis and treatment of these ulcers.

Pyoderma gangrenosum--a review

Pyoderma gangrenosum (PG) is a rare noninfectious neutrophilic dermatosis. Clinically it starts with sterile pustules that rapidly progress and turn into painful ulcers of variable depth and size with undermined violaceous borders. The legs are most commonly affected but other parts of the skin and mucous membranes may also be involved. Course can be mild or malignant, chronic or relapsing with remarkable morbidity. In many cases PG is associated with an underlying disease, most commonly inflammatory bowel disease, rheumatic or haematological disease and malignancy. Diagnosis of PG is based on history of an underlying disease, typical clinical presentation, histopathology, and exclusion of other diseases that would lead to a similar appearance. The peak of incidence occurs between the ages of 20 to 50 years with women being more often affected than men. Aetiology has not been clearly determined yet.

The treatment of PG is a challenge. Randomized, double-blinded prospective multicenter trials for PG are not available. The best documented treatments are systemic corticosteroids and ciclosporin A. Combinations of steroids with cytotoxic drugs are used in resistant cases. The combination of steroids with sulfa drugs or immunosuppressants has been used as steroid-sparing modalities. Anti-tumor necrosis alpha therapy in Crohn's disease showed a rapid response of PG. Skin transplants and the application of bioengineered skin is useful in selected cases as a complement to the immunosuppressive treatment. Topical therapy with modern wound dressings is useful to minimize pain and the risk of secondary infections. Despite recent advances in therapy, the prognosis of PG remains unpredictable.

Pyoderma gangrenosum. Pyoderma gangraenosum

Pyoderma gangrenosum (PG) is a non-infectious reactive neutrophilic dermatosis which typically starts with pustules which rapidly evolve to painful ulcers of variable size and depth with undermined violaceous borders. Since its first description in 1930, the pathogenesis of PG has remained elusive even as an ever-widening range of systemic diseases has been described in association with it. The diagnosis of PG is based on clinical and pathologic features and requires exclusion of other conditions that produce ulcerations, since misdiagnosis exposes patients to risks associated with treatment. Critical to proper management are correct diagnosis, identification and treatment of any underlying disorder, and the appropriate choice of topical and systemic therapy. PG has four distinctive clinical and histologic variants, and the specific clinical features of the lesion may provide a clue to the associated disease. The most common associated diseases are inflammatory bowel disease, rheumatological or hematological disease or malignancy. Although there is no single successful treatment for PG, certain type of PG lesions are recognized to respond more readily to accepted therapies than others. Local treatment may be sufficient for mild disease, while systemic immunosuppressive therapy is necessary for severe cases. The treatments with the best clinical evidence are oral or pulse intravenous corticosteroids, and cyclosporine. Surgical therapy is useful in selected cases in conjunction with immunosuppression. Wound stabilization is obtained only through control of the systemic and local inflammatory process. Emerging therapies include use of platelet-derived growth factor and cell culture grafts when re-epithelialization is slow, and the TNF-alpha blocking agent infliximab for refractory disease. Despite advances in therapy, the long-term outcome for patients with PG remains unpredictable, because relapses are common.

A prospective, open-label trial assessing dexamethasone pulse therapy in moderate to severe ulcerative colitis

BACKGROUND

Severe ulcerative colitis is conventionally treated with parenteral corticosteroids followed by oral corticosteroids. Regular use of corticosteroids is associated with side effects. Corticosteroid pulse therapy, i.e., use of supraphysiologic dose followed by complete withdrawal, which is likely to have fewer side effects, was tried in the current study.

STUDY

Dexamethasone pulse therapy, i.e., 100-mg/d infusion in 5% dextrose, was used for 3 consecutive days in 14 patients with severe ulcerative colitis. Ulcerative colitis disease activity was assessed on days 7, 15, 30, and 60. The primary end point was defined as the number of patients who achieved clinical remission and an activity index less than 150 at day 15. The second end point was the number of patients who remained in remission and had an activity index less than 150 at 30 and 60 days. None of the patients enrolled got subsequent oral corticosteroids after their 3 days of megadose corticosteroid infusion.

RESULTS

Clinical remission was achieved in 93% patients (13 of 14 patients) by day 15. Two of these 13 patients suffered relapse during follow-up, and hence, the clinical remission was sustained in 79% patients at 30 and 60 days.

CONCLUSIONS

Dexamethasone pulse therapy is highly effective in inducing remission in patients with ulcerative colitis, but randomized controlled trials are needed to compare dexamethasone pulse therapy with standard oral continuous corticosteroid regimens.

Pyoderma gangrenosum in two siblings: a familial predisposition

We report pyoderma gangrenosum in two siblings with onset during childhood and no associated systemic abnormalities. The patients were born of nonconsanguineous, healthy parents. Treatment with oral corticosteroids produced an excellent clinical response, followed by recurrence after cessation of therapy. Steroids were restarted in combination with dapsone to prevent further recurrence.

Pyoderma gangrenosum. A comparison of typical and atypical forms with an emphasis on time to remission. Case review of 86 patients from 2 institutions

Pyoderma gangrenosum (PG) is an idiopathic, inflammatory, ulcerative disease of undetermined cause. The diagnosis is based on clinical and pathologic features and requires exclusion of conditions that produce ulcerations. An atypical bullous variant (atypical pyoderma gangrenosum, APG) exists with clinical features similar to those of Sweet syndrome. Because PG is a rare disease, few large case series have been reported. Pyoderma gangrenosum was first recognized as a unique disease entity in the first half of the 20th century. Cumulative knowledge of PG is based on a handful of case series and multiple individual case reports. To augment that knowledge, we present our experience with a large number of patients over a significant time. We performed a retrospective analysis of the medical records of 86 patients with PG who were evaluated and treated over 12 years at 2 university-based dermatology departments. The mean (+/- standard deviation) age of onset of PG and APG, respectively, was 44.6 +/- 19.7 years and 52.2 +/- 15.3 years. Lower extremity involvement was most common in PG, whereas upper extremity involvement was most common in APG. Associated relevant systemic diseases were seen in 50% of patients. Inflammatory bowel disease was the most common association in patients with PG, whereas hematologic disease or malignancy was most common in those with APG. Although a few patients were managed with local measures or nonimmunosuppressive treatment, the majority required oral corticosteroid therapy, often with systemic immunosuppressive treatment. PG patients required a mean 11.5 +/- 11.1 months of treatment to achieve remission compared with 9.0 +/- 13.7 months for patients with APG. Five patients (5.8%) had disease that was extremely refractory to multiple intensive therapies. The prognosis and disease associations for PG and APG appear to be different. Compared with PG, APG is more often associated with hematologic disease or malignancy, and remits more quickly.

Split skin grafts in the treatment of pyoderma gangrenosum. A report of four cases

BACKGROUND

Pyoderma gangrenosum (PG) is an uncommon necrotising, non-infective ulceration of the skin. The management of PG is aimed at limiting tissue destruction, promoting the healing of the wound, and providing an acceptable cosmetic result. However, skin grafting is normally avoided because of the potential risk of pathergy-the localization of skin damaged by trauma.

REPORT

We describe the use of split skin grafts in the management of ulcerative pyoderma gangrenosum in 4 patients.

RESULTS

Our cases demonstrate that split skin grafts are a useful treatment modality in patients with ulcerative PG, producing a good cosmetic result. One case illustrates the importance of ensuring the disease is quiescent prior to grafting, to avoid pathergy. The other cases emphasise the need for prolonged immunosuppressive therapy to minimise the chance of reactivation of the disease process.

CONCLUSION

Our preliminary experience of 4 cases of ulcerative PG indicates that split skin grafts have a role to play in its management. The ultimate cosmetic result is considered to be superior to allowing the wound to heal by secondary intention. To limit the risk of pathergy developing, our experience suggests a role for prolonged courses of immunosuppressive therapy. The most effective dose and duration of immunosuppressive therapy in patients with PG treated with split skin grafts remains to be determined. A controlled study would be of benefit to compare it with other current treatment options.

Myelodysplastic syndrome and associated skin lesions: a review of the literature

The skin involvement of the myelodysplastic syndrome (MDS) can take the form of either a neoplastic infiltration or various non specific lesions. The occurrence of these lesions may be the presenting feature of the disease (MDS) or may herald its progression to acute leukemia. Recognition and early diagnosis have therapeutic and prognostic significance.

Pyoderma gangrenosum and cranial osteolysis: case report and review of the paediatric literature

Pyoderma gangrenosum is a poorly understood, ulcerating cutaneous disorder which is rarely seen in the paediatric age-group. We report a 3-year-old boy who developed an ulcer over the left frontoparietal scalp at the age of 1 year. A 9-cm area of underlying cranial bone was destroyed. The appearance on radiographs and CT scan was suggestive of eosinophilic granuloma, osteomyelitis, or other destructive processes. Biopsies of the scalp lesion and calvaria showed granulation tissue and degenerating bone. After the biopsies the scalp lesion increased in size, and wound dehiscence occurred. Ulceration developed at the site of a PPD skin test, which on biopsy was consistent with the diagnosis of pyoderma gangrenosum. Pyoderma gangrenosum should be added to the differential diagnosis of cutaneous disorders which can result in osteolytic/osteonecrotic defects.

Dexamethasone-cyclophosphamide pulse therapy for pemphigus

BACKGROUND

During the last 12 years, we have used a different approach, arbitrarily designed by us, for treating pemphigus patients that has given us very different and encouraging results.

METHOD

The treatment schedule consists of giving 100 mg dexamethasone on 3 consecutive days and 500 mg cyclophosphamide on one day and repeating these pulses (DCPS) every 4 weeks. In between the DCPS, the patient receives only 50 mg cyclophosphamide orally daily and generally no corticosteroids. An essential component of the regimen is to administer a specified amount of the treatment for 1.5 years after achieving clinical remission.

RESULTS

Of the 300 patients enrolled for this treatment, 61 patients could not complete the treatment, whereas 12 patients have died, some of them due to unrelated causes. Of the remaining 227 patients, 190 patients (84%) have already completed the treatment and are free of the disease even after complete withdrawal of all treatment, the duration of posttreatment follow-up being more than 5 years in 48 patients, 2 to 5 years in 75 patients, and less than 2 years in 67 patients. The maximum duration of posttreatment follow-up is 9 years. The remaining patients are also showing the same trend. Twenty-four patients are in remission but have not yet completed the treatment schedule, whereas 13 patients are still having evidence of clinically active disease, although it has already become much milder. The blood levels of intercellular antibody also decrease as the treatment progresses. The side effects commonly observed during treatment with corticosteroids are generally absent or insignificant. The relapses of the disease, seen so far in 59 patients, have been observed mostly in those patients who defaulted during the treatment, but a further course of the DCP regimen led again to complete recovery.

CONCLUSIONS

If substantiated by further follow-up, this treatment schedule may prove curative in this potentially fatal disease.

Efficacy of dexamethasone pulse therapy in progressive systemic sclerosis

BACKGROUND

Systemic sclerosis is a disease of unknown etiology for which no specific treatment is effective. Pulse therapy with corticosteroids has been tried for various autoimmune disorders with minimal side effects. We undertook this study to determine the efficacy of dexamethasone pulse therapy in progressive systemic sclerosis (PSS).

METHODS

Five women with PSS between the ages 30 and 60 years, received 100 mg dexamethasone in 500 mL of 5% dextrose by slow intravenous infusion over 3 hours for 3 consecutive days, once a month.

RESULTS

All patients had symptomatic and clinical improvement. The vital capacity improved in three and posttreatment histopathologic regression was seen in two patients.

CONCLUSIONS

Dexamethasone pulse therapy may provide an additional option for treating systemic sclerosis.

Steroid-pulse therapy in pemphigus vulgaris long term follow-up

BACKGROUND

Patients with pemphigus vulgaris may occasionally present the highly active, widespread form of the disease, and/or maybe resistant to conventional oral steroid therapy, and/or manifest significant side effects from the prolonged use of high oral prednisone dosage. Our purpose was to evaluate the efficacy of steroid "pulse" therapy (PT) in these patients.

METHODS

Eight patients were given alternate-day, one hour, infusions of 8, 9, or 10 mg/kg methylprednisolone Na succinate. Oral prednisone and a second immunosuppressive agent were simultaneously administered; these were rapidly decreased when control of the disease was achieved.

RESULTS

All patients initially responded well to therapy. The disease recurred in four patients after 3, 4, 9, and 16 months of remission, respectively. Three of these patients were treated again with PT and went into remission. None of the patients who received cyclophosphamide had a recurrence. One patient died of cardiac arrest, 12 days after PT. On a follow-up of 59 +/- 25 months since the last relapse, patients continue in remission.

CONCLUSIONS

Pulse therapy is recommended as an adjunct to the total management plan of severely affected patients with pemphigus vulgaris. The addition of cyclophosphamide may prevent the disease from recurring. Alternate-day small-quantity bolus infusions over 16-20 days, may be equally effective as the administration of 15 mg/kg/daily for 3-5 days. The risk of cardiac arrest exists even with this, less aggressive form of PT therapy. A medical history of supraventricular arrhythmias may be considered a risk factor.

Pyoderma gangrenosum in infants and children

Pyoderma gangrenosum is an uncommon ulcerative skin disorder that occurs in all age groups. Approximately 4% of patients are infants and children. There are several notable differences between the childhood and adult manifestations of the disease, including the distribution of lesions and associated disorders. We reviewed the childhood cases (< or = 18 yrs of age) of unequivocal pyoderma gangrenosum in the English literature and tabulated the trends in clinical features, associated disorders, and therapy. We report our 3-week-old patient, the youngest documented case. Of the 46 patients, only 4 were less than 1 year of age. A systemic illness was present in 74% of the older children, most commonly, ulcerative colitis. Only one infant had an associated problem (HIV+) at the time of onset. Infants appear to have an unusual distribution of perianal and genital lesions not often described in other age groups. Our review suggests that pyoderma gangrenosum in children has a similar clinical appearance to that in adults. It is associated with some of the same underlying disorders, but with different frequencies. The distribution of lesions in children is similar, often involving the lower extremities, but pyoderma gangrenosum of the head and face appears to be more common in children. Infants may have ulcers in genital and perianal areas. The most frequently prescribed treatment for children is systemic corticosteroids, which generally are very effective.

Pyoderma gangrenosum--response to topical nitrogen mustard

We report a 69-year-old caucasian male patient with long-standing pyoderma gangrenosum; the lesions preceded the appearance of an IgA monoclonal gammopathy by 2 years. A number of systemic treatments, including high dose steroids and immunosuppressive agents, were poorly tolerated and resulted in serious side-effects. The skin and haematological conditions, however, were kept under control for 2 years with regular plasmapheresis. Pyoderma gangrenosum recurred as vascular access became exhausted but new lesions healed completely with topical application of 20% nitrogen mustard.

Infantile pyoderma gangrenosum

A six month old female infant with pyoderma gangrenosum is reported. Pyoderma gangrenosum in an infant is rare. The child responded to pulse therapy with intravenous dexamethasone and intralesional triamcinolone acetonide.

Superficial granulomatous pyoderma

Superficial granulomatous pyoderma, recently described as a variant of pyoderma gangrenosum, would be better termed pathergic granulomatous cutaneous ulceration as the seven previously described cases, as well as our own two cases, have significant dermal involvement histologically and heal with scarring. In contrast to pyoderma gangrenosum, lesions of superficial granulomatous pyoderma respond to less toxic anti-inflammatory agents.

Erythema multiforme major in a 2-month-old child with human immunodeficiency virus (HIV) infection

A case is presented of severe erythema multiforme occurring in a 2-month-old boy from Zimbabwe which was probably triggered by phenobarbitone. He later developed the acquired immunodeficiency syndrome and serological tests suggested that it was a congenital HIV-I infection.

Pyoderma gangrenosum in childhood leukemia

A case of pyoderma gangrenosum (PG) in a 14-year-old boy with acute myelogenous leukemia (AML) is described. The onset of pyoderma gangrenosum coincided with the relapse of AML. The lesions responded dramatically to treatment with oral prednisone despite the persistence of leukemia. Pyoderma gangrenosum should be included in the differential diagnosis of any nodular, pustular, or necrotic cutaneous eruption in children with leukemia.

Skin manifestations in congenital deficiency of leucocyte-adherence glycoproteins (CDLG)

In congenital deficiency of leucocyte-adherence glycoproteins (CDLG) there is an immunodeficiency with impaired leucocyte function and cutaneous and extracutaneous infections occur. In more than 30% of cases the condition has a fatal course. We report the skin manifestations of three siblings with CDLG in which areas of skin necrosis occurred that resembled pyoderma gangrenosum.

Dexamethasone-cyclophosphamide pulse therapy in pemphigus

Fifty patients with pemphigus (45 pemphigus vulgaris, 5 pemphigus foliaceus) were treated with dexamethasone-cyclophosphamide pulse therapy. The pulse consisted of 136 mg dexamethasone dissolved in 5% dextrose given in a drip over a period of 1-2 hours on 3 consecutive days. In addition, 500 mg cyclophosphamide was added in the drip on the first day. Such pulses were given at monthly intervals. In between the pulses patients were given 50 mg cyclophosphamide orally each day. The results were encouraging, the chief advantage being freedom from side effects of corticosteroid therapy. The lesions healed in 3-4 days and the patients were able to resume their work within one week. Further scope of such therapy in pemphigus is discussed.

Controversy: are systemic steroids indicated in the treatment of erythema multiforme?

The treatment of erythema multiforme major with systemic steroids became established during the 1950s. Recently, two retrospective case reviews comparing steroid-treated and nonsteroid-treated groups of patients with erythema multiforme found that these agents may be associated with complications. As a result, many clinicians have become uncertain as to the appropriate therapy of this disease entity. We successfully treated the condition with steroids in two children and one adolescent. The controversy over the potential efficacy of such therapy for erythema multiforme persists, however.

Cutaneous changes associated with inflammatory bowel disease

Inflammatory bowel disease often begins during adolescence, but may affect younger children. Associated skin lesions are not uncommon. Occasionally, cutaneous alterations may precede the onset of signs or symptoms of the gastrointestinal disorder. Erythema nodosum and pyoderma gangrenosum are the most common associated specific skin changes, but numerous others may be found. Although the skin condition often responds to treatment of the bowel, it may require additional therapy.

Stosstherapy: a fresh look at some principles of therapy--especially chemotherapy

Stosstherapy is the treatment of disease by a single or short-term, large and sometimes massive, dose of a therapeutic agent. It was most commonly used after the discovery of sulphonamides and penicillin, but has been revived with the recent use of single-dose chemotherapy. It is effective in many disorders, and these are documented, together with the dosage ranges which can be used. Stosstherapy has a rational basis, is safe, effective, has many advantages compared with long-term therapy, and could be used much more frequently. Reasons are given why stosstherapy conforms with accepted principles of chemotherapy, but it is given for a much shorter period because the time for an infection to be overcome may be much shorter than has been assumed. It is postulated that the duration of chemotherapy could be shortened in many diseases.

Pyoderma gangrenosum after cholecystectomy

Images

Pyoderma gangrenosum

Since its description 50 years ago, pyoderma gangrenosum has continued to capture the attention and imagination of all those who see its dramatic presentation. Clinical observation still provides the only reliable diagnosis. As investigative techniques increase, more and more intriguing immunologic abnormalities associated with this disorder are discovered, but understanding of the pathogenesis remains elusive. It is now recognized as an independent condition as well as a co-condition with many systemic disorders. Many new treatment options are available, allowing much individualization of treatment. For now, pyoderma gangrenosum remains an impressive, relatively easily recognized, but poorly understood disease.

Direct immunofluorescence in pyoderma gangrenosum

Direct immunofluorescence was done in fifty-one cases of pyoderma gangrenosum. Biopsy specimens were taken from the peripheral erythematous zone of the lesion. In thirty-one cases (61%), there was positive immunofluorescence, with perivascular deposition of immune reactants being the most frequent pattern (twenty-seven cases). These findings support a vasculitic pathogenesis of pyoderma gangrenosum.