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John K, John E, Lange D, Friedling F, Meyer F, Stadie V. Differenzialdiagnostische Fallstricke aus der klinischen Dermatologie. AKTUELLE DERMATOLOGIE 2022. [DOI: 10.1055/a-1460-0074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Kühn JP, Vogt T, Schick B. [A cervical inflammation and signs of sepsis]. HNO 2021; 69:501-503. [PMID: 32876718 DOI: 10.1007/s00106-020-00936-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- J P Kühn
- Klinik für Hals‑, Nasen- und Ohrenheilkunde, Universitätsklinikum des Saarlandes, Kirrberger Straße, 66421, Homburg, Deutschland.
| | - T Vogt
- Klinik für Dermatologie, Venerologie und Allergologie, Universitätsklinikum des Saarlandes, Homburg, Deutschland
| | - B Schick
- Klinik für Hals‑, Nasen- und Ohrenheilkunde, Universitätsklinikum des Saarlandes, Kirrberger Straße, 66421, Homburg, Deutschland
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Saternus R, Schwingel J, Müller CSL, Vogt T, Reichrath J. Ancient friends, revisited: Systematic review and case report of pyoderma gangrenosum-associated autoinflammatory syndromes. J Transl Autoimmun 2020; 3:100071. [PMID: 33305249 PMCID: PMC7718158 DOI: 10.1016/j.jtauto.2020.100071] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 11/15/2020] [Accepted: 11/16/2020] [Indexed: 12/29/2022] Open
Abstract
In the last decade, new scientific findings significantly improved our understanding of the molecular pathogenesis of autoinflammation and have resulted in the identification and definition of several pyoderma gangrenosum-associated autoinflammatory syndromes (PGAAIS) as new and distinct clinical entities. These different clinical entities include PAPA (pyogenic arthritis, pyoderma gangrenosum and acne conglobata), PASH (pyoderma gangrenosum, acne and suppurative hidradenitis), PAPASH (pyoderma gangrenosum, acne, suppurative hidradenitis and pyogenic arthritis), PsAPASH (pyoderma gangrenosum, acne, suppurative hidradenitis and psoriatic arthritis), PASS (pyoderma gangrenosum, acne conglobata, suppurative hidradenitis, and axial spondyloarthritis) and PAC (pyoderma gangrenosum, acne and ulcerative colitis), which can be distinguished by their clinical presentation and the presence or absence of mutations in several genes, such as the genes encoding proline-serine-threonine phosphatase-interacting protein 1 (PSTPIP1), nicastrin (NCSTN), Mediterranean fever (MEFV) and nucleotide-binding oligomerization domain-containing protein (NOD). In this systematic review, we summarize the present knowledge of this rapidly developing hot topic and provide a guide to enable the easy diagnosis of these syndromes in everyday clinical practice. Moreover, we report a rare case of PASS syndrome demonstrating successful treatment with adalimumab and another case of a previously unreported combination of symptoms, including psoriatic arthritis, pyoderma gangrenosum, suppurative hidradenitis and Crohn’s disease (newly coined PsAPSC), as examples. Because of the identification of similar genetic and pathogenic mechanisms of PGAAIS, we think the wide variety of seemingly different syndromes may represent distinct phenotypes of one disease. New scientific findings improved the understanding of the molecular pathogenesis of autoinflammation. There is a similar genetic background and clinical findings of PGAAIS. Because of the similar genetic and pathogenic mechanisms of PGAAIS may represent distinct phenotypes of one disease. We present a 4-sep guide to enable the easy diagnosis of theses disease in clinical practice.
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Affiliation(s)
- Roman Saternus
- Department of Dermatology, The Saarland University Hospital, 66421, Homburg, Germany
| | - Jérôme Schwingel
- Department of Internal Medicine, Caritasklinikum Saarbrücken St. Theresia, 66113, Saarbrücken, Germany
| | - Cornelia S L Müller
- Department of Dermatology, The Saarland University Hospital, 66421, Homburg, Germany
| | - Thomas Vogt
- Department of Dermatology, The Saarland University Hospital, 66421, Homburg, Germany
| | - Jörg Reichrath
- Department of Dermatology, The Saarland University Hospital, 66421, Homburg, Germany
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Partridge ACR, Bai JW, Rosen CF, Walsh SR, Gulliver WP, Fleming P. Effectiveness of systemic treatments for pyoderma gangrenosum: a systematic review of observational studies and clinical trials. Br J Dermatol 2018; 179:290-295. [PMID: 29478243 DOI: 10.1111/bjd.16485] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/19/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND Pyoderma gangrenosum (PG) is a neutrophilic dermatosis with substantial morbidity. There is no consensus on gold-standard treatments. OBJECTIVES To review the effectiveness of systemic therapy for PG. METHODS We searched six databases for 24 systemic therapies for PG. Primary outcomes were complete healing and clinical improvement; secondary outcomes were time to healing and adverse effects. RESULTS We found 3326 citations and 375 articles underwent full-text review; 41 studies met the inclusion criteria. There were 704 participants in 26 retrospective cohort studies, three prospective cohort studies, seven case series, one case-control study, two open-label trials and two randomized controlled trials (RCTs). Systemic corticosteroids were the most studied (32 studies), followed by ciclosporin (21 studies), biologics (16 studies) and oral dapsone (11 studies). One RCT (STOP-GAP, n = 121) showed that prednisolone and ciclosporin were similar: 15-20% of patients showed complete healing at 6 weeks and 47% at 6 months. Another RCT (n = 30) found that infliximab was superior to placebo at 2 weeks (46% vs. 6% response), with a 21% complete healing rate at 6 weeks. Two uncontrolled trials showed 60% and 37% healing within 4 months for canakinumab and infliximab, respectively; other data suggest that patients with concurrent inflammatory bowel disease may benefit from biologics. The remaining studies were poor quality and had small sample sizes but supported the use of corticosteroids, ciclosporin and biologics. CONCLUSIONS Systemic corticosteroids, ciclosporin, infliximab and canakinumab had the most evidence in treating PG. However, current literature is limited to small and lower-quality studies with substantial heterogeneity.
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Affiliation(s)
- A C R Partridge
- MD Program, Faculty of Medicine, University of Toronto, Toronto, Canada
| | - J W Bai
- MD Program, Faculty of Medicine, University of Toronto, Toronto, Canada
| | - C F Rosen
- Division of Dermatology, University of Toronto, Toronto, Canada.,Department of Medicine, University Health Network, Toronto, Canada
| | - S R Walsh
- Division of Dermatology, University of Toronto, Toronto, Canada.,Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - W P Gulliver
- Department of Medicine, Faculty of Medicine, Memorial University of Newfoundland, St. John's, Canada
| | - P Fleming
- Division of Dermatology, University of Toronto, Toronto, Canada
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Mason JM, Thomas KS, Ormerod AD, Craig FE, Mitchell E, Norrie J, Williams HC. Ciclosporin compared with prednisolone therapy for patients with pyoderma gangrenosum: cost-effectiveness analysis of the STOP GAP trial. Br J Dermatol 2017; 177:1527-1536. [PMID: 28391619 PMCID: PMC5811816 DOI: 10.1111/bjd.15561] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/05/2017] [Indexed: 11/30/2022]
Abstract
Background Pyoderma gangrenosum (PG) is a painful, ulcerating skin disease with poor evidence for management. Prednisolone and ciclosporin are the most commonly used treatments, although not previously compared within a randomized controlled trial (RCT). Objectives To compare the cost‐effectiveness of ciclosporin and prednisolone‐initiated treatment for patients with PG. Methods Quality of life (QoL, EuroQoL five dimensions three level questionnaire, EQ‐5D‐3L) and resource data were collected as part of the STOP GAP trial: a multicentre, parallel‐group, observer‐blind RCT. Within‐trial analysis used bivariate regression of costs and quality‐adjusted life years (QALYs), with multiple imputation of missing data, informing a probabilistic assessment of incremental treatment cost‐effectiveness from a health service perspective. Results In the base case analysis, when compared with prednisolone, ciclosporin was cost‐effective due to a reduction in costs [net cost: −£1160; 95% confidence interval (CI) −2991 to 672] and improvement in QoL (net QALYs: 0·055; 95% CI 0·018–0·093). However, this finding appears driven by a minority of patients with large lesions (≥ 20 cm2) (net cost: −£5310; 95% CI −9729 to −891; net QALYs: 0·077; 95% CI 0·004–0·151). The incremental cost‐effectiveness of ciclosporin for the majority of patients with smaller lesions was £23 374/QALY, although the estimate is imprecise: the probability of being cost‐effective at a willingness‐to‐pay of £20 000/QALY was 43%. Conclusions Consistent with the clinical findings of the STOP GAP trial, patients with small lesions should receive treatment guided by the side‐effect profiles of the drugs and patient preference – neither strategy is clearly a preferred use of National Health Service resources. However, ciclosporin‐initiated treatment may be more cost‐effective for patients with large lesions. What's already known about this topic? Pyoderma gangrenosum is characterized by severe, painful skin ulcers. Although prednisolone has been the main systemic treatment, ciclosporin has been used increasingly because of its perceived greater effectiveness and fewer side‐effects. STOP GAP was a pragmatic randomized controlled trial comparing ciclosporin and prednisolone: clinical effectiveness was similar, but only 50% of ulcers had healed by 6 months on either drug and adverse events were common with both drugs.
What does this study add? For patients with small lesions (< 20 cm2), neither treatment is clearly more cost‐effective than the other. However, ciclosporin‐initiated treatment may be the more cost‐effective option in patients with large (≥ 20 cm2) lesions. Decisions about treatment will continue to be informed primarily by patient preference, underlying comorbidities, and drug side‐effect profiles (e.g. serious infections with prednisolone, hypertension and renal dysfunction with ciclosporin).
Linked Comment: Bray. Br J Dermatol 2017; 177:1475–1476. Plain language summary available online
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Affiliation(s)
- J M Mason
- Warwick Medical School, University of Warwick, Coventry, CV4 7AL, U.K
| | - K S Thomas
- Centre of Evidence Based Dermatology, University of Nottingham, NG7 2NR, U.K
| | - A D Ormerod
- Division of Applied Medicine, Aberdeen University, Aberdeen, AB24 2ZD, U.K
| | - F E Craig
- Department of Dermatology, NHS Forth Valley, Stirling, FK8 2AU, U.K
| | - E Mitchell
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, NG7 2UH, U.K
| | - J Norrie
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, EH16 4TU, U.K
| | - H C Williams
- Centre of Evidence Based Dermatology, University of Nottingham, NG7 2NR, U.K
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Ludwig DJ, Roshani H, Steffens MG, Moll FC, Teepe RG. Pyoderma Gangrenosum in the Urologist Clinic. Curr Urol 2016; 9:159-162. [PMID: 27867335 DOI: 10.1159/000447133] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2015] [Accepted: 11/24/2015] [Indexed: 11/19/2022] Open
Abstract
Pyoderma gangrenosum is a rare non-infectious skin disorder. It is often associated with systemic diseases, like the inflammatory bowel disease, rheumatological disease and (hematological) malignancy. The diagnosis is affirmed through a process of elimination and is principally based on clinical presentation and course. We present a 59-year-old male with T-cell large granular lymphocyte leukemia and pyoderma gangrenosum of penis and scrotum. Finally the patient was successfully treated with systemic prednisolone.
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Affiliation(s)
- Dina J Ludwig
- Department of Urology, Haga Teaching Hospital, The Hague, Netherlands
| | - Hossain Roshani
- Department of Urology, Haga Teaching Hospital, The Hague, Netherlands
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Pyoderma gangraenosum – from the right diagnostic investigations to targeted therapy. PHLEBOLOGIE 2016. [DOI: 10.12687/phleb2339-5-2016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
SummaryPyoderma gangrenosum (PG) is a rarely diagnosed neutrophilic skin disorder that still remains a diagnosis of exclusion. Therefore, the diagnosis has to be done in the synopsis of typical clinical findings, patient’s history and exclusion of relevant differential diagnoses. There are numerous references to relevant comorbidities from the metabolic syndrome, rheumatoid arthritis and inflammatory bowel diseases. Of particular importance is the potential association of PG with (haematologic) neoplasms. Treatment of PG includes topical and systemic immuno-modulating or immuno-suppressant therapies. Most important are for topical as well as systemic treatments are glucocorticoids. All other treatments represent an off-label-use. Especially Cyclosporine and TNF-α-inhibitors demonstrated very good and promising clinical results. Accompanying modern moist wound-therapy concepts avoiding painful dressings and an analgesic therapy are recommended.
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Khajehnoori M, O'Brien T. A case of surgically treated peristomal pyoderma gangrenosum in a patient with rheumatoid arthritis. J Surg Case Rep 2016; 2016:rjw103. [PMID: 27302499 PMCID: PMC4906534 DOI: 10.1093/jscr/rjw103] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Peristomal pyoderma gangrenosum (PPG) is a rare subtype of pyoderma gangrenosum that is difficult to diagnose and treat. It is characterized by the rapid progression of painful necrotic ulcer surrounding an area of abdominal stoma. It is almost exclusively associated with inflammatory bowel disease even after bowel surgery and is associated with significant morbidity. Diagnosis of pyoderma gangrenosum is based on exclusion of other disorders replicating some of its clinical features and histopathological evidence. This is a case report of a 56-year-old lady with rheumatoid arthritis who presented with rapidly progressing abdominal ulcer 8 months after a Hartmanns procedure for perforated diverticulitis. The ulcer had formed a large cavity causing faecal filling in the dependent defect. The other causes of ulcer were excluded with negative histopathology, negative polymerase chain reaction for Mycobacterium ulcerans and negative acid fast bacillus (AFB) test. She was diagnosed with PPG which is routinely treated medically due to risk of setting off a second focus of pyoderma if surgically intervened. However due to increased risk of faecal peritonitis, it was decided to proceed with surgical debridement. This article will discuss the case in more detail and briefly discuss diagnosis and treatment options for PPG.
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Affiliation(s)
- Masoomeh Khajehnoori
- Department of General Surgery, University Hospital, Barwon Health, Geelong, VIC, Australia,
| | - Tim O'Brien
- Department of Medicine, University Hospital, Barwon Health, Geelong, VIC, Australia
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Reynolds C, Schofer N, Zengin E, Lohse AW, Faiss S, Schmiedel S. [Multiple abscesses after a cruise along the Latin American coast]. Internist (Berl) 2016; 57:284-8. [PMID: 26782091 DOI: 10.1007/s00108-015-0004-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
We report a case of an extracutaneous involvement of pyoderma gangrenosum. The patient initially presented with multiple sterile abscesses of the skin, heart, prostate, and kidney. Extracutaneous involvement in pyoderma gangrenosum is very rare. Confirmation of the diagnosis was only possible after exclusion of other relevant differential diagnoses. Continuous search for microbes proved negative and after an empiric therapeutic attempt with prednisolone, the patient improved quickly. However, each time we reduced the steroids even in combination with methotrexate or with azathioprine the patient relapsed. Only after therapy with the tumor necrosis factor-α-inhibitor infliximab was permanent remission achieved.
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Affiliation(s)
- C Reynolds
- I. Medizinische Klinik und Poliklinik, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - N Schofer
- Universitäres Herzzentrum Hamburg GmbH, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - E Zengin
- Universitäres Herzzentrum Hamburg GmbH, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - A W Lohse
- I. Medizinische Klinik und Poliklinik, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - S Faiss
- Gastroenterologie und Interventionelle Endoskopie, Viszeralmedizinisches Zentrum, Asklepios-Klinik Barmbek, Hamburg, Deutschland
| | - S Schmiedel
- I. Medizinische Klinik und Poliklinik, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland. .,Ambulanzzentrum, Bereich Infektiologie, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland.
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Ormerod AD, Thomas KS, Craig FE, Mitchell E, Greenlaw N, Norrie J, Mason JM, Walton S, Johnston GA, Williams HC. Comparison of the two most commonly used treatments for pyoderma gangrenosum: results of the STOP GAP randomised controlled trial. BMJ 2015; 350:h2958. [PMID: 26071094 PMCID: PMC4469977 DOI: 10.1136/bmj.h2958] [Citation(s) in RCA: 158] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To determine whether ciclosporin is superior to prednisolone for the treatment of pyoderma gangrenosum, a painful, ulcerating skin disease with a poor evidence base for management. DESIGN Multicentre, parallel group, observer blind, randomised controlled trial. SETTING 39 UK hospitals, recruiting from June 2009 to November 2012. PARTICIPANTS 121 patients (73 women, mean age 54 years) with clinician diagnosed pyoderma gangrenosum. Clinical diagnosis was revised in nine participants after randomisation, leaving 112 participants in the analysis set (59 ciclosporin; 53 prednisolone). INTERVENTION Oral prednisolone 0.75 mg/kg/day compared with ciclosporin 4 mg/kg/day, to a maximum dose of 75 and 400 mg/day, respectively. MAIN OUTCOME MEASURES The primary outcome was speed of healing over six weeks, captured using digital images and assessed by blinded investigators. Secondary outcomes were time to healing, global treatment response, resolution of inflammation, self reported pain, quality of life, number of treatment failures, adverse reactions, and time to recurrence. Outcomes were assessed at baseline and six weeks and when the ulcer had healed (to a maximum of six months). RESULTS Of the 112 participants, 108 had complete primary outcome data at baseline and six weeks (57 ciclosporin; 51 prednisolone). Groups were balanced at baseline. The mean (SD) speed of healing at six weeks was -0.21 (1.00) cm(2)/day in the ciclosporin group compared with -0.14 (0.42) cm(2)/day in the prednisolone group. The adjusted mean difference showed no between group difference (0.003 cm(2)/day, 95% confidence interval -0.20 to 0.21; P=0.97). By six months, ulcers had healed in 28/59 (47%) participants in the ciclosporin group compared with 25/53 (47%) in the prednisolone group. In those with healed ulcers, eight (30%) receiving ciclosporin and seven (28%) receiving prednisolone had a recurrence. Adverse reactions were similar for the two groups (68% ciclosporin and 66% prednisolone), but serious adverse reactions, especially infections, were more common in the prednisolone group. CONCLUSION Prednisolone and ciclosporin did not differ across a range of objective and patient reported outcomes. Treatment decisions for individual patients may be guided by the different side effect profiles of the two drugs and patient preference. Trial registration Current Controlled Trials ISRCTN35898459.
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Affiliation(s)
| | - Kim S Thomas
- Centre of Evidence Based Dermatology, University of Nottingham, NG7 2NR, UK
| | - Fiona E Craig
- Department of Dermatology, Aberdeen Royal Infirmary, Aberdeen, UK
| | - Eleanor Mitchell
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Nicola Greenlaw
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, UK
| | - John Norrie
- Centre for Healthcare Randomised Trials, Aberdeen University, Aberdeen, UK
| | - James M Mason
- School of Medicine, Pharmacy and Health, Durham University, Durham, UK
| | - Shernaz Walton
- Department of Dermatology, Hull Royal Infirmary, Hull, UK
| | | | - Hywel C Williams
- Centre of Evidence Based Dermatology, University of Nottingham, NG7 2NR, UK
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Hinterberger L, Müller CSL, Vogt T, Pföhler C. Adalimumab: a treatment option for pyoderma gangrenosum after failure of systemic standard therapies. Dermatol Ther (Heidelb) 2012; 2:6. [PMID: 23205329 PMCID: PMC3510423 DOI: 10.1007/s13555-012-0006-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2012] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Pyoderma gangrenosum (PG) belongs to a group of neutrophilic dermatoses and is often associated with systemic disorders. The authors present a patient with a recalcitrant PG that did not respond to systemic standard therapies, and discuss further treatment options with impact on quality of life. CASE REPORT A 42-year-old woman with recurrent PG since 2005 was presented to the dermatology department in April 2010. Systemic standard therapies including azathioprine, corticosteroids, mycophenolate mofetil, and cyclophosphamide in combination with intensive topical treatment showed to be ineffective. Hence, in October 2010 the authors discontinued any previous systemic therapies and implemented a subcutaneously-administered therapy with adalimumab starting with 80 mg in week 0 and 40 mg in week 1, followed by 40 mg every second week. Under this therapy the ulceration got steadily smaller and healed nearly completely within 64 weeks. However, treatment with adalimumab is still ongoing, with the intent of consolidation and treatment success, but application intervals have been extended to 4-week intervals. Therapy with adalimumab was well tolerated without any side effects and led to an increased quality of life measured with the Dermatology Life Quality Index. DISCUSSION An immune-modulatory monotherapy with adalimumab is a viable treatment option for recalcitrant PG. Thanks to the easy administration, rare side effects, and good healing action it is a convincing therapeutic strategy.
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Affiliation(s)
- Louisa Hinterberger
- Department of Dermatology, Saarland University Hospital, Kirrbergerstrasse, 66421 Homburg/Saar, Germany
| | - Cornelia S. L. Müller
- Department of Dermatology, Saarland University Hospital, Kirrbergerstrasse, 66421 Homburg/Saar, Germany
| | - Thomas Vogt
- Department of Dermatology, Saarland University Hospital, Kirrbergerstrasse, 66421 Homburg/Saar, Germany
| | - Claudia Pföhler
- Department of Dermatology, Saarland University Hospital, Kirrbergerstrasse, 66421 Homburg/Saar, Germany
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Abstract
Pyoderma gangrenosum is a rare affection of unknown etiology, which is often associated with systemic diseases such as chronic inflammatory bowel disease, hematologic disorders, carcinomas and arthritis. Treatment may include topical corticosteroids or calcineurin inhibitors in combination with systemic corticosteroids, cyclosporine A, azathioprine, cyclophosphamide, mycophenolate mofetil, intravenous immunoglobulins or monoclonal antibodies against TNFα but all these approaches are off-label. Surgical therapy is difficult because of pathergy. Nevertheless, after having stopped the inflammation, the ulcers can be treated by split thickness skin grafts and simultaneous immunosuppression. We present three cases with successful surgical treatment.
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