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Sanchez-Melendez SN, Malik R, Patel PM, Milosavljevic S, Patel S, Nambudiri VE. Pyoderma gangrenosum and impact on quality of life: A narrative review. Exp Dermatol 2024; 33:e14876. [PMID: 37424357 DOI: 10.1111/exd.14876] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 06/21/2023] [Accepted: 06/23/2023] [Indexed: 07/11/2023]
Abstract
Pyoderma gangrenosum (PG) is an autoinflammatory disorder typically characterized by progressive ulcers with dense neutrophilic infiltrates in the absence of infectious causes. The chronic nature of this disease significantly impacts the patients' quality of life (QoL). Yet there is currently a dearth of information in the literature regarding standardised treatment guidelines and the impact of PG on patients' QoL. We conducted a literature search on PubMed using the terms "pyoderma gangrenosum" AND "quality of life." We identified nine relevant articles that provide insight into which domains are affected and what treatment can improve QoL. The most common domains involved are physical, emotional, and psychological. Patients tend to feel depressed/anxious, isolated, and embarrassed secondary to PG manifestations. Comorbidities such as Crohn's disease, monoclonal gammopathy of dermatologic significance, and ulcerative colitis can worsen the impact on these patients' QoL. Pain is also a significant contributor to decreasing patients' QoL. Treatments such as topical steroids, adalimumab, and canakinumab may help improve QoL scores. We believe this information can help clinicians guide the care of patients with PG and highlight the need for more studies and clinical trials focusing on PG treatments' impact on QoL.
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Affiliation(s)
- Stephanie N Sanchez-Melendez
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Ponce Health Sciences University, School of Medicine, Ponce, Puerto Rico, USA
| | - Rhea Malik
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Payal M Patel
- Department of Dermatology, Cutaneous Biology Research Center, Massachusetts General Hospital, Harvard University, Boston, Massachusetts, USA
| | | | - Shrey Patel
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Vinod E Nambudiri
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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2
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Nishimura M, Mizutani K, Yokota N, Goto H, Akeda T, Kitagawa H, Habe K, Hayashi A, Yamanaka K. Treatment Strategy for Pyoderma Gangrenosum: Skin Grafting with Immunosuppressive Drugs. J Clin Med 2022; 11:jcm11236924. [PMID: 36498498 PMCID: PMC9739536 DOI: 10.3390/jcm11236924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Revised: 11/20/2022] [Accepted: 11/21/2022] [Indexed: 11/25/2022] Open
Abstract
Pyoderma gangrenosum (PG) is a relatively rare neutrophilic dermatosis presenting as a rapidly progressive and painful skin ulcer characterized by undermined borders and peripheral erythema. Immunosuppressive therapy is the first-line treatment for PG; however, large ulcers often take months or years to heal. Surgical treatments, such as negative pressure wound therapy (NPWT) and skin grafting, are still controversial due to the risk of inducing the pathergy phenomenon and eliciting PG development by traumatic factors. Herein, we report on four cases of PG treated with skin grafting, with or without NPWT, under the control of immunosuppressive drugs at our institution. All cases adapted well, but one case showed recurrence at the periphery of the grafted area five months postoperatively. The current patients were treated with the following doses of oral prednisolone (PSL): PSL 10 mg daily, PSL 5 mg daily + adalimumab 40 mg/week, PSL 12 mg + 6 mg of tacrolimus daily, and PSL 20 mg daily during skin grafting. No severe complications, including infections, were observed. Surgical treatments, such as skin grafting with or without NPWT, may accelerate wound healing, shorten the administration of analgesics and long-term immunosuppressive therapy, and reduce the risk of infection.
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Affiliation(s)
- Mai Nishimura
- Department of Dermatology, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu 514-8507, Japan
| | - Kento Mizutani
- Department of Dermatology, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu 514-8507, Japan
| | - Naho Yokota
- Department of Dermatology, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu 514-8507, Japan
| | - Hiroyuki Goto
- Department of Dermatology, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu 514-8507, Japan
| | - Tomoko Akeda
- Department of Dermatology, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu 514-8507, Japan
| | - Hiroshi Kitagawa
- Department of Dermatology, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu 514-8507, Japan
| | - Koji Habe
- Department of Dermatology, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu 514-8507, Japan
| | - Akinobu Hayashi
- Department of Oncologic Pathology, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu 514-8507, Japan
| | - Keiichi Yamanaka
- Department of Dermatology, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu 514-8507, Japan
- Correspondence: ; Tel.: +81-59-232-1111
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Yamasaki K, Yamanaka K, Zhao Y, Iwano S, Takei K, Suzuki K, Yamamoto T. Adalimumab in Japanese patients with active ulcers of pyoderma gangrenosum: Final analysis of a 52-week phase 3 open-label study. J Dermatol 2022; 49:479-487. [PMID: 35243682 PMCID: PMC9313851 DOI: 10.1111/1346-8138.16337] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 01/20/2022] [Accepted: 02/10/2022] [Indexed: 02/02/2023]
Abstract
In this 52-week, phase 3 open-label study, efficacy and safety of adalimumab were evaluated in Japanese patients with active ulcers due to pyoderma gangrenosum (PG) during a 26-week treatment period and another 26-week extension period. Patients received adalimumab 160 mg at week 0, 80 mg at week 2, and 40 mg every week from week 4. At week 26, 12 of 22 patients (54.5%, p < 0.001) achieved the primary efficacy endpoint of PG area reduction 100 (PGAR 100, complete skin re-epithelialization) for the target ulcer. Nine patients with Physician's Global Assessment (PGA) score of 1, 2, or 3, including four patients achieving PGAR 100, continued into the extension period. During the extension period, six of nine patients (66.7%) achieved PGAR 100 for the target PG ulcer at 52 weeks; one patient who achieved PGAR 100 before week 26 experienced a relapse 162 days after achieving this endpoint. Six patients achieved PGA 0 by week 52, and one patient reported new ulcers at day 57 of the extension period. Continued improvements from study baseline to week 52 were observed in pain (mean [95% CI] -4.0 [-6.5 to -1.5] numeric rating scale) and Dermatology Life Quality Index (-7.3 [-15.1 to 0.4]). In addition to the adverse events (AE) reported in 18 patients (including four serious AE) through week 26 (most commonly infections [n = 11]), there was one 1 additional AE (infection) during the extension period. These results suggest that adalimumab is effective and generally well tolerated in Japanese patients with active PG ulcers.
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Affiliation(s)
- Kenshi Yamasaki
- Department of Dermatology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Keiichi Yamanaka
- Department of Dermatology, Mie University Graduate School of Medicine, Tsu, Japan
| | - Yiwei Zhao
- AbbVie Inc., Cambridge, Massachusetts, USA
| | | | | | | | - Toshiyuki Yamamoto
- Department of Dermatology, Fukushima Medical University, Fukushima, Japan
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4
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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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5
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Yamasaki K, Yamanaka K, Zhao Y, Iwano S, Takei K, Suzuki K, Yamamoto T. Adalimumab in Japanese patients with active ulcers of pyoderma gangrenosum: Twenty-six-week phase 3 open-label study. J Dermatol 2020; 47:1383-1390. [PMID: 32804433 PMCID: PMC7754463 DOI: 10.1111/1346-8138.15533] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 07/04/2020] [Indexed: 12/01/2022]
Abstract
This phase 3 multicenter study, including 26‐week treatment and extension periods, evaluated the efficacy and safety of adalimumab in Japanese patients with active ulcers due to pyoderma gangrenosum. Patients received adalimumab 160 mg at week 0, 80 mg at week 2, and then 40 mg every week starting at week 4. Of the 22 enrolled patients, 12 (54.5%, P < 0.001) achieved the primary efficacy end‐point of pyoderma gangrenosum area reduction 100 (PGAR 100, defined as complete skin re‐epithelialization) for the target ulcer at week 26 assessed by digital planimetry. PGAR 100 response was observed as early as week 6 (13.6%) and continued to increase over time. The mean percent change from baseline in target ulcer area was −31.8% at week 6 and −63.8% at week 26. A Physician’s Global Assessment score of 0 (PGA 0, all ulcers completely clear) was achieved by two patients (9.1%) at week 6 and eight (36.4%) at week 26, while PGA 0/1 (completely/almost clear) was achieved by five (22.7%) and 12 patients (54.5%) at week 6 and 26, respectively. Mean changes from baseline in pain numeric rating scale (−1.8 at week 6 and −2.5 at week 26) and the Dermatology Life Quality Index (−3.1 at week 6 and −3.6 at week 26) improved over time. Adverse events were reported by 18 patients, most commonly infections (n = 11), and serious adverse events by four. These results suggest that adalimumab is effective and generally well tolerated in Japanese patients with active ulcers of pyoderma gangrenosum.
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Affiliation(s)
- Kenshi Yamasaki
- Department of Dermatology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Keiichi Yamanaka
- Department of Dermatology, Graduate School of Medicine, Mie University, Tsu, Japan
| | - Yiwei Zhao
- AbbVie Inc., Cambridge, Massachusetts, USA
| | | | | | | | - Toshiyuki Yamamoto
- Department of Dermatology, Fukushima Medical University School of Medicine, Fukushima, Japan
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Mitra D, Chopra A, Saraswat N, Mitra B, Talukdar K, Agarwal R. Biologics in Dermatology: Off-Label Indications. Indian Dermatol Online J 2020; 11:319-327. [PMID: 32695686 PMCID: PMC7367577 DOI: 10.4103/idoj.idoj_407_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2018] [Revised: 06/05/2019] [Accepted: 06/10/2019] [Indexed: 11/04/2022] Open
Abstract
Skin and subcutaneous diseases affect millions of people worldwide, causing significant morbidity. Biologics are becoming increasingly useful for the treatment of many skin diseases, particularly as alternatives for patients who have failed to tolerate or respond to conventional systemic therapies. Biological therapies provide a targeted approach to treatment through interaction with specific components of the underlying immune and inflammatory disease processes. Advances in the understanding of disease pathophysiology for inflammatory skin diseases and in drug development have ushered in biologic therapies in dermatology. Biologic therapies are molecules that target specific proteins implicated in immune-mediated disease. This review article highlights the increasing evidence base for biologics in dermatology for off-label use.
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Affiliation(s)
- Debdeep Mitra
- Department of Dermatology, Base Hospital Delhi Cantt, New Delhi, India
| | - Ajay Chopra
- Department of Dermatology, Base Hospital Delhi Cantt, New Delhi, India
| | - Neerja Saraswat
- Department of Dermatology, Base Hospital Delhi Cantt, New Delhi, India
| | - Barnali Mitra
- Department of Pediatrics, Base Hospital Delhi Cantt, New Delhi, India
| | - Krishna Talukdar
- Department of Dermatology, Jorhat Medical College and Hospital, Jorhat, Assam, India
| | - Reetu Agarwal
- Department of Dermatology, Base Hospital Delhi Cantt, New Delhi, India
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7
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Raj C, Ray A, Panda A, Panda M. Giant pyoderma gangrenosum treated successfully with combination of dexamethasone pulse and cyclosporine. INDIAN JOURNAL OF DRUGS IN DERMATOLOGY 2020. [DOI: 10.4103/ijdd.ijdd_48_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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8
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DaCunha M, Siscos S, Downing M, Tarantino I, Hall J. Pyoderma gangrenosum controlled with rituximab. JAAD Case Rep 2019; 5:593-595. [PMID: 31312710 PMCID: PMC6610635 DOI: 10.1016/j.jdcr.2019.04.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Affiliation(s)
- Matthew DaCunha
- Division of Dermatology, University of Kansas Medical Center, Kansas City, Kansas
| | - Spyros Siscos
- Division of Dermatology, University of Kansas Medical Center, Kansas City, Kansas
| | - Malia Downing
- Division of Dermatology, University of Kansas Medical Center, Kansas City, Kansas
| | - Isadore Tarantino
- Division of Dermatology, University of Kansas Medical Center, Kansas City, Kansas
| | - John Hall
- Division of Dermatology, University of Kansas Medical Center, Kansas City, Kansas
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9
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Ben Abdallah H, Fogh K, Bech R. Pyoderma gangrenosum and tumour necrosis factor alpha inhibitors: A semi-systematic review. Int Wound J 2019; 16:511-521. [PMID: 30604927 PMCID: PMC7949186 DOI: 10.1111/iwj.13067] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Revised: 12/12/2018] [Accepted: 12/18/2018] [Indexed: 12/13/2022] Open
Abstract
Pyoderma gangrenosum (PG) is a rare ulcerative skin disease that presents a therapeutic challenge. Tumour necrosis factor alpha (TNFα) inhibitors have been reported to successfully control PG. Our aim was to systematically evaluate and compare the clinical effectiveness of TNFα inhibitors in adults with PG. A literature search including databases such as PubMed, Embase, Scopus, and Web of Science was conducted, using search terms related to PG and TNFα inhibitors. Studies and case reports were included if patients were diagnosed with PG, over the age of 18 and administered TNFα inhibitor. A total of 3212 unique citations were identified resulting in 222 articles describing 356 patients being included in our study. The study we report found an 87% (95% CI: 83%-90%) response rate and a 67% (95% CI: 62%-72%) complete response rate to TNFα inhibitors. No statistically significant differences in the response rates (P = 0.6159) or complete response rates (P = 0.0773) to infliximab, adalimumab, and etanercept were found. In our study TNFα inhibitors demonstrated significant effectiveness with response and complete response rates supporting the use of TNFα inhibitors to treat PG in adults. Our study suggests that there is no significant difference in effectiveness among infliximab, adalimumab, and etanercept.
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Affiliation(s)
- Hakim Ben Abdallah
- Institute of Clinical Medicine, Aarhus Faculty of Health SciencesAarhus UniversityAarhusDenmark
| | - Karsten Fogh
- Department of DermatologyAarhus University HospitalAarhusDenmark
| | - Rikke Bech
- Department of DermatologyAarhus University HospitalAarhusDenmark
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10
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Quist SR, Kraas L. Treatment options for pyoderma gangrenosum. J Dtsch Dermatol Ges 2019; 15:34-40. [PMID: 28140549 DOI: 10.1111/ddg.13173] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Accepted: 08/02/2016] [Indexed: 12/19/2022]
Abstract
Pyoderma gangrenosum (PG) is an orphan disease. While research on such disorders is based on only few randomized multicenter as well as retrospective studies, most of the data comes from case series of small patient groups. Apart from topical and intralesional therapeutic options for early stages and mild disease courses, treatment predominantly involves systemic therapeutic agents. Besides systemic corticosteroids and cyclosporine A (CsA), options also include intravenous immunoglobulins (IVIG) and biologics such as the TNFα inhibitors infliximab, adalimumab, and etanercept; the interleukin (IL) 12/23 antibody ustekinumab; the IL-1 receptor antagonist anakinra; and the IL-1β antibody canakinumab. The best evidence-based study data is available for CsA, prednisolone, and infliximab; the latter especially in patients with concomitant ulcerative colitis or Crohn's disease. A response to IVIG and canakinumab has been reported in smaller case series. First described by Brocq almost 100 years ago, it was soon recognized that PG did in fact require treatment. To this day, however, such treatment remains a clinical challenge. Despite the severe - albeit rare -clinical picture, improvement in therapeutic options may be expected in the future, primarily due to further clinical studies - especially with a greater number of patients, a better understanding of the etiopathogenesis, as well as the use of modern targeted therapies with higher efficacy and a lower rate of side effects than conventional immunosuppressants such as prednisolone and CsA.
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Affiliation(s)
- Sven R Quist
- Department of Dermatology and Venereology, Otto von Guericke University, Magdeburg, Germany
| | - Luise Kraas
- Department of Dermatology and Venereology, Otto von Guericke University, Magdeburg, Germany
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11
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McKenzie F, Cash D, Gupta A, Cummings LW, Ortega-Loayza AG. Biologic and small-molecule medications in the management of pyoderma gangrenosum. J DERMATOL TREAT 2018; 30:264-276. [PMID: 30051737 DOI: 10.1080/09546634.2018.1506083] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Pyoderma gangrenosum (PG) is an uncommon inflammatory skin disorder characterized by neutrophil dysfunction. There are currently no FDA-approved drugs for the treatment of this disease, and treatment has typically relied on traditional immunosuppressive medications such as prednisone or cyclosporine. The efficacy of biologics in the treatment of other pro-inflammatory conditions such as psoriasis, rheumatoid arthritis, and inflammatory bowel disease is well-documented in the literature. Therefore, the use of biologic medications for the treatment of rarer inflammatory skin conditions, such as PG, is a compelling topic for investigation. Biologic and small-molecule therapies allow physicians to target specific pro-inflammatory mediators that underlie PG pathogenesis. This review provides an update on the use of biologic and small-molecule medications for the treatment of PG and summarizes the latest data on the clinical efficacy and pharmacology of these treatments.
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Affiliation(s)
- Fatima McKenzie
- a Department of Dermatology , Oregon Health & Science University , Portland , OR , USA
| | - Devin Cash
- b School of Medicine , Virginia Commonwealth University , Richmond , VA , USA
| | - Angela Gupta
- b School of Medicine , Virginia Commonwealth University , Richmond , VA , USA
| | - Laurel W Cummings
- b School of Medicine , Virginia Commonwealth University , Richmond , VA , USA
| | - Alex G Ortega-Loayza
- a Department of Dermatology , Oregon Health & Science University , Portland , OR , USA
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13
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Garcovich S, De Simone C, Berti E, Marzano AV. Drug management of neutrophilic dermatoses. Expert Rev Clin Pharmacol 2017; 10:1119-1128. [PMID: 28715916 DOI: 10.1080/17512433.2017.1356719] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Neutrophilic dermatoses are a heterogenous group of chronic, cutaneous inflammatory conditions characterized by the accumulation of neutrophils in the skin and by systemic inflammation. Neutrophilic dermatoses can be idiopathic or associated with other inflammatory or systemic diseases, including the group of the hereditary, autoinflammatory syndromes. Clinical management is challenging, due to limited clinical evidence and lack of clinical practice guidelines. Areas covered: This review provides an overview of current therapeutic management of the three prototypical neutrophilic dermatoses, aseptic pustulosis of the folds, Sweet syndrome and pyoderma gangrenosum. In addition, we describe innovative, pathogenesis-oriented treatment approaches, which are based on recent advances in the pathophysiology of neutrophilic dermatoses and autoinflammatory syndromes. The increasing role of the IL-1 cytokine family in initiating neutrophilic inflammation in both idiopathic and syndromic disease opened the way for the use of targeted biological treatment. Another promising treatment strategy is aimed at blocking downstream effector cytokines, such as IL12/23 and IL-17, involved in the autoinflammatory immune cascade. Expert commentary: In chronic-recurrent and syndromic cases of neutrophilic dermatoses, there is an unmet clinical need for long-term, continuous disease control. Future controlled clinical studies will optimize the use of targeted-biological agents in sequential or combination treatment strategies.
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Affiliation(s)
- Simone Garcovich
- a Institute of Dermatology , Policlinico A. Gemelli University Hospital, Catholic University of the Sacred Heart , Rome , Italy
| | - Clara De Simone
- a Institute of Dermatology , Policlinico A. Gemelli University Hospital, Catholic University of the Sacred Heart , Rome , Italy
| | - Emilio Berti
- b UOC Dermatologia, IRCCS Fondazione Ca' Granda Ospedale Maggiore Policlinico, Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti , Università Degli Studi di Milano , Milan , Italy
| | - Angelo Valerio Marzano
- b UOC Dermatologia, IRCCS Fondazione Ca' Granda Ospedale Maggiore Policlinico, Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti , Università Degli Studi di Milano , Milan , Italy
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14
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Alavi A, French LE, Davis MD, Brassard A, Kirsner RS. Pyoderma Gangrenosum: An Update on Pathophysiology, Diagnosis and Treatment. Am J Clin Dermatol 2017; 18:355-372. [PMID: 28224502 DOI: 10.1007/s40257-017-0251-7] [Citation(s) in RCA: 169] [Impact Index Per Article: 24.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Pyoderma gangrenosum (PG) is a rare inflammatory neutrophilic disorder with prototypical clinical presentations. Its pathophysiology is complex and not fully explained. Recent information regarding the genetic basis of PG and the role of auto-inflammation provides a better understanding of the disease and new therapeutic targets. PG equally affects patients of both sexes and of any age. Uncontrolled cutaneous neutrophilic inflammation is the cornerstone in a genetically predisposed individual. Multimodality management is often required to reduce inflammation, optimize wound healing, and treat underlying disease. A gold standard for the management of PG does not exist and high-level evidence is limited. Multiple factors must be taken into account when deciding on the optimum treatment for individual patients: location, number and size of lesion/ulceration(s), extracutaneous involvement, presence of associated disease, cost, and side effects of treatment, as well as patient comorbidities and preferences. Refractory and rapidly progressive cases require early initiation of systemic therapy. Newer targeted therapies represent a promising pathway for the management of PG, and the main focus of this review is the management and evidence supporting the role of new targeted therapies in PG.
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15
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Quist SR, Kraas L. Therapieoptionen beim Pyoderma gangraenosum. J Dtsch Dermatol Ges 2017; 15:34-41. [DOI: 10.1111/ddg.13173_g] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Accepted: 08/02/2016] [Indexed: 01/02/2023]
Affiliation(s)
- Sven R. Quist
- Klinik für Dermatologie und Venerologie; Otto-von-Guericke Universität; Magdeburg
| | - Luise Kraas
- Klinik für Dermatologie und Venerologie; Otto-von-Guericke Universität; Magdeburg
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16
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Kashiwado Y, Uchino A, Ota T, Nagano S. Intestinal Behçet's disease with pyoderma gangrenosum successfully treated with the combination therapy of adalimumab and glucocorticoids. Mod Rheumatol 2016; 28:901-905. [PMID: 27142127 DOI: 10.3109/14397595.2016.1174327] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
A 24-year-old male presented with orogenital ulcers, folliculitis, and progressive painful skin ulcers with a raised inflammatory border. Colonoscopy revealed volcano-shaped intestinal ulcers in the ascending colon, and hence, he was diagnosed as intestinal Behçets disease (BD) with pyoderma gangrenosum (PG). Treatment with systemic glucocorticoids and adalimumab dramatically improved the patient's symptoms. Our case demonstrates that early induction of adalimumab may contribute to the successful treatment of such difficult-to-treat conditions as intestinal BD with PG.
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Affiliation(s)
- Yusuke Kashiwado
- a Department of Rheumatology , Aso Iizuka Hospital , Fukuoka , Japan
| | - Ayumi Uchino
- a Department of Rheumatology , Aso Iizuka Hospital , Fukuoka , Japan
| | - Toshiyuki Ota
- a Department of Rheumatology , Aso Iizuka Hospital , Fukuoka , Japan
| | - Shuji Nagano
- a Department of Rheumatology , Aso Iizuka Hospital , Fukuoka , Japan
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Abstract
Biologic therapy has dramatically changed the way medicine, and specifically dermatology, is practiced today. The use of biologic agents in dermatology is evolving, with psoriasis being the most common indication for which biologics are used currently. However, several other dermatologic diseases seem to be responsive to biologic therapy, and continuing research and development efforts are elucidating the benefit-risk profiles of various biologic medications in these dermatologic conditions. Although biologic agents have revolutionized the management of dermatologic conditions, cost must also be considered when evaluating management options, especially compared with traditional agents. For example, the cost of 1 year of induction and maintenance treatment of psoriasis in 2014 was estimated to be $53,909 for ustekinumab, $46,395 for etanercept, and $39,041 for adalimumab. Nonetheless, because of their efficacy, the cost of a biologic may be offset by significant reductions in the number of hospital stays, reduction in use of other systemic therapies, and increased satisfaction by patients.32 Thus, understanding their mechanisms of action, labeled and off-label uses in dermatology, and common adverse effects helps to inform clinical decision making and improve patient outcomes.
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Affiliation(s)
- Ramin Fathi
- Department of Dermatology, University of Colorado Denver, 1665 Aurora Court, Room 3234, Mail Stop F703, Aurora, CO 80045, USA.
| | - April Wang Armstrong
- Department of Dermatology, University of Colorado Denver, 1665 Aurora Court, Room 3234, Mail Stop F703, Aurora, CO 80045, USA
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Abstract
The advent of biologics in dermatologic treatment armentarium has added refreshing dimensions, for it is a major breakthrough. Several agents are now available for use. It is therefore imperative to succinctly comprehend their pharmacokinetics for their apt use. A concerted endeavor has been made to delve on this subject. The major groups of biologics have been covered and include: Drugs acting against TNF-α, Alefacept, Ustekinumab, Rituximab, IVIG and Omalizumab. The relevant pharmacokinetic characteristics have been detailed. Their respective label (approved) and off-label (unapproved) indications have been defined, highlighting their dosage protocol, availability and mode of administration. The evidence level of each indication has also been discussed to apprise the clinician of their current and prospective uses. Individual anti-TNF drugs are not identical in their actions and often one is superior to the other in a particular disease. Hence, the section on anti-TNF agents mentions the literature on each drug separately, and not as a group. The limitations for their use have also been clearly brought out.
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Affiliation(s)
- Virendra N Sehgal
- Dermato-Venereology (Skin/VD) Center, Sehgal Nursing Home, Delhi, India
| | - Deepika Pandhi
- Department of Dermatology and STD, University College of Medical Sciences and Associated Guru Teg Bahadur Hospital, Delhi, India
| | - Ananta Khurana
- Department of Dermatology and STD, University College of Medical Sciences and Associated Guru Teg Bahadur Hospital, Delhi, India
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19
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Wollina U, Tchernev G. Pyoderma gangrenosum: pathogenetic oriented treatment approaches. Wien Med Wochenschr 2014; 164:263-73. [DOI: 10.1007/s10354-014-0285-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2014] [Accepted: 05/01/2014] [Indexed: 01/10/2023]
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20
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Abstract
The review provides an update on pyoderma ganrenosum, a rare chronic disease from a group of neutrophilic dermatoses. It considers its pathogenesis, its association with background visceral disease, and the specific features of skin and visceral involvement. Major and minor diagnostic criteria and differential treatment approaches are given.
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21
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Abstract
Parastomal pyoderma gangrenosum (PPG) is an unusual neutrophilic dermatosis characterized by painful, necrotic ulcerations occurring in the area surrounding an abdominal stoma. It typically affects young to middle-aged adults, with a slight female predominance. The underlying etiology for PPG remains enigmatic but aberrant immune response to injury may play a pivotal role. The reported risk factors for the development of PPG include the presence of extra-intestinal manifestations, autoimmune disorders and obesity, along with local factors, such as the presence of parastomal hernia or pressure ulcer. PPG can develop at any time after the stoma construction. The histopathological features of PPG are not pathognomonic and its diagnosis is mainly based on clinical features. The management of PPG often requires a multidisciplinary approach, with a combination of local wound care and systemic medications.
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Affiliation(s)
- Xian-Rui Wu
- Department of Colorectal Surgery, the Cleveland Clinic Foundation,Cleveland, Ohio, USA and Department of Gastroenterology/Hepatology, the Cleveland Clinic Foundation, Cleveland, Ohio, USA
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