Successful treatment of pyoderma gangrenosum with intravenous human immunoglobulin

Intravenous immunoglobulin as adjunct therapy for refractory pyoderma gangrenosum: systematic review of cases and case series

Pyoderma gangrenosum (PG) is a rare neutrophilic dermatosis. Treatment regimens for refractory cases are nonstandardized. Intravenous immunoglobulin (IVIG) is an emerging treatment with reported success, but the efficacy of IVIG for PG is unknown. In this systematic review of cases and case series, we assessed the efficacy of IVIG for the treatment of PG, as observed at our institution and reported in the literature. A retrospective chart review at two tertiary care hospitals between 2000 and 2015, and literature searches in PubMed/MEDLINE, EMBASE and Web of Science from all years were conducted. In total, there were 49 patients, including 43 patients from 26 articles and six institutional cases. There was complete or partial response in 43 (88%) patients and complete response in 26 (53%) patients. The mean time to initial response to treatment and treatment length were 3·5 (SD 3·3) weeks and 5·9 (SD 7·8) months, respectively. On average, 2·6 treatments had been trialled before IVIG initiation. IVIG was administered with systemic steroids in 43 (88%) cases. Mild adverse events, especially nausea and headache, were reported in 12 (24·5%) patients. Our systematic review suggests a potential role for IVIG as adjuvant therapy for refractory PG. Prospective clinical trials testing the efficacy of IVIG for refractory PG are needed to validate these findings.

Intravenous immunoglobulin as salvage therapy in refractory pyoderma gangrenosum: report of a case and review of the literature

Pyoderma gangrenosum is a neutrophilic dermatosis that occurs both as a primary disorder as well as secondary to an underlying disease. Due to its low prevalence there are limited data on therapeutics, particularly in refractory cases. Here, we discuss a case successfully managed with intravenous immunoglobulin and review the supporting literature.

Large leg ulcers due to autoimmune diseases

Background

Large leg ulcers (LLU) may complicate autoimmune diseases. They pose a therapeutic challenge and are often resistant to treatment. To report three cases of autoimmune diseases complicated with LLU.

Case Report

Case 1. A 55-year old woman presented with long-standing painful LLU due to mixed connective tissue disease (MCTD). Biopsy from the ulcer edge showed small vessel vasculitis. IV methylprednisolone (MethP) 1 G/day, prednisolone (PR) 1mg/kg, monthly IV cyclophosphamide (CYC), cyclosporine (CyA) 100mg/day, IVIG 125G, ciprofloxacin+IV Iloprost+enoxaparin+aspirin (AAVAA), hyperbaric oxygen therapy (HO), maggot debridement and autologous skin transplantation were performed and the LLU healed. Case 2. A 45-year old women with MCTD developed multiple LLU’s with non-specific inflammation by biopsy. MethP, PR, hydroxychloroquine (HCQ), azathioprine (AZA), CYC, IVIG, AAVAA failed. Treatment for underlying the LLU tibial osteomyelitis and addition of CyA was followed by the LLU healing. Case 3. A 20-year-old man with history of polyarteritis nodosa (PAN) developed painful LLU’s due to small vessel vasculitis (biopsy). MethP, PR 1 mg/kg, CYC, CyA 100 mg/d, AAVAA failed. MRSA sepsis and relapse of systemic PAN developed. IV vancomycin, followed by ciprofloxacin, monthly IVIG (150 g/for 5 days) and infliximab (5 mg/kg) were instituted and the LLU’s healed.

Conclusions

LLU are extremely resistant to therapy. Combined use of multiple medications and services are needed for healing of LLU due to autoimmune diseases.

Pyoderma gangrenosum-like lesions in leukocyte adhesion deficiency I treated with intravenous immunoglobulin

A 31-year-old Caucasian male with leukocyte adhesion deficiency I and a 20-year history of recurrent, painful cutaneous ulcerations on the extremities presented with fatigue and worsening pain in both legs. He had experienced minimal improvement in his leg ulcers from treatment with systemic steroids, numerous courses of systemic antibiotics, and brief trials of infliximab and mycophenolate mofetil. He was treated with monthly intravenous immunoglobulin infusions. Upon completion of six courses of intravenous immunoglobulin his ulcerations had nearly healed for the first time in a decade.

Treatment of refractory pyoderma gangrenosum with intravenous immunoglobulin

We report a patient with pyoderma gangrenosum successfully treated with intravenous immunoglobulin. He had previously been treated for 4 years with high-dose corticosteroids and had developed insulin-dependent diabetes mellitus. Multiple corticosteroid-sparing agents had failed or were contraindicated. He developed no adverse effects from intravenous immunoglobulin, which allowed reduction of his prednisone to 3 mg/day, and his ulcer has completely healed.

Pyoderma gangrenosum: an update

Pyoderma gangrenosum (PG) can be differentiated into classic and atypical forms. The classic form is characterized by ulcers and the atypical form by deep erosions with bullous blue-gray margins. Pathergy, the development of cutaneous lesions at sites of trauma, is a common feature of both forms of PG. Approximately 50% of patients who have PG have underlying systemic diseases, most commonly inflammatory bowel disease, myeloproliferative disorders, and various forms of inflammatory arthritis. The diagnosis of PG is one of exclusion. The management of this disorder begins with treatment of any underlying disease and local or systemic glucocorticoids or immunomodulating therapies.

The use of i.v. IG therapy in dermatology

The intravenous administration of exogenous pooled human immunoglobulin (i.v. IG) was originally licensed as antibody replacement therapy in patients with primary immunodeficiencies and there are currently six FDA-approved uses for this agent. Despite a current lack of FDA approval, off-label treatment of a multitude of dermatologic disorders with i.v. IG has shown exciting potential for this unique treatment modality. The diseases successfully treated with i.v. IG include autoimmune bullous diseases, connective tissue diseases, vasculitides, toxic epidermal necrolysis, and infectious disorders (such as streptococcal toxic shock syndrome). Currently the biggest drawback in the consideration of i.v. IG therapy in dermatologic disorders is the lack of randomized controlled trials. Nevertheless, there is a significant body of evidence demonstrating the efficacy of i.v. IG in patients with dermatologic disorders that are resistant to treatment with standard agents. In summary, i.v. IG constitutes a valuable and potentially life-saving agent in managing patients with a variety of dermatologic disorders under the appropriate circumstances.

Successful treatment of pyoderma gangrenosum associated with myelodysplastic syndrome using high-dose intravenous immunoglobulin

We report the case of a 61-year-old man with pyoderma gangrenosum (PG) who was successfully treated with high-dose intravenous immunoglobulin (IVIg). He was transported to hospital with fever, pain and ulcer of the left inner thigh, and pancytopenia. PG associated with myelodysplastic syndrome was diagnosed, and treatment with methyl-prednisolone at 1.0 g/day for 3 days was followed by oral prednisolone. As the ulcer deteriorated when prednisolone dose was reduced, he was admitted to our hospital. IVIg was administered twice, with high fever promptly subsiding and the ulcer markedly decreasing in size. IVIg may represent a good option when steroid therapy proves insufficient.

Treatment of pyoderma gangrenosum with intravenous immunoglobulin

BACKGROUND

Intravenous immunoglobulin (IVIG) is increasingly being used to treat inflammatory and autoimmune disease.

OBJECTIVES

To elucidate the efficacy of IVIG as an adjunct treatment for pyoderma gangrenosum (PG).

PATIENTS/METHODS

Ten patients with PG were treated with IVIG at Johns Hopkins Department of Dermatology. All patients had severe mutilating and/or refractory disease requiring multi-agent therapy. The charts were reviewed retrospectively.

RESULTS

Seven of the ten patients had clearance of PG lesions in the setting of IVIG and six of these patients maintained efficacy with repeated IVIG treatment. Five patients complained of nausea with treatment, and in one case nausea was severe and intractable. One patient developed an immune reaction requiring diphenhydramine and methylprednisolone and another experienced aseptic meningitis.

CONCLUSIONS

IVIG may be an effective adjuvant in the treatment of PG and has an acceptable side-effect profile. Randomized, placebo-controlled, double-blinded trials are needed to confirm this hypothesis.

Pyoderma gangrenosum treated with high-dose intravenous immunoglobulins: Two cases and review of the literature

Pyoderma gangrenosum (PG) is a neutrophilic skin disease commonly treated with immunosuppressants. High-dose intravenous immunoglobulins are used to treat a range of inflammatory diseases, but we found only five reports of the use of high-dose intravenous immunoglobulins in the treatment of PG. We report on two patients with PG for whom immunosuppressants could not be prescribed and who were treated with high-dose intravenous immunoglobulins. Case 1 was a 58-year-old man who presented with a 6-year history of PG. He was initially treated with prednisone. The 20 mg/day dosage of prednisone could not be reduced and treatment had to be discontinued after 1 year because of serious adverse effects. Minocycline treatment led to improvement but had to be discontinued after 6 years because of facial skin hyperpigmentation. Case 2 was a 66-year-old man who presented with a 3-year history of PG. Different therapeutic procedures for PG (prednisone, topical tacrolimus or betamethasone) had failed. High-dose intravenous immunoglobulins were administered monthly at a dose of 2 g/kg for 6 months. The treatment induced stabilisation of the disease and made it possible to reduce corticosteroid use in both patients. These cases show that high-dose intravenous immunoglobulins represent a therapeutic alternative for PG, but the efficacy of this treatment should be confirmed in further studies.

Off-label uses of biologics in dermatology: Interferon and intravenous immunoglobulin (Part 1 of 2)

The introduction of a number of biologic therapies into the market has revolutionized the practice of dermatology. These therapies include interferons, intravenous immunoglobulin, infliximab, adalimumab, etanercept, efalizumab, alefacept, and rituximab. Most dermatologists are familiar with the Food and Drug Administration-approved indications of these medications. However, numerous off-label uses have evolved. As part 1 of a 2-part series, this article will review the literature regarding the off-label uses of the interferons and intravenous immunoglobulin in dermatology.

Off-Label Uses of Biologic Agents in Dermatology: A 2006 Update

The introduction of a number of biologic therapies into the market has revolutionized the practice of dermatology. These therapies include adalimumab, alefacept, efalizumab, etanercept, infliximab, IVIg, omalizumab, and rituximab. Most dermatologists are familiar with the indications of these medications that have been approved by the Food and Drug Administration; however, numerous off-label uses have evolved. To update the reader on more recent uses of the biologics for off-label dermatologic use, this article will emphasize more recent published data from 2005 through the date of submission in May 2006.

Treatment recommendations for pyoderma gangrenosum: an evidence-based review of the literature based on more than 350 patients

Because the incidence of pyoderma gangrenosum (PG) is low, no prospective randomized controlled trials and only a few studies with case numbers of more than 15 patients have been published. To date no guidelines for treatment of PG have been established far. The aim of the study was to provide an evidence-based review of the literature and an evaluation of recommendations for PG treatment. We performed an electronic search using the PubMed database and the term "pyoderma-gangrenosum." Literature published in the English language during the past two decades was reviewed. All relevant studies that could be obtained regardless of the study design were evaluated for grades of recommendation and levels of evidence. Data on patient characteristics including severity of the disease, localization of lesions, associated diseases, and treatment procedures were abstracted and evaluated for therapeutic outcome. We conclude that therapeutic efficacy of systemic treatment with corticosteroids and cyclosporine is best documented in the literature for disseminated as well as for localized disease and should be considered first-line therapy. In cases that do not respond to this treatment, we recommend alternative therapeutic procedures (eg, systemic treatment with corticosteroids and mycophenolate mofetil; mycophenolate mofetil and cyclosporine; tacrolimus; infliximab; or plasmapheresis), considering additional factors including associated diseases.

Pyoderma gangrenosum related to a new granulocyte colony-stimulating factor

A 23-year-old Caucasian man diagnosed with stage IVB Hodgkin's disease was referred to a university oncology section after completing 1.5 cycles of chemotherapy. His chemotherapy consisted of doxorubicin HCL, bleomycin, dacarbazine, and vinblastine, with prophylactic administration of a granulocyte colony stimulating factor. He had developed postchemotherapy complications of possible cellulitis and necrotizing fasciitis that required wound debridement. The wound and tissue cultures were negative. Biopsies taken at the time revealed a dense inflammatory infiltrate consistent with an abscess. Over the course of 2 months, the wound healed with systemic antibiotics. The patient was reluctant to resume chemotherapy for his Hodgkin's disease because of his previous presumed skin infections. However, positive emission tomographic scanning revealed disease progression. Doxorubicin, bleomycin, dacarbazine, and prophylactic pegfilgrastim (a granulocyte colony-stimulating factor), were administered. Vinblastine was excluded from the new regimen. Shortly after chemotherapy and an injection of pegfilgrastim, the patient developed poorly defined, rapidly progressive erythema, edema, and pain in his right forearm. He presented to the emergency room, was evaluated by the orthopedics service, and taken to the operating room for debridement of suspected necrotizing fasciitis. When the dermatology service consulted the following day, the patient had developed an erythematous, edematous, tender plaque on his chest. After developing two additional lesions that began to ulcerate despite treatment with imipenem, vancomycin, clindamycin, rifampin, and gentamicin, the patient consented to a skin biopsy. His wound cultures continued to be negative.

Use of IGIV in the treatment of atopic dermatitis, urticaria, scleromyxedema, pyoderma gangrenosum, psoriasis, and pretibial myxedema

There has been a rapid expansion in the use of IGIV for an ever-growing number of conditions. It is a product with an excellent safety record without the side effects of steroids or other immunosuppressive agents. There have been numerous recent advances in our understanding of the mechanisms of action of IGIV in many of the conditions for which it is being used, but there is still much to be learned. IGIV has had a major impact in neurology, haematology, immunology, rheumatology and dermatology. The limitations for IGIV are cost of the preparation itself and the logistical problems associated with its administration. Here we describe the published evidence for the use of high-dose IGIV in the dermatological conditions atopic dermatitis, urticaria, scleromyxedema, pyoderma gangrenosum, psoriasis and pretibial myxedema. These conditions have an emerging evidence base for hdIGIV which is relatively small consisting mainly of case reports and small case series. The outcomes in a number of these conditions appear encouraging, but as the reports are likely to reflect a bias for positive results, one must be cautious about drawing firm conclusions.

Tumorous variant of scleromyxedema. Successful therapy with intravenous immunoglobulins

We present an unusual tumorous variety of scleromyxedema mimicking facies leonina in lymphoma. In spite of pronounced and widespread cutaneous changes, hypergammaglobulinaemia and paraproteinaemia, the general condition of the patient was satisfactory, there was no internal involvement and no symptoms of any malignancy. Initially, melphalan and corticosteroids were applied but were not effective. High-dose intravenous immunoglobulin (IVIG) therapy had dramatic effect, and after five 5-day monthly courses the tumours almost regressed and the skin became less hard. After a further five courses in the following year there was complete clearance, which was sustained without any therapy for 1 year (until now). IVIG appears to be the therapy of choice for scleromyxedema. We stress, however, that at the start of therapy, IVIG applications should be supplemented with small doses of melphalan and/or corticosteroids.

Optimal treatment of pyoderma gangrenosum

The optimal treatment of pyoderma gangrenosum includes a combination of local wound care and systemic medications. Oral and pulse intravenous corticosteroids have traditionally been the most commonly recommended first-line systemic therapies. Cyclosporine, with or without corticosteroids, has more recently emerged as a first-line systemic treatment. A multitude of immunosuppressive and immune-modulating medications, as well as antimicrobial agents with anti-inflammatory properties have also been widely prescribed. Often, it is difficult to achieve control of aggressive cases of pyoderma gangrenosum, necessitating administration of a combination of systemic therapies. Furthermore, patients recalcitrant to one or many medications are frequently reported. Concomitant disease, intolerance to a class of medications, and the patient's response to prior therapies can help guide a practitioner in choosing the optimal treatment of pyoderma gangrenosum.

Einsatz hochdosierter intravenoser Immunglobuline in der Dermatologie. High dose intravenous immunoglobulin therapy: dermatologic applications

High dose intravenous immunoglobulins (IVIG) are important agents in the treatment of numerous diseases in rheumatology and dermatology. Because the diseases treated with IVIG are rare, their use is mostly not based on controlled randomized trials. Since the high costs of therapy often prohibit the use of IVIG as first line therapy and as there are no guidelines on the use of IVIG in dermatologic diseases, a consensus conference was held in Wiesbaden, Germany, to address these issues. This manuscript documents the expert consensus on the use of IVIG in dermatology and reflects current clinical practice. It should be a guideline for the practitioner for the use of IVIG in dermatologic diseases.

Clinical management of pyoderma gangrenosum

Pyoderma gangrenosum is a noninfectious neutrophilic dermatosis that usually starts with sterile pustules which rapidly progress to painful ulcers of variable depth and size with undermined violaceous borders. In 17 to 74% of cases, pyoderma gangrenosum is associated with an underlying disease, most commonly inflammatory bowel disease, rheumatological or hematological disease or malignancy. Diagnosis of pyoderma gangrenosum is based on a history of an underlying disease, typical clinical presentation and histopathology, and exclusion of other diseases that would lead to a similar appearance. Randomized, double-blinded prospective multicenter trials investigating the treatment of pyoderma gangrenosum are not available. The treatments with the best clinical evidence are systemic corticosteroids (in the initial phase usually 100 to 200 mg/day) and cyclosporine (mainly as a maintenance treatment). Combinations of corticosteroids with cytotoxic drugs such as azathioprine, cyclophosphamide or chlorambucil are used in patients with disease that is resistant to corticosteroids. The combination of corticosteroids with sulfa drugs, such as dapsone, or clofazimine, minocycline and thalidomide, has been used as a corticosteroid-sparing alternative. Limited experience has been documented with methotrexate, colchicine, nicotine, and mycophenolate mofetil, among other drugs. Alternative treatments include local application of granulocyte-macrophage colony-stimulating factor, intravenous immunoglobulins and plasmapheresis. Skin transplants (split-skin grafts or autologous keratinocyte grafts) and the application of bioengineered skin is useful in selected cases in conjunction with immunosuppression. Topical therapy with modern wound dressings is useful to minimize pain and the high risk of secondary infection. The application of topical antibacterials cannot be recommended because of their potential to sensitize and their questionable efficacy, but systemic antibacterial therapy is mandatory when infection is present. Despite recent advances in therapy, the prognosis of pyoderma gangrenosum remains unpredictable.

Efficacy of pulsed intravenous immunoglobulin therapy in mixed connective tissue disease

We describe a 69-year-old patient with long-standing mixed connective tissue disease who suffered from severe skin eruptions that did not respond to various immunosuppressive regimens. Therapy with high-dose intravenous immunoglobulin was successful in controlling the patient's disease without major side effects. We think that this regimen-although expensive-might be an interesting therapeutic option in selected patients with mixed connective tissue disease that is refractory to other treatment modalities.

Dapsone and sulfones in dermatology: overview and update

In their 60-year history, dapsone and the sulfones have been used as both antibacterial and anti-inflammatory agents. Dapsone has been used successfully to treat a range of dermatologic disorders, most successfully those characterized by abnormal neutrophil and eosinophil accumulation. This article reviews and updates the chemistry, pharmacokinetics, clinical application, mechanism of action, adverse effects, and drug interactions of dapsone and the sulfones in dermatology.

High-dose intravenous immunoglobulins: An approach to treat severe immune-mediated and autoimmune diseases of the skin

Adjuvant high-dose intravenous immunoglobulins (IVIgs) are being used increasingly in a range of immune-mediated and autoimmune diseases. Although numerous immunomodulatory mechanisms have been suggested, the exact mechanisms of action are poorly understood. The efficacy of IVIg in certain diseases has been proven in clinical trials, insofar as IVIg is approved as the therapy of choice for Kawasaki syndrome or idiopathic thrombocytopenic purpura. IVIg treatment has been shown to be safe, without the many drug-related adverse effects, including systemic immunosuppression, that are related to corticosteroids and other immunosuppressive agents. Current dermatologic uses of IVIg are increasing, which calls for adequately controlled clinical trials. This review focuses on experiences with IVIg therapy for skin diseases and discusses current opinion concerning its potential immunomodulating mechanisms.

The use of high-dose immunoglobulin in the treatment of pyoderma gangrenosum

BACKGROUND

Immunosuppressive medications such as corticosteroids and cyclosporin are the most commonly employed therapies in pyoderma gangrenosum. We describe a patient with multiple ulcers of pyoderma gangrenosum on the lower extremities in whom immunosuppressive therapy caused serious side effects and had to be discontinued but who was subsequently treated successfully with high dose intravenous immunoglobulin (IVIG).

METHODS

IVIG was given intravenously at a dose of 400 mg/kg per day for 5 consecutive days. After 1 week there was an arrest in the progression of the ulcers and a marked reduction in pain. Two weeks later clinical improvement of the ulcers was observed. Subsequently, IVIG was given at a dose of 1 g/kg per day for 2 consecutive days.

RESULTS

The treatment induced a dramatic clinical improvement of one ulcer and healing of the others. Side effects were minimal and well tolerated, and consisted of chills and a slight fever, which resolved with the administration of acetaminophen.

CONCLUSION

We feel that IVIG can be used in patients with pyoderma gangrenosum in whom conventional therapies are ineffective or produce serious side effects.

Recalcitrant pyoderma gangrenosum treated with thalidomide

Pyoderma gangrenosum is a painful, noninfectious, ulcerating skin disorder often associated with systemic disease. Thalidomide has been used to treat many inflammatory dermatologic conditions and has been reintroduced in the United States to treat immune-modulated diseases such as pyoderma gangrenosum. The patient described, a 47-year-old man, had histologically confirmed pyoderma gangrenosum that did not respond to treatment with several courses of methylprednisolone. The ulcer healed with 10 weeks of oral thalidomide administration.

Palliative care in inflammatory bowel disease: an evidence-based approach

The management of the patient with inflammatory bowel disease (IBD) is challenging for both the physician and the patient. IBD imposes both a physical and emotional burden on patients' lives. Palliative care is important for IBD patients because it focuses on improving quality of life. While palliative care does not change the natural history of the disease, it provides relief from pain and other distressing symptoms. This article focuses on various aspects of care for IBD patients including pain control, management of oral and skin ulcerations, stomal problems in IBD patients, control of nausea and vomiting, management of chronic diarrhea and pruritus ani, evaluation of anemia, treatment of steroid-related bone disease, and treatment of psychological problems associated with IBD. Each of these areas is reviewed using an evidence-based approach. Evidence in category A refers to evidence from clinical trials that are randomized and well controlled. Category B Evidence refers to evidence from cohort or case-controlled studies. Category C is evidence from case reports or flawed clinical trials. Evidence from category D is limited to the clinical experience of the authors. Evidence labelled as category E refers to situations where there is insufficient evidence available to form an opinion. Algorithms for management of pain and nausea in IBD patients are presented.

Intravenous immunoglobulin in autoimmune and inflammatory dermatoses. A review of proposed mechanisms of action and therapeutic applications

Off-label use of intravenous immunoglobulin (IVIG) at high doses has resulted in numerous anecdotal reports of its effectiveness in a variety of autoimmune and inflammatory conditions. Despite its growing acceptance as a viable therapeutic option in the management of several such disorders, the poorly defined mechanism of action of IVIG has stifled its rational therapeutic application. The lack of carefully designed prospective randomized clinical trials has further fueled controversy and mitigates against optimal application of this burgeoning therapy. Nevertheless, some standardization of IVIG therapy is slowly advancing that promises to support the use of this treatment for a growing number of autoimmune and inflammatory dermatoses.