Commentary by Jane Fellows

Although these patients present with different lesions, they demonstrate the importance of accurate assessment, with particular emphasis on a patient's medical history. In both of these case studies, the lesions were a result of an inflammatory process associated with an underlying disease.

As the first author reported, pyoderma gangrenosum is a complex problem and requires an individualized care plan. The patient she describes responded well to systemic corticosteroids. This is an effective treatment modality for pyoderma; however, there are patients for whom this therapy is contraindicated. The underlying inflammatory diseases that seem to predispose patients to pyoderma are often treated with steroids, and adverse effects may have occurred. Patients who have experienced the side effects of bone loss, weight gain, gastrointestinal disturbances, or edema are unlikely to want to have systemic corticosteroids prescribed for pyoderma. Other systemic treatment considerations include infliximab, methotrexate, and cyclosporine, but these drugs also have an extensive side-effect profile. Those patients with comorbid conditions, such as diabetes, renal insufficiency, and cardiac disease, may not be appropriate candidates for systemic therapies. An effective topical therapy could be the first line of treatment for these patients.

A review of the literature makes it clear that there is no agreement on one best treatment for pyoderma, and no randomized controlled trials have been done for the topical treatment of these inflammatory ulcers.1 Topical treatment choices included benzyl peroxide, nicotine, calcium alginate, PVA foam with a methylene blue and gentian violet complex attached, growth factors, steroid cream, cyclosporine solution, tacrolimus, pimecrolimus, and others.2-4 Several case studies show promising results with tacrolimus ointment. This is a steroid-free immunomodulator ointment that has been widely studied in the treatment of atopic dermatitis and now appears to have a role in cutaneous manifestations of autoimmune diseases. Tacrolimus inhibits T-cell activation and cytokine production to decrease inflammation.5

For the clinician, the most difficult aspects of treating peristomal pyoderma are pain and maintaining an intact pouching system over draining wounds. Tacrolimus may be mixed with Orabase with Benzocaine (Colgate, New York), a putty-like substance indicated in the treatment of mouth ulcers. This provides adhesion to the wound bed and rapid pain relief while applying the pouching system. A thin layer of this mixture is applied over ulcerated areas and covered with a thin foam or hydrocolloid dressing. This provides a dry pouching surface and depending on the drainage from the pyoderma will last for 2-3 days. Pain control is significantly improved within 1 week of treatment. Wound healing and skin resurfacing are apparent within 2 weeks of treatment.6,7

In the second study the author describes a lower extremity inflammatory ulcer. The underlying diagnosis was vasculitis. Vasculitis is an inflammation of the blood vessels with resultant necrosis and potential for ulceration. As such, treatment is aimed at reduction of this inflammation and usually consists of steroids or other immunosuppressive agents.8,9 Topical therapy follows the established principles of moist wound healing and will include debridement if necessary, control of exudate, packing of dead space, and insulation. Hydrocolloids and hydrogels may provide some local pain relief.

Pyoderma may occur on any skin surface but is frequently seen on lower extremities and around the stoma of patients, as we saw with the first case study. Ling reports that topical tacrolimus 0.1% under occlusion has been successful in treating pyoderma when systemic drugs have failed.10 Richter-Hintz et al report a case study involving a lower extremity ulcer where corticosteroids were ineffective. The ulcer healed with topical tacrolimus and the researchers found that while tacrolimus inhibited the destructive inflammatory process, it did not slow the proliferative phase of wound healing or impair collagen synthesis.11 Chiba et al describe a case study of a patient with lower extremity pyoderma ulceration for 14 years that was also refractory to corticosteroids. Topical tacrolimus provided healing and pain reduction in a few weeks of treatment.12

Although the likelihood of recurrence is high, the use of tacrolimus at the first sign of skin eruption decreases the severity of the ulceration and prevents the ulcers from becoming very painful.10 No adverse reactions have been reported with topical tacrolimus in the treatment of pyoderma. Outcomes suggest that this is a treatment that should be considered when pyoderma gangrenosum occurs.

In both of the cases presented here, careful attention to the underlying disease process, along with the appropriate topical therapy, resulted in healing of the ulcers.

References