First-Line Rx in Pyoderma Gangrenosum

Mekkes JR. Editorials: Treatment of pyoderma gangrenosum. Ciclosporin and prednisolone are comparable first line options, now with supporting evidence. BMJ. 12 June 2015; 350:h3175 doi: 10.1136/bmj.h3175

Ormerod AD, Thomas KS, Craig FE, et al, on behalf of the UK Dermatology Clinical Trials Network’s STOP GAP team. Research: Comparison of the two most commonly used treatments for pyoderma gangrenosum: results of the STOP GAP randomised controlled trial. The BMJ. 12 June 2015;350:h2958 doi: 10.1136/bmj.h2958

Cyclosporine and prednisolone were equally effective for treating pyoderma gangrenosum, but had different side effect profiles.

By 6 months, half the ulcers healed in each group. This was less effective than expected, and disappointing.

Those treated with prednisolone reported more serious infections (11.3% vs 0%). Those treated with cyclosporine reported more renal toxicity (30.5% vs 1.9%).

Pyoderma gangrenosum is a rare disease, with an incidence of 0.63/100,000 in the UK. There is little high quality evidence on the effectiveness of different treatments. A consensus paper recommended prednisolone as the preferred treatment and cyclosporine as second-ranked treatment. There is a long list of possible treatments, most of them anti-inflammatory agents.

This study randomized 112 participants. The primary outcome was speed of healing over 6 weeks, assessed by digital images. Secondary outcomes were time to healing, global treatment response, resolution of inflammation, pain, quality of life, treatment failures, adverse reactions, and time to recurrence.

Diagnosis is made by clinical criteria. There are no diagnostic tests, and biopsy is avoided because pyoderma gangrenosum is made worse (and sometimes precipitated) by skin trauma.