Mycophenolate mofetil in pyoderma gangrenosum

Pyoderma Gangrenosum: Treatment Options

Pyoderma gangrenosum is a rare neutrophilic dermatosis that leads to exceedingly painful ulcerations of the skin. Although the exact pathogenesis is not yet fully understood, various auto-inflammatory phenomena with increased neutrophil granulocyte activity have been demonstrated. Despite the limited understanding of the pathogenesis, it is no longer a diagnosis of exclusion, as it can now be made on the basis of validated scoring systems. However, therapy remains a major multidisciplinary challenge. Various immunosuppressive and immunomodulatory therapies are available for the treatment of affected patients. In addition, concomitant topical pharmacologic therapy, wound management and pain control should always be addressed. Corticosteroids and/or cyclosporine remain the systemic therapeutics of choice for most patients. However, in recent years, there has been an increasing number of studies on the positive effects of biologic therapies such as inhibitors of tumour necrosis factor-α; interleukin-1, interleukin-17, interleukin-23 or complement factor C5a. Biologics have now become the drug of choice in certain scenarios, particularly in patients with underlying inflammatory comorbidities, and are increasingly used at an early stage in the disease rather than in therapy refractory patients.

Pyoderma Gangrenosum: An Updated Literature Review on Established and Emerging Pharmacological Treatments

Pyoderma gangrenosum is a rare inflammatory skin disease classified within the group of neutrophilic dermatoses and clinically characterized by painful, rapidly evolving cutaneous ulcers with undermined, irregular, erythematous-violaceous edges. Pyoderma gangrenosum pathogenesis is complex and involves a profound dysregulation of components of both innate and adaptive immunity in genetically predisposed individuals, with the follicular unit increasingly recognized as the putative initial target. T helper 17/T helper 1-skewed inflammation and exaggerated inflammasome activation lead to a dysregulated neutrophil-dominant milieu with high levels of tumor necrosis factor-α, interleukin (IL)-1β, IL-1α, IL-8, IL-12, IL-15, IL-17, IL-23, and IL-36. Low-evidence studies and a lack of validated diagnostic and response criteria have hindered the discovery and validation of new effective treatments for pyoderma gangrenosum. We review established and emerging treatments for pyoderma gangrenosum. A therapeutic algorithm based on available evidence is also provided. For emerging treatments, we review target molecules and their role in the pathogenesis of pyoderma gangrenosum.

Mycophenolate mofetil as adjunctive therapy to corticosteroids for the treatment of pyoderma gangrenosum: a case series and literature review

Pyoderma gangrenosum is a rare neutrophilic dermatosis that is commonly treated with systemic corticosteroids; however, their potent side effects may warrant tapering, and non-steroidal systemic immunosuppressants may help maintain or bolster disease clearance during weaning. Although cyclosporine is regarded as a favorable corticosteroid-sparing agent, it is associated with several side effects, such as renal toxicity and hypertension, that may limit its feasibility. Mycophenolate mofetil is a well-tolerated alternative with limited data. Institutional review board approval was obtained to review patients from a single institution who received mycophenolate mofetil for pyoderma gangrenosum between January 1, 2010, and December 31, 2019. A systematic MEDLINE (PubMed) review was performed of articles containing linked keywords: "mycophenolate mofetil" and "pyoderma gangrenosum". Patient demographics, presentation details, and treatment regimen characteristics were recorded. Fourteen of our pyoderma gangrenosum patients were treated with mycophenolate mofetil concomitantly with prednisone. Ninety-three percent of our patients achieved improvement within 12 months (mean 4.5 months), including five patients who experienced complete healing. Outcomes in literature patients were comparable; 77% either improved or maintained clearance with mycophenolate mofetil. Greater than 80% of total patients experienced healing or adequate disease control at a median dose of 2000 mg daily. The most common side effects of mycophenolate mofetil were myelosuppression and gastrointestinal upset, which were both seen in 18% of patients. Although this study is subject to publication bias, mycophenolate mofetil appears to be an efficacious and well-tolerated adjunctive therapy option for pyoderma gangrenosum.

Neutrophilic dermatoses: Pyoderma gangrenosum and other bowel- and arthritis-associated neutrophilic dermatoses

Neutrophilic dermatoses are a heterogeneous group of inflammatory skin disorders that present with unique clinical features but are unified by the presence of a sterile, predominantly neutrophilic infiltrate on histopathology. The morphology of cutaneous lesions associated with these disorders is heterogeneous, which renders diagnosis challenging. Moreover, a thorough evaluation is required to exclude diseases that mimic these disorders and to diagnose potential associated infectious, inflammatory, and neoplastic processes. While some neutrophilic dermatoses may resolve spontaneously, most require treatment to achieve remission. Delays in diagnosis and treatment can lead to significant patient morbidity and even mortality. Therapeutic modalities range from systemic corticosteroids to novel biologic agents, and the treatment literature is rapidly expanding. The second article in this continuing medical education series reviews the epidemiology, clinical characteristics, histopathologic features, diagnosis, and management of pyoderma gangrenosum as well as bowel-associated dermatosis-arthritis syndrome and the arthritis-associated neutrophilic dermatoses rheumatoid neutrophilic dermatitis and adult Still disease.

Practical guidelines for the use of steroid-sparing agents in the treatment of chronic pruritus

Chronic pruritus in the adult patient is both an underappreciated and a difficult to treat condition. In the vast majority of cases, itch is the result of inflammatory skin disease and therefore may be responsive to systemic anti-inflammatory therapies. Urticarial dermatitis is an under-recognized cause of chronic itch in the adult population. Patients with this disorder are characterized by prolonged, prednisone-responsive pruritus, often in the absence of substantial cutaneous findings. Skin findings, when present, can range from subtle, persistent urticarial lesions to excoriated papules, often intermixed with urticaria, eczematous change, and lichenification secondary to chronic scratching. Hereby, we describe our algorithm for evaluation and management of adult patients with refractory pruritus (urticarial dermatitis in particular), including evaluation for other etiologies of pruritus, pre-immunosuppression workup, and the use of azathioprine and other steroid-sparing agents for treatment of recalcitrant itch.

Mycophenolate mofetil: a novel immunosuppressant in the treatment of dystrophic epidermolysis bullosa, a randomized controlled trial

BACKGROUND

No effective treatment has been found for epidermolysis bullosa dystrophica (EBD).

OBJECTIVE

To evaluate the efficacy and safety mycophenolate mofetil (MMF) in treating EBD.

METHODS

This randomized controlled double-blinded study included 35 patients with severe generalized EBD. Patients were randomly divided into two groups: group I (18 patients) received cyclosporine therapy (5 mg/kg/day) and group II (17 patients) received MMF therapy (500-1500 mg/day). Clinical assessment was made weekly for 3 months from the start of the treatment. Patients were assessed by measuring the extent of the disease, the % of improvement, assessing the number of new blister formation and the time of complete healing of new blisters. Side effects were recorded when detected.

RESULTS

The % of improvement in the disease extent was statistically significantly higher (p = 0.009) in group I (mean ± SD: 59.21 ± 22.676) than in group II (mean ± SD: 44.03 ± 25.71). As regards the number of new blisters and the rate of healing of blisters, there was no statistically significant difference between both groups (p = 0.693 and 0.404, respectively). No serious side effects were reported.

CONCLUSION

MMF seems to be a good therapeutic option for the long-term treatment of EBD, it can be a good alternative for patients who cannot tolerate cyclosporine.

Etiology and management of pyoderma gangrenosum: a comprehensive review

Pyoderma gangrenosum (PG) is a rare neutrophilic dermatosis characterized by painful, necrotic ulceration. It typically affects patients in the third to sixth decades of life, with almost equal incidence in men and women. PG occurs most frequently on the lower extremities. Five clinical variants are currently recognized: classic, bullous, pustular, vegetative, and peristomal types. Half of PG cases are seen in association with systemic disease. Mimickers include infection, vascular insufficiency ulcers, systemic vasculitides, autoimmune disease, cancer, and exogenous tissue injury, among others. PG is often a diagnosis of exclusion, as there are no specific laboratory or histopathologic findings to confirm the diagnosis. PG thus presents many clinical challenges: it is difficult to diagnose, is frequently misdiagnosed, and often requires a work-up for underlying systemic disease. Successful management of PG typically requires multiple modalities to reduce inflammation and optimize wound healing, in addition to treatment of any underlying diseases. Prednisone and cyclosporine have been mainstays of systemic treatment for PG, although increasing evidence supports the use of biologic therapies, such as tumor necrosis factor-α inhibitors, for refractory cases of PG. Here, we review the clinical presentation and pathophysiology of PG, as well as its associated conditions, diagnostic work-up, and management.

Dermatoses neutrofílicas: parte I

Os autores apresentam uma revisão das dermatoses neutrofílicas que possuem grande repercussão à saúde dos pacientes: síndrome de Sweet, pioderma gangrenoso, doença de Behçet e urticária neutrofílica. São discutidos, baseados nos resultados e conclusões de estudos relevantes publicados recentemente e na experiência dos autores, os principais aspectos clínicos, as importantes alterações histopatológicas e as opções para o manejo.

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.

Pyoderma gangrenosum--a review

Pyoderma gangrenosum (PG) is a rare noninfectious neutrophilic dermatosis. Clinically it starts with sterile pustules that rapidly progress and turn into painful ulcers of variable depth and size with undermined violaceous borders. The legs are most commonly affected but other parts of the skin and mucous membranes may also be involved. Course can be mild or malignant, chronic or relapsing with remarkable morbidity. In many cases PG is associated with an underlying disease, most commonly inflammatory bowel disease, rheumatic or haematological disease and malignancy. Diagnosis of PG is based on history of an underlying disease, typical clinical presentation, histopathology, and exclusion of other diseases that would lead to a similar appearance. The peak of incidence occurs between the ages of 20 to 50 years with women being more often affected than men. Aetiology has not been clearly determined yet.

The treatment of PG is a challenge. Randomized, double-blinded prospective multicenter trials for PG are not available. The best documented treatments are systemic corticosteroids and ciclosporin A. Combinations of steroids with cytotoxic drugs are used in resistant cases. The combination of steroids with sulfa drugs or immunosuppressants has been used as steroid-sparing modalities. Anti-tumor necrosis alpha therapy in Crohn's disease showed a rapid response of PG. Skin transplants and the application of bioengineered skin is useful in selected cases as a complement to the immunosuppressive treatment. Topical therapy with modern wound dressings is useful to minimize pain and the risk of secondary infections. Despite recent advances in therapy, the prognosis of PG remains unpredictable.

Therapy Insight: pyoderma gangrenosum—old disease, new management

Well-designed studies that help guide physicians to apply the optimal therapeutic strategy for the management of pyoderma gangrenosum are lacking in the literature. A multidisciplinary approach is paramount for the effective management of this condition, with close involvement of a wound-care specialist and a microbiologist. Treatment should be stepwise in nature. Local wound care, avoidance of trauma and the application of local steroid or tacrolimus ointment are the first-line treatments. Steroid therapy is the most widely published effective therapy for achieving resolution of pyoderma gangrenosum, although there is growing evidence for the efficacy of infliximab in refractory cases. Other therapies such as dapsone and clofazamine should be left as third-line agents for refractory pyoderma gangrenosum, while novel treatments such as granulocyte apheresis should only be used under trial conditions, to gain an objective evaluation of their efficacy. This article reviews the published treatment strategies in current use, and aims to guide the effective management of pyoderma gangrenosum.