Pyoderma gangrenosum and tumour necrosis factor alpha inhibitors: A semi-systematic review

Inflammatory Skin Diseases: The Importance of Immunological Signatures

BACKGROUND

The understanding and classification of inflammatory skin diseases is shifting from a historical-descriptive perspective to a molecular-pathophysiological one based on immune response patterns. These are derived from a few key immunological mediators, each of which induces its own characteristic clinical, histopathological, and molecular patterns in the skin.

METHODS

This discussion of the definition of the immune response patterns of inflammatory skin diseases is based on information from pertinent publications retrieved by a selective literature search. A systematic literature search was also conducted on the response of inflammatory skin diseases to treatment with specific biologic agents.

RESULTS

The described immune response patterns are: autoinflammation; type 1, cytotoxic; type 2a, eczematous; type 2b, blistering; type 3, psoriasiform; type 4a, fibrosing; and type 4b, granulomatous. Each signature can usually be treated in a targeted manner. In general, each therapeutic target structure is associated with an adequate treatment response if and only if the skin disease under treatment has the relevant signature type. Hardly any biomarkers are currently available for the determination of immune response patterns in routine clinical practice.

CONCLUSION

The classification of inflammatory skin diseases by their immune response patterns opens up the prospect of specifically targeted immunotherapy for each immune response pattern regardless of the historical-descriptive disease entity. Targeting is intended to improve response rates. Initial findings suggest that this strategy is likely to succeed.

Anti-IL 17 biologics and pyoderma gangrenosum - therapeutic or causal?

Pyoderma gangrenosum (PG) is a rare neutrophilic dermatosis characterized by pustules that rapidly progress into ulcers that commonly affect the lower limbs. Recently, successful treatment of PG has been reported with anti-IL 17 treatments. However, there have also been several reports of "paradoxical" induction of new PG lesions after use of IL-17 inhibitors. In this narrative review, we present the currently published English literature on cases in which PG has been successfully treated with IL-17 inhibitors and cases of possible newly induced PG after the use of IL-17 inhibitors. After use of the Naranjo Adverse Drug Reaction Probability Scale, it is difficult to conclude an adverse reaction of PG from anti-IL 17 biological agents. Our review also concludes that IL-23 and IL-36 inhibitors can be considered an alternative treatment for PG.

[Application of advanced treatment in chronic inflammatory bowel diseases]

BACKGROUND

The treatment options for chronic inflammatory bowel diseases (IBD) have been greatly expanded due to a better understanding of the underlying pathogenesis. A total of five classes of advanced treatment are available.

OBJECTIVE

A practical overview of advanced treatment of IBD.

METHODS

Narrative review.

RESULTS AND DISCUSSION

Advanced treatments are indicated for moderate to severe IBD. A timely use is recommended to achieve better response rates and to avoid irreversible bowel damage. Tumor necrosis factor (TNF) inhibitors and Janus kinase (JAK) inhibitors have a broad efficacy, also for extraintestinal disease manifestations. The risk of reactivation of varicella zoster virus is increased with JAK inhibitors. In high-risk patients and an age >65 years there is possibly a moderately elevated cardiovascular risk and neoplastic side effects. The integrin alpha4beta7 inhibitor vedolizumab and the interleukin (IL) 12 and 23 inhibitor ustekinumab have very good safety profiles. Selective IL-23 inhibitors are sometimes superior to ustekinumab with comparable safety profiles with respect to efficacy. The sphingosine-1-phosphate receptor modulators ozanimod and etrasimod are approved for oral treatment of ulcerative colitis. The treatment success of the medications remains still limited and a minority of patients will not respond to every individual treatment. Thus, sequential administration of several treatments is often needed. Due to the lack of comparative studies, the personalized choice, sequence and decision for treatments are usually based on personal experience and should take patient preferences, efficacy, safety and individual patient profiles into consideration.

Inflammatory and vaso-occlusive ulcers: Part II - Management

In the second part of this CME, we present an approach for the management of inflammatory and vaso-occlusive ulcers and highlight the need for further research in this field. The 3 overarching principles for management are etiology-specific treatment, ulcer care, and consideration of patient comorbidities and risk factors for poor healing. Both etiology-specific treatment and management of patient comorbidities and risk factors often require collaboration with providers from other specialties. Ulcer care is governed by tissue debridement, infection control, management of moisture imbalance, and epithelial edge advancement. As wound healing is a dynamic process, management should be adapted to changes in the status of the ulcer.

Rapidly Progressive Idiopathic Pyoderma Gangrenosum in a Pediatric Patient Successfully Treated With Infliximab

Pyoderma gangrenosum (PG) is a rare skin disorder with poorly understood pathophysiology. PG infrequently occurs in children, and approximately 4% of patients with PG are infants and children. First line therapy is topical and systemic corticosteroids, which typically yields rapid response. We report a case of rapidly progressive pediatric PG of unknown inciting cause that ultimately required multi-modal therapy with systemic and topical corticosteroids, high-dose infliximab, and colchicine.

PSTPIP1-associated myeloid-related proteinemia inflammatory (PAMI) syndrome: A case report and review of the literature

PSTPIP1-associated myeloid-related proteinemia inflammatory (PAMI) syndrome is a rare autoinflammatory disorder often arising in pediatric patients. We present a case of an 18-year-old female with a past medical history of growth failure, immunoglobulin A nephropathy, and inflammatory arthritis who presented to a pediatric dermatology clinic with findings of acne, psoriasiform dermatitis, and hidradenitis suppurativa, whose clinical, genetic, and laboratory findings were most consistent with PAMI syndrome. We conducted a literature review to better characterize this rare condition in the context of dermatologic findings. Recognition of the distinctive skin findings seen in PAMI syndrome can help distinguish it from other inflammatory disorders, enabling expedited diagnosis and treatment.

Analysis of clinical characteristics and factors affecting treatment responses in patients with pyoderma gangrenosum: a multicenter study of 239 patients☆

BACKGROUND

Pyoderma Gangrenosum (PG) is a chronic disease characterized by recalcitrant skin ulcers.

OBJECTIVE

We aimed to evaluate the demographic, clinical characteristics, treatments and factors affecting the treatment responses of patients with PG.

METHODS

We performed a multicenter study of 12 tertiary care centers. We analyzed the data of the patients who were followed up with a diagnosis of PG between the years 2012‒2022 retrospectively.

RESULTS

We included a total of 239 patients of whom 143 were female and 96 were male, with an average age of 54.2 ± 17.4 years. The most common treatment was systemic steroids (n = 181, 75.7%). Among these patients, 50.8% (n = 92) used systemic steroids as the sole systemic agent, while 49.2% (n = 89) used at least one adjuvant immunosuppressive agent. The independent factors determined in regression analysis to influence response to systemic steroids positively were disease onset age ≥ 30-years, negative pathergy, absence of leukocytosis, negative wound culture, presence of a single lesion, and absence of upper extremity involvement. Biological agents were used in 18.4% (n = 44) of the patients in the present study. We also analyzed pathergy positive PG and early onset (onset age < 30) PG separately due to their distinct clinical features which were revealed during statistical analysis.

STUDY LIMITATIONS

Retrospective nature of the present study.

CONCLUSIONS

Analyses of the factors influencing treatment responses are addressed in this study. Also, we concluded that investigation for accompanying autoinflammatory diseases of pathergy positive PG and early onset PG is necessary and the patients in these two groups are more resistant to treatment, necessitating more complicated treatments.

Tofacitinib therapy for severe pyoderma gangrenosum in a patient with enteropathic arthritis: a case-based review

Pyoderma gangrenosum (PG) is a rare neutrophilic dermatosis that is associated with systemic inflammatory conditions. Currently, there is no universally accepted standard therapy for PG, but immunosuppressive (IS) treatment seems essential. We report a patient here who was successfully treated with tofacitinib despite being PG-refractory to multiple anti-tumor necrosis factor alpha (anti-TNF) therapies and conventional IS. In addition, we performed a comprehensive review of all cases of PG treated with JAK inhibitors. We identified 27 cases treated with JAK inhibitors. Approximately 80% of the patients achieved complete recovery within a median of 12 weeks, even though 17 patients (63%) had received biologics before JAKinib treatment. Notably, this recovery could appear as early as 2 weeks. JAK inhibitors may prove useful in the future, particularly for treating immunosuppressive and steroid-resistant pyoderma gangrenosum, according to recent case reports.

Current prescribing for pyoderma gangrenosum in the UK and access to biologic medications: results from a UK Dermatology Clinical Trials Network survey of dermatologists

Pyoderma gangrenosum (PG) is an ulcerative inflammatory disorder affecting the lower legs in 80% of patients. The use of biologic medications to treat PG is increasing, although there is a limited evidence base to guide treatment choices. In some health systems, such as the UK National Health Service, limitations are placed on biologic prescribing for PG, leading to wide variations in prescribing. A survey of mainly UK clinicians showed that prednisolone remains the first-line treatment for PG (90%, 34/38). Biologics have been used by 66% (25/38) of clinicians as second-line therapy, but 19% (7/38) have had prescribing requests declined. Further research is needed to determine optimal treatment strategies for PG.

Monoclonal Antibodies in the Management of Inflammation in Wound Healing: An Updated Literature Review

Chronic wounds pose a significant clinical challenge due to their complex pathophysiology and the burden of long-term management. Monoclonal antibodies (mAbs) are emerging as a novel therapeutic option in managing difficult wounds, although comprehensive data on their use in wound care are lacking. This study aimed to explore existing scientific knowledge of mAbs in treating chronic wounds based on a rationale of direct inhibition of the main molecules involved in the underlying inflammatory pathophysiology. We performed a literature review excluding primary inflammatory conditions with potential ulcerative outcomes (e.g., hidradenitis suppurativa). mAbs were effective in treating wounds from 16 different etiologies. The most commonly treated conditions were pyoderma gangrenosum (treated with 12 different mAbs), lipoid necrobiosis, and cutaneous vasculitis (each treated with 3 different mAbs). Fourteen mAbs were analyzed in total. Rituximab was effective in 43.75% of cases (7/16 diseases), followed by tocilizumab (25%, 4/16 diseases), and both etanercept and adalimumab (18.75%, 3/16 conditions each). mAbs offer therapeutic potential for chronic wounds unresponsive to standard treatments. However, due to the complex molecular nature of wound healing, no single target molecule can be identified. Therefore, the use of mAbs should be considered as a translational approach for limited cases of multi-resistant conditions.

Targeted therapy for immune mediated skin diseases. What should a dermatologist know?

BACKGROUND

Molecularly targeted therapies, such as monoclonal antibodies (mAbs) and Janus Kinase inhibitors (JAKis), have emerged as essential tools in the treatment of dermatological diseases. These therapies modulate the immune system through specific signaling pathways, providing effective alternatives to traditional systemic immunosuppressive agents. This review aims to provide an updated summary of targeted immune therapies for inflammatory skin diseases, considering their pathophysiology, efficacy, dosage, and safety profiles.

METHODS

The review followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. A systematic search was conducted on PubMed over the past 10 years, focusing on randomized clinical trials, case reports, and case series related to targeted immune therapies in dermatology. Eligibility criteria were applied, and data were extracted from each study, including citation data, study design, and results.

RESULTS

We identified 1360 non-duplicate articles with the initial search strategy. Title and abstract review excluded 1150, while a full-text review excluded an additional 50 articles. The review included 143 studies published between 2012 and 2022, highlighting 39 drugs currently under investigation or in use for managing inflammatory skin diseases.

STUDY LIMITATIONS

The heterogeneity of summarized information limits this review. Some recommendations originated from data from clinical trials, while others relied on retrospective analyses and small case series. Recommendations will likely be updated as new results emerge.

CONCLUSION

Targeted therapies have revolutionized the treatment of chronic skin diseases, offering new options for patients unresponsive to standard treatments. Paradoxical reactions are rarely observed. Further studies are needed to fully understand the mechanisms and nature of these therapies. Overall, targeted immune therapies in dermatology represent a promising development, significantly improving the quality of life for patients with chronic inflammatory skin diseases.

Pyoderma Gangrenosum, a Challenging Postpartum Diagnosis-Case Report and Literature Review

Background/Objectives: The infrequent occurrence of pyoderma gangrenosum (PG) during pregnancy and in postpartum, with its subsequent diagnostic intricacies, caused us to present the following case. Methods: This article describes a rare case of PG in postpartum in a patient without any prior pathology and a short review of the literature, aiming to identify similar rare instances. Results: We conducted a literature review to ascertain the prevalence of postpartum pyoderma gangrenosum, and we identified a total of 41 cases. Conclusions: Our article underlines again the importance of interdisciplinary collaboration for the prompt identification and commencement of necessary therapeutic interventions in postpartum women afflicted by pyoderma gangrenosum.

Treatment of Pyoderma Gangrenosum

Pyoderma gangrenosum is a rare neutrophilic dermatosis that results in painful cutaneous ulcers and is frequently associated with underlying hematologic disorders, inflammatory bowel disease, or other autoimmune disorders. Pathogenesis involves an imbalance between proinflammatory and anti-inflammatory mediators, leading to tissue damage from neutrophils. First-line treatment options with the greatest evidence include systemic corticosteroids, cyclosporine, and tumor necrosis factor alpha inhibitors. Other steroid-sparing therapies such as dapsone, mycophenolate mofetil, intravenous immunoglobulin, and targeted biologic or small molecule inhibitors also have evidence supporting their use. Wound care and management of underlying associated disorders are critical parts of the treatment regimen.

The Pathophysiology and Treatment of Pyoderma Gangrenosum-Current Options and New Perspectives

Pyoderma gangrenosum (PG) is an uncommon inflammatory dermatological disorder characterized by painful ulcers that quickly spread peripherally. The pathophysiology of PG is not fully understood; however, it is most commonly considered a disease in the spectrum of neutrophilic dermatoses. The treatment of PG remains challenging due to the lack of generally accepted therapeutic guidelines. Existing therapeutic methods focus on limiting inflammation through the use of immunosuppressive and immunomodulatory therapies. Recently, several reports have indicated the successful use of biologic drugs and small molecules administered for coexisting diseases, resulting in ulcer healing. In this review, we summarize the discoveries regarding the pathophysiology of PG and present treatment options to raise awareness and improve the management of this rare entity.

New treatment of pyoderma gangrenosum and hidradenitis suppurativa: A review

Pyoderma gangrenosum (PG) and hidradenitis suppurativa (HS) are stubborn inflammatory skin diseases categorized as neutrophilic hypodermal dermatoses. These conditions exhibit connections with other autoinflammatory disorders driven by immune responses. Their pathogenesis is complex, rooted in significant imbalances in both innate and adaptive immune systems, particularly featuring elevated levels of tumor necrosis factor-α (TNF-α), interleukin (IL)-1, IL-8, IL-17, and IL-23. Studies involving skin tissue pathology and serology have indicated that targeting specific cytokines can bring therapeutic benefits. Indeed, many patients in clinical settings have responded positively to such interventions. Yet, given the diverse cytokines in play, focusing on a single one with antibody therapy might not always be effective. When resistance to biologics emerges, a combined approach targeting multiple overactive cytokines with immunosuppressants, for example cyclosporine and Janus kinase inhibitors, could be an option. In the current review, we explore recent therapeutic developments for PG and HS.

Certolizumab treatment of localized pyoderma gangrenosum in a pregnant patient

THE PURPOSE OF THE ARTICLE

Pyoderma gangrenosum (PG) is an ulcerating neutrophilic dermatosis with an incidence of 3-10 patients per million. PG equally affects patients of both sexes and of any age. Of these patients, 50-75% are associated with auto-immune disease. The lower extremities are the most commonly affected body parts. Minor trauma to the skin may result in the development of new lesions. Patients complain of chronic, nonhealing ulcers with associated pain. Treatment starts with systemic or intralesional corticosteroids, however, no official treatment protocol currently exists. Recent success has been found with biologic agents such as TNF-a inhibitor, although the treatment efficacy in these reports is limited. As for the pregnant patient, the drug selection is difficult. In this report, we want to assess the efficiency of certolizumab in the pregnant patient.

RESULTS

We report a case of a patient with PG, who responded well to certolizumab, 400 mg as a booster dose, followed by 200 mg biweekly for 8 weeks. The lesions gradually resolved and followed up for 5months without side effect. In addition, we reviewed the literature and compared the current treatment efficiency in the treatment of PG.

CONCLUSION

Certolizumab may be a promising therapeutic option for patients with severe PG.

Treatment Strategies in Neutrophilic Dermatoses: A Comprehensive Review

Neutrophilic dermatoses (NDs) are a group of noninfectious disorders characterized by the presence of a sterile neutrophilic infiltrate without vasculitis histopathology. Their physiopathology is not fully understood. The association between neutrophilic dermatoses and autoinflammatory diseases has led some authors to propose that both are part of the same spectrum of diseases. The classification of NDs depends on clinical and histopathological features. This review focuses on the recent developments of treatments in these pathologies.

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.

Successful switching treatment of adalimumab for refractory pyoderma gangrenosum in a patient with rheumatoid arthritis with prior use of tumour necrosis factor inhibitors: A case report and review of the literature

Pyoderma gangrenosum (PG) is a rare chronic skin disease characterised by painful skin ulcers. There are no treatment guidelines for PG, but systemic treatments including biologics are often used. Recently, adalimumab (ADA), a fully human monoclonal antibody against tumour necrosis factor, was approved for refractory PG treatment in Japan. Herein, we report a case of rheumatoid arthritis with refractory PG 2 months after orthopaedic surgery of the foot during treatment with low-dose etanercept and methotrexate. Although adding a moderate dose of glucocorticoid did not improve her PG, the patient showed a remarkable response after switching from etanercept to ADA in a higher dose than that used to treat rheumatoid arthritis. This higher dose of ADA may be effective for the treatment of refractory PG after the failure of other tumour necrosis factor inhibitors.

Multiple Lesions at Different Stages of Pyoderma Gangrenosum in a Crohn's Disease Patient

Pyoderma gangrenosum (PG) is an inflammatory dermatosis characterized by the rapid progression of a painful, necrolytic ulcer with an irregular and undermined border. The prevalence of PG in patients with Crohn’s disease (CD) has been estimated to be 0.7%. Here, we report a case that presented various painful skin lesions, including erythema, vesicles, plaques, and ulcers, one week before the fourth infliximab infusion for CD. PG was diagnosed and the lesions subsided after a 390-mg ustekinumab infusion for one month. It suggests that different lesions of PG may occur concomitantly in CD patients, and the therapy should be re-evaluated on time.

Atypical Forms of Pyoderma Gangrenosum in Inflammatory Bowel Disease: Report of Four Cases and Literature Review

Background

Cutaneous involvement is the second-most frequent extraintestinal manifestation of inflammatory bowel disease, with pyoderma gangrenosum (PG) a particularly relevant form because of its frequency, morbidity, and recurrence. The limited number of clinical trials involving PG increases the challenge to gastroenterologists in the management of this condition.

Case Presentation

Four cases of atypical presentations of PG are reported. A 25-year-old patient with ulcerative colitis presented an extensive chronic ulcerative lesion on her left leg that was associated with significant bleeding; the intestinal disease was in remission under the use of azathioprine. The patient was on long-term use of 60 mg corticosteroid with no improvement in the skin disease; however, initiation of cyclosporine induced remission. In the second case, a 52-year-old woman was a carrier of Crohn’s disease, with a history of partial colectomy. The patient’s skin condition had evolved with a cutaneous lesion localized in the perineal region, buttocks, and colostomy pouch, simulating a case of impetigo, and this had been treated with antibiotic cycles without improvement. Lesion biopsy suggested a diagnosis of PG. Consequently, the patient was started on biological therapy with infliximab, and the PG regressed. In the third case, a 38-year-old woman with a history of pancolitis presented a picture of PG with an extensive and deep ulcerative lesion in the right breast. The lesion regressed after treatment with oral corticosteroid. The final case was a 44-year-old woman with Crohn’s disease suffering from Crohn’s disease pancolitis. The patient’s condition evolved with a mixed pattern with pustules, bullae, and ulcerative lesions in the vulva, oral cavity, gluteus, right auricular region, scalp, and left flank, and was resolved by administration of adalimumab.

Conclusion

PG is an important and frequent manifestation of inflammatory bowel disease, with a spectrum of clinical variants, significant morbidity, and requiring a variety of therapeutic approaches.

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.

Inflammatory skin diseases and wounds

Inflammatory wounds of the skin can be caused by many different diseases. Of particular importance here are the very heterogeneous groups of vasculitides and vasculopathies. These are usually interdisciplinary relevant diseases that require extensive diagnostics in specialized centres. Clinically, these inflammatory wounds present as very painful ulcers that develop from necrosis and are surrounded by erythematous livid borders. The healing process is often difficult and protracted. Moreover, it considerably impairs the quality of life of the affected patients. In addition to clinical evaluation, histopathological examination of biopsies taken as early as possible is particularly important in diagnosis. Numerous differential diagnoses must be ruled out. Therapeutically, in addition to the often necessary systemic therapies, which include immunosuppressants (immunomodulating drugs and/or rheologics), appropriate topical wound treatment, usually in combination with compression therapy, should always be considered. Whenever possible, the causative factors should be diagnosed early and avoided or treated.

When Recurring Infections Mask an Atypical Presentation of Inflammatory Bowel Disease (IBD): A Re-Visitation and Literature Review

Pyoderma gangrenosum (PG) is an uncommon and severe extra-intestinal manifestation (EIM) of inflammatory bowel disease (IBD). Head or scalp involvement in this condition is exceedingly rare. Approximately one-third of presentations can be precipitated by skin trauma or infection, a phenomenon known as pathergy. These ulcers develop acutely, do not necessarily correlate with IBD activity, and can precede IBD diagnosis. Here, we present an atypical presentation of PG that became a cornerstone finding in the subsequent diagnosis of IBD.

Pyoderma Gangrenosum and Interleukin Inhibitors: A Semi-Systematic Review

BACKGROUND

Pyoderma gangrenosum (PG) is a rare ulcerating skin disease associated with multiple comorbidities and increased mortality. In recent decades, newer biologics such as interleukin inhibitors have been used to treat PG; however, the literature is scarce, consisting predominantly of case reports and caseseries. The aim of our review was to evaluate the effectiveness and safety of interleukin inhibitors for the treatment of PG in adults.

SUMMARY

A literature search was conducted using search terms related to PG and interleukin inhibitors in databases such as PubMed, Embase, Scopus, Web of Science, and Cochrane Library. The study eligibility criteria included patients diagnosed with PG, over the age of 18, and treated with an interleukin inhibitor. Our study included 60 papers describing 81 patients fulfilling the eligibility criteria. The treatment with interleukin inhibitors resulted in 70% (95% CI 59-80%) response and 57% (95% CI 45-68%) complete response rates, and few (4%) mild adverse events, hence supporting the off-label use for the treatment of recalcitrant PG in adults. The response and complete response rates were 59% (17/29) and 38% (11/29) for anakinra, 64% (7/11) and 55% (6/11) for canakinumab, and 79% (27/34) and 71% (24/34) for ustekinumab, respectively. Limitations include publication bias that might have overestimated the efficacy as successful cases responding to treatment are more likely to be reported than nonresponding cases. Additionally, the heterogeneity of the treatment groups does not allow conclusions of superiority or inferiority of the different interleukin inhibitors to be drawn. Further studies are needed to investigate the efficacy of the different interleukin inhibitors and to investigate the importance of underlying disease for treatment response.

Case Report: A Rare Case of Autoinflammatory Phospholipase Cγ2 (PLCγ2)-Associated Antibody Deficiency and Immune Dysregulation Complicated With Gangrenous Pyoderma and Literature Review

Background

Autoinflammatory phospholipase Cγ2 (PLCγ2)-associated antibody deficiency and immune dysregulation (APLAID) is a rare autoinflammatory disease caused by gain-of-function mutations in the PLCG2 gene. Here we report a rare case of APLAID patient carrying a novel heterozygous missense PLCG2 I169V mutation with gangrenous pyoderma and concomitant high serum immunoglobulin (Ig) E level.

Methods

The patient was diagnosed as APLAID and has been treated in our department. His phenotype and genotype were carefully documented and studied. We also conducted a comprehensive literature review on APLAID.

Results

A 23-year-old Chinese Han man presented with recurrent fever for 18 years and vesiculopustular rashes for 9 years, along with chronic bronchitis, leukocytosis, increased C-reactive protein, immunodeficiency and high serum IgE. Skin biopsy showed chronic inflammatory cells infiltration. A paternal heterozygous missense variant in exon 6 of the PLCG2 gene p. I169V was identified. His vesiculopustular and IgE level responded to medium dose corticosteroids. After withdrawal of steroids, he developed severe arthritis and a large deteriorating ulceration resembling pyoderma gangrenosum on the left knee. Large dose corticosteroids were suboptimal. Then he received adalimumab with satisfactory response for arthritis and skin lesion. But he got an immunodeficiency-associated lymphoproliferative disorder 2 months later. Through literature review, there were a total of 10 APLAID patients reported by six English-language publications. Vesiculopustular rashes, sinopulmonary infection and immunodeficiency were the most frequent symptoms of APLAID patients. Glucocorticoids, intravenous immunoglobulin and biologics were clinically used to treat APLAID but none of these patients had a complete recovery.

Conclusions

The rarity and diversity of APLAID make it difficult to be diagnosed. Our study reported the first case of APLAID with gangrenous pyoderma and concomitant high IgE carrying a novel PLCG2 mutation, which may expand the clinical phenotype and genotype of APLAID.

Efficacy and safety of skin grafting in treatment of vasculitic ulcer and pyoderma gangrenosum-A systematic review

Chronic painful ulcers caused by pyoderma gangrenosum (PG) and cutaneous vasculitis remain to be a therapeutic challenge. Skin grafts have been used with success in selected cases but are generally avoided due to the fear of pathergy. The aim of this study was to investigate the safety and efficacy of skin grafting in the treatment of primary vasculitic ulcer (PVU) and PG. MEDLINE, Embase, the Cochrane Library, Clinicaltrial.gov, and WHO International Clinical Trials Registry Platform (ICTRP) were searched from inception to March 2020. A search for grey literature was conducted in May 2020. We included studies assessing the efficacy and safety of skin grafting in the treatment of PG and PVU. Studies were only included if skin grafting was performed after establishment of PG or PVU diagnosis. A total of 721 articles was identified through the database search of which 92 were included in this study. Ten articles were identified by handsearching the reference list of included studies. Finally, 102 articles describing 212 wounds in 153 patients were included. Complete healing was found in 75.5% of the wounds. The average time to complete was 10.8 weeks (95% CI 6.1-15.6). The mean donor site healing time was 1.9 weeks (95% CI 0.52-3.20). Pathergy was reported in 8 (5.2%) patients. One patient had severe infection related to skin grafting. A statistically significant difference in the number of patients receiving preoperative (P = .0079) and postoperative (P = .002) immunosuppressive therapy was found between the groups with complete healing/reduction and no improvement/aggravation. This systematic review finds the current evidence on efficacy and safety of skin grafting in treatment of PG and PVU to be promising but limited to the size and lack of studies superior to case reports and case series. Future placebo-controlled trials are required to draw a stronger conclusion.

Pyoderma gangrenosum and tumour necrosis factor alpha inhibitors: A semi-systematic review

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.