An update on adalimumab for pyoderma gangrenosum

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.

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.

Toxic epidermal necrolysis after injection of sclerosing agent and medical adhesive into oesophageal variceal ligation in a patient with a malignant liver tumour: A case report

Chronic liver disease can cause an increase in portal sinus pressure, which may lead to rupture and bleeding of esophageal and gastric varices. Oesophageal variceal ligation, with use of sclerosing agent and tissue glue injection is commonly used in clinical practice to address oesophageal bleeding. A 58-year-old male patient with chronic liver disease was treated with oesophageal variceal ligation, sclerosing agent and tissue glue injection due to oesophageal and gastric variceal bleeding. After 2 days, the skin of the patient exhibited erythema to different degrees. After 10 days of dexamethasone treatment, the whole-body rash worsened, and a severe skin reaction appeared that was suggestive of toxic epidermal necrolysis (TEN). Strict mucosal care was provided, and corticosteroids, γ globulin and adalimumab were concurrently used for treatment. After 20 days, the patient recovered from the skin problems. To the best of our knowledge, TEN after endoscopic surgery has rarely been reported in the relevant literature. Furthermore, when patients being treated with multiple drugs have erythema multiforme, physicians should be alert to the possibility of its development into TEN. The present case report summarizes the treatment methods for patients with TEN, providing a practical clinical basis and direction for the future diagnosis and treatment of the condition.

A Case of Paradoxical Reactions to Biologic Therapy for Psoriasis

Introduction

Psoriasis is an immune-mediated chronic inflammatory skin disease. As our understanding of the pathogenesis of psoriasis has improved, biologic agents have become increasingly important in the treatment of psoriasis. However, the use of biologic agents is associated with cutaneous side effects. A new type of side effect called paradoxical reactions is an emerging threat arising from the increasing use of biologic agents.

Case

Here, we present a case of paradoxical skin reactions - pyoderma gangrenosum (PG) and eczema - induced by biologic therapy. The case was successfully and eventually treated with baricitinib.

Discussion

PG is a rare inflammatory disease characterised by painful and necrotic ulcerations containing neutrophils. It has been associated with autoimmune diseases such as inflammatory bowel disease (IBD). TNF (tumor necrosis factor) -α inhibitors can effectively treat refractory PG, while IL (interleukin) -17A inhibitors may worsen IBD symptoms. The cause of PG in this case was believed to be secukinumab, not adalimumab. The patient was diagnosed with eczematous dermatitis due to TNF-α inhibitors, and baricitinib was added to treat eczematous dermatitis.

Conclusion

Paradoxical reactions are unpredictable events that may occur during treatment with biologics at anytime. They need further research in order to formulate personalised treatment.

A Rare Case of Severe Post-operative Pyoderma Gangrenosum After Surgery for Perforated Diverticulitis at the Sigmoid Colon

Pyoderma gangrenosum (PG) is a nonbacterial ulcerating skin condition. It is typically associated with other systemic disorders. However, approximately 20%-30% of cases are idiopathic. Post-operative PG (PPG) is a rare type of PG with a rapidly expanding cutaneous ulcer at a surgical site and is often misdiagnosed as a wound infection. The difficulty in diagnosis can lead to unnecessary surgical interventions and delay in the treatment of PG. Herein, we present the case of a 68-year-old patient with severe PPG with no underlying diseases. He underwent an emergency laparotomy (Hartmann's procedure) for perforated diverticulitis. After the operation, systemic inflammatory response syndrome (SIRS) developed and the skin around the incisional wound, stoma, injection venous lines, and electrocardiogram monitoring pads gradually became erythematous. Skin biopsy and the absence of a source of infection confirmed the diagnosis of PG. Drug therapy for PG with steroids, and tumor necrosis factor-α inhibitors improved SIRS and the patient recovered.

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.