Pyoderma Gangrenosum is a skin condition characterised by large, painful ulcers. This article explores this inflammatory skin condition and learn about the best topical and localised treatments to support healing and reduce flare-ups.

The treatment for Pyoderma Gangrenosum mainly focuses on two types of treatments. The first is topical, and the second is localised, which focuses on two key areas: wound care and corticosteroid creams.¹ Wound care involves a simple procedure, such as gently cleaning the wound with saline, taking precautions to avoid any trauma to the area, and applying non-adhesive dressings to maintain moisture while protecting the ulcer. Applying corticosteroids topically around the edge of skin ulcers controls inflammation and helps to prevent further tissue damage. A combination of both of these treatments synergistically will help minimise pain, reduce inflammation, and create a suitable environment for healing, especially when used consistently and during the onset of the inflammation.

The purpose of this article is to raise awareness of this rare condition, Pyoderma Gangrenosum, and its treatment options. 

What is pyoderma gangrenosum (PG)?

The name Pyoderma Gangrenosum is historical.² Contrary to what its name suggests, this skin condition is not an infection caused by any external source, nor does it cause gangrene as a disease. Rather, PG belongs to the group of autoinflammatory disorders, such as neutrophilic dermatoses. In this condition, there is a full-thickness ulcer on the skin with blue or purple undermined borders, followed by a flare-up of skin lesions. It is a rare disorder that mainly affects the legs and other body parts; however, the exact cause of PG is not known to date. The condition often clears with proper treatment, but sores and lesions that also cause pain often leave scars. 

Early detection is very important in Pyoderma Gangrenosum, as the underlying conditions are found in up to 50% of cases and can be investigated thoroughly.³ As soon as a diagnosis of PG has been made, the treatment is done according to the severity and rate of progression. In some cases, even in early, well-recognised conditions, there is often failure to make a diagnosis of PG. When assessing ulcers, the possibility of PG should be taken into consideration because early treatment can avoid further complications like delayed wound healing and scarring.

Understanding pyoderma gangrenosum

What causes PG? 

Commonly, Pyoderma Gangrenosum is associated with rheumatoid arthritis, inflammatory bowel diseases, and other autoimmune and inflammatory conditions. Also, PG is associated with solid tumours and malignancies.^]Pyoderma Gangrenosum has a connection to up to 5% to 12% of cases of ulcerative colitis and 1% to 2% with Crohn's disease.⁴ Still, it is unclear whether PG gets worse with inflammatory bowel diseases. The estimated range falls in less than 5% of cases in it occurs in children. The major age group falls under the category of 11 to 89 years of age.

Why does localised treatment matter in PG?

Localised treatments have many benefits: they give faster results as they effectively control inflammation and promote healing of smaller and superficial skin ulcers, whilst also avoiding systemic side effects and targeting the affected area accurately.⁵ Wound care is also easy for the patient to manage by themselves. As in the severe conditions of PG, the trauma to the skin is unbearable, so avoiding any surgical treatment or procedure is important.

Role of wound care in managing PG

The optimisation of wound care methods, strategies and different types of modes for anti-inflammatory approaches is necessary to alleviate multiple connecting pathways of inflammation leading to delayed healing, which further complicates and traumatises the wound.⁶  

Recent developments have been made on targeted therapies of PG with topical and systemic medications. The wound management includes normal gentle cleansing without sharp debridement and by using limited topical antibacterial use. 

Additionally, compression therapy and wound dressing together give a wide variety of treatment options. The purpose of wound dressing should aim to target the specific PG wound area, depending on the depth and exudative nature of the wound. The types of wounds, like superficial wounds, granulating wounds, and colonised wounds, are managed with variable approaches.  

Use of topical steroid creams

Why steroids?

Current studies prove that topical corticosteroids are the most commonly used topical agents. The topical calcineurin inhibitors, particularly tacrolimus, may represent an alternative to topical agents.⁷ Corticosteroids and calcineurin inhibitors both have similar benefits and are generally well tolerated. The mechanism of action of corticosteroids is to minimise the immune system’s overactive response.  For example, PG involves a buildup of neutrophils, a type of white blood cell that damages the skin and tissues. Hence, steroids are a good option in cases of mild or localised wounds caused by Pyoderma Gangrenosum.⁸ Various studies show that corticosteroids can be useful and safe alternatives to systemic immunosuppressant therapy in the treatment of PG.

Types of steroids used

The majorly used corticosteroids in the treatment of Pyoderma Gangrenosum are prednisone and methylprednisolone.⁹ The potent corticosteroid used in most treatments is Clobetasol propionate 0.5%.¹⁰ One study shows that in the group of 66, 43.8% of patients had their ulcers healed in 6 months.¹¹ In more severe cases, systemic corticosteroids are needed for proper treatment.

Treatment protocol

Most patients used a stepwise approach and both topical and systemic treatments.¹² The main treatment is using immunosuppressants, the most commonly used drugs being corticosteroids and ciclosporin.  Considering topical treatments, the highly potent topical corticosteroid prednisolone is used; however, patients exposed to these treatments for a long time are at risk of steroid-related side effects.

Side effects and precautions

The maximum use of topical corticosteroids can give a burning sensation; however, as time passes, this improves as your skin gets used to the treatment. Less common side effects include the spreading of a skin infection you already have. Additionally, thinning of the skin can make the affected area more prone to damage.¹³ In some cases, it will also give permanent stretch marks that become less noticeable over time. For patients with dark skin colour tones, the existing skin colour tone may noticeably change. Side effects are commonly seen if you use more potent corticosteroids for a long time or over a large area.

Combining wound care and topical steroids

A combination of wound care and application of topical steroids is the best method for treatment. Taking care of the wound, regularly cleaning the wound, focusing on preventing further complications like frequent infection, and promoting healing, along with corticosteroids, helps reduce inflammation and pain. This synergistic treatment can help manage the complications in PG.

When to escalate treatment

In case of an extensively and rapidly progressing disease or treatment-resistant skin lesions, physicians may escalate treatment.¹⁴ This is mainly done by systemic therapies: corticosteroids can be given systemically to get faster results. Also, several antibiotics may be used to manage PG treatment in severe conditions.

Tips for patients and caregivers

For patients

• Follow the medical advice and adhere to the wound care instructions provided by your physician, including cleaning, dressing, and medication, if any
• Wash the wounds with soap and running water, then cover them with non-adhesive bandages to prevent infection
• Be cautious to avoid any trauma that could worsen the situation and cause more infection
• Immediately communicate any pain to your physician and follow their advice and recommendations for pain relief

For caregivers

• PG can be challenging, so try to be understanding with the patient
• Keep reminding the patient to take medications and attend the scheduled appointments
• Assist the patient in wound care tasks if needed, following the instructions provided by the physician
• Support the patient in maintaining a healthy lifestyle
• Caregiving can be stressful, so seek support from friends and family or join support groups

Summary

Pyoderma Gangrenosum (PG) requires a very careful and in-line approach, mainly focused on wound care and topical corticosteroids. To avoid complications like scarring and infection, early diagnosis and treatment are very important. Wound care management, like cleansing and nonadhesive dressing, helps maintain a healing environment. A combination of wound care and topical steroid application ensures faster and more effective results, especially in mild and or localised cases.

Patients and fellow caregivers should follow the medical recommendations, avoid trauma, and stay informed. With timely and proper care, PG can be effectively managed, improving the quality of life for those affected by this rare disease.