The Use of Cellular- and/or Tissue-Based Therapy for the Management of Pyoderma Gangrenosum

A Case Series and Review of the Literature

Mabel Ching-Yee Chan, MD; Crystal James, MD; Munir Patel, MD; Scott Ellis, MD; John C. Lantis II, MD

Disclosures

Wounds. 2021;33(6):161-168. 

In This Article

Case Presentations

Case 1

A 48-year-old male with a history of ulcerative colitis (UC) presented to the emergency department (ED) for a painful purpuric lesion on the right shin that showed no improvement after a 2-week course of oral trimethoprim/sulfamethoxazole and doxycycline. Prior to presentation the patient had been evaluated by his primary care physician when the wound had rapidly progressed from a small lesion the patient had unroofed. The patient had been treated with mercaptopurine (PURINETHOL; Teva Pharmaceuticals USA) and mesalamine (Asacol HD; Allergan) for UC and had not had any ulcerative lesions since diagnosis. The patient denied any gastrointestinal (GI) issues, such as bloody diarrhea or abdominal pain. A dose of vancomycin and cefepime was given by the ED physician preemptively, but it was not continued during the patient's hospitalization.

Physical examination revealed a 10-cm × 8-cm hyperemic shallow ulceration with violaceous borders and skin sloughing circumferentially at the edges on the right shin. Figure 1A shows the appearance of the lesion on admission. Blood tests showed a normal white blood cell (WBC) count of 8.3 K/uL (range, 4.5–11.0 K/uL), an elevated erythrocyte sedimentation rate (ESR) of 75 mm/hour (range, 0–13 mm/hour), and a C-reactive protein (CRP) level of 89.35 mg/L (range, 0–5.1 mg/L). Dermatology and gastroenterology specialists were consulted for optimization of medical management of UC, and the patient was restarted on home medications for UC as previously mentioned and prescribed 1 prednisone 50 mg tablet daily.

Because of its size and to aid in slowing down progression, the cutaneous lesion was treated with CTP. Sharp debridement of the edges of sloughed skin was performed with a scalpel under local anesthesia. Fetal bovine dermis (FBD) (PriMatrix; Integra LifeSciences) was applied and sutured in place with simple interrupted 3–0 chromic gut sutures. Biopsy of the wound edge was also done at the time of debridement, revealing skin with ulceration, severe acute inflammation and abscess, and absence of giant cells. The FBD was bolstered to the wound bed with nonadherent cellulose acetate mesh (ADAPTIC TOUCH Non-Adhering Silicone Dressing; 3M) and wrapped with a multilayered zinc oxide compression boot.

The dressing was removed on postoperative day 4, at which time the wound appeared less hyperemic and exhibited successful engraftment of FBD (Figure 1B). A new multilayer dressing was placed, and the patient was discharged on a prednisone taper. Steroid treatment duration and type were dictated by dermatology and gastroenterology specialists.

By the follow-up appointment with the dermatology specialist 1 week later, the wound had contracted around the edges and granulation tissue had formed at the base. The borders were clean and without purpura (Figure 1C). Triamcinolone acetonide 80 mg (Kenalog 20 mg/mL) was injected at the periphery of the wound. The patient was also evaluated at the authors' clinic on the same day at which time the dressing was reapplied. At 1-month follow-up, the wound bed was almost completely reepithelialized, with small areas of ulceration at the edges (Figure 1D).

Case 2

A 31-year-old female with a history of UC presented to the ED with worsening right foot pain for 1 month. She had been evaluated in the ED multiple times previously with similar issues, but laboratory values and radiologic images demonstrated no signs of infection and the patient was discharged home on oral antibiotics. By the time of this most recent visit the patient's pain had progressed to the point that she could not ambulate without difficulty; at that time these authors were consulted in the ED. The patient had been on mesalamine when she was diagnosed with acute flare of UC 2 years previously, but at the time she was not undergoing treatment with corticosteroids or immunomodulators. The patient also denied any GI issues.

Physical examination revealed marked edema of the right medial forefoot to mid shin and ruptured bullae with overlying eschar that was exquisitely tender to palpation (Figure 2A). Pedal pulses were palpable bilaterally. Intravenous (IV) vancomycin and ceftriaxone was started for a presumed working differential diagnosis of PG and cellulitis. Blood tests showed a normal WBC count of 8.3 K/uL as well as an elevated ESR and CRP level of 78 mm/hr and 58.3 mg/L, respectively. Magnetic resonance imaging of the foot demonstrated osteomyelitis of the navicular bone with devitalized soft tissue. The dermatology and gastroenterology specialists who were consulted did not believe the wound was PG and deferred treatment or workup.

Figure 2.

Case 2: Photographic temporal evolution of pyoderma gangrenosum on the right ankle. Wound is shown (A) at presentation, (B) after hydrosurgical debridement, (C) after fetal bovine dermis (FBD) placement, (D) 3 weeks after FBD, and (E) at 1 month following split-thickness skin graft.

The patient underwent wide hydrosurgical debridement; FBD was used to cover the wound and was sutured in place with 4–0 chromic gut (Figure 2B, 2C). The authors' protocol for use of tangential hydrosurgical debridement includes cutting the skin edges back to a 45° angle to healthy bleeding tissue under ×2.5 loupe magnification. The base of the wound was then debrided with tangential hydrosurgery until punctate bleeding was observed under ×2.5 loupe magnification. Skin biopsy was also done at the time of debridement, which showed skin with underlying abscess that was nonspecific with neutrophilic infiltration and hemorrhage. The wound was covered with a petrolatum-based gauze and topical bacitracin and bolstered to the wound bed with moist gauze and compressive wrap. Wound culture of the drainage grew no organisms after 5 days. The patient was discharged on 6 weeks of oral antibiotics given the underlying abscess. By 3-week follow-up, the wound exhibited adequate graft take (Figure 2D). Fetal bovine dermis that was not fully engrafted to the wound was excised, and the base of the wound was pulse irrigated with saline. Split-thickness skin graft was harvested from the contralateral hip and secured to the wound with nonadherent mesh and negative pressure wound therapy (NPWT). On postoperative day 4, NPWT was discontinued and the patient was discharged with a multilayer compression dressing. The STSG appeared to exhibit 100% take and complete healing after 1 month (Figure 2E).

Three months postoperatively, however, the patient had an acute UC flare and was prescribed hydrocortisone for 2 weeks; she declined to continue immunosuppressant therapy when her GI symptoms resolved. She was later examined in the authors' clinic for swelling over the medial malleolus of the STSG site. The fluid was aspirated and sent for culture, which was found to be negative for any organisms. The patient presented to the ED the follow week with purple discoloration at the site of aspiration and intense pain. The patient reported subjective fevers at home and indicated she was taking oral antibiotics prescribed by her primary care physician for a presumed cough. On physical examination, the 20% of the graft at its center appeared to have a violaceous plaque with hemorrhagic oozing. Blood tests showed an elevated ESR and CRP level with a normal WBC count. At the time of presentation, the patient was experiencing infrequent episodes of diarrhea and bright red blood per rectum, but she continued to decline immunosuppressive therapy. The patient returned to the operating room for debridement of the necrotic center of the wound and copious irrigation with hydrogen peroxide. She was advised to soak her foot daily in hydrogen peroxide and cover her wound with petrolatum-based gauze. The patient was lost to follow-up after discharge.

Case 3

A 35-year-old male with a history of sickle cell anemia presented to an outpatient vascular surgery clinic with an ulcer of the right lower extremity (Figure 3A). The patient was treated with local wound care and compression therapy for possible venous stasis ulcer. At 2-week follow-up, the wound appeared to be enlarging with erythema and induration around the borders, measuring 6 cm × 7 cm and 3 cm × 2 cm (Figure 3B). The patient was sent to the ED and was found to have a normal WBC count with an elevated ESR (150 mm/hour) and CRP level (51.3 mg/L). He was again presumed to have worsening of the venous stasis ulcer and was admitted for IV antibiotics and daily dressing changes with SILVADENE Cream (Monarch Pharmaceuticals).

Figure 3.

Case 3: Photographic temporal evolution of pyoderma gangrenosum on the right lower extremity. Wound is shown (A) at presentation in the outpatient clinic, (B) 1 month later at presentation in the emergency room, (C) at presentation during second hospitalization, (D) at the 3-months follow-up visit, and (E) after 4 months of negative wound pressure therapy.

After discharge, the patient was evaluated in the authors' clinic for a second opinion. At that time, the decision was made to start the patient on prednisone owing to high suspicion for PG. However, his wounds had coalesced and enlarged to a size of 11 cm × 8 cm (Figure 3C), and he was readmitted to the hospital for IV antibiotics and local wound care. The dermatology specialist who was consulted for PG recommended nonsurgical management with outpatient follow-up. The medical team also adamantly refused to allow the patient to undergo CTP placement. The patient was discharged after 10 days of treatment with IV antibiotics, steroids, and local wound care. He was evaluated in the dermatology clinic 2 days after discharge; at that time he was on a steroid taper and received intralesional Kenalog 20 mg/mL injections. Weekly follow-up was continued for 3 months, and the patient eventually underwent NPWT to manage excessive drainage from the wound (Figure 3D). Surgical management with debridement and placement of CTPs was offered, but the patient declined and continued NPWT for 4 months. At the end of NPWT treatment, the wound was approximately one-half its original size (Figure 3E).

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