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 Table of Contents  
LETTER TO EDITOR
Year : 2020  |  Volume : 6  |  Issue : 1  |  Page : 41-43

Giant pyoderma gangrenosum treated successfully with combination of dexamethasone pulse and cyclosporine


Department of DVL, Institute of Medical Sciences and SUM Hospital, S 'O'A University, Bhubaneswar, Odisha, India

Date of Submission24-Aug-2019
Date of Decision04-Mar-2020
Date of Acceptance18-Apr-2020
Date of Web Publication23-Jun-2020

Correspondence Address:
Dr. Chinmoy Raj
Department of DVL, Institute of Medical Sciences and SUM Hospital, S 'O'A University, Bhubaneswar, Odisha
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijdd.ijdd_48_19

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How to cite this article:
Ray A, Raj C, Panda AK, Panda M. Giant pyoderma gangrenosum treated successfully with combination of dexamethasone pulse and cyclosporine. Indian J Drugs Dermatol 2020;6:41-3

How to cite this URL:
Ray A, Raj C, Panda AK, Panda M. Giant pyoderma gangrenosum treated successfully with combination of dexamethasone pulse and cyclosporine. Indian J Drugs Dermatol [serial online] 2020 [cited 2020 Oct 31];6:41-3. Available from: https://www.ijdd.in/text.asp?2020/6/1/41/287433



Sir,

Pyoderma gangrenosum is a rare neutrophilic dermatosis, commonly associated with an underlying systemic illness. The most commonly seen variant is the classical pyoderma gangrenosum, which presents as a painful, rapidly progressive necrolytic ulcer with an irregular, undermined, violaceous border.

The mainstay of treatment is with corticosteroids and other immunosuppressive agents such as azathioprine, cyclophosphamide, arabinoside, chlorambucil, colchicines, and daunorubicin. Cyclosporine is a highly effective agent, and pyoderma gangrenosum not responding to other immunosuppressants has shown rapid response to cyclosporine.[1]

Dexamethasone pulse therapy is the administration of suprapharmacological doses for rapid control of steroid-responsive dermatological disease conditions; the pulse therapy constituted administering 100 mg dexamethasone in 500 ml of 5% dextrose given as slow intravenous infusion over 3 h for 3 consecutive days.[2]

We report a case of giant pyoderma gangrenosum treated successfully with dexamethasone pulse therapy after there was no pronounced response with daily dexamethasone (8 mg) and oral cyclosporine.

A 42-year-old obese female presented with an acutely painful, tender ulcer over the abdomen, which initially presented as an erythematous papule, ruptured on scratching, and rapidly enlarged to a size of 20 cm × 15 cm over 5 days. Ulcer had irregular, indurated, violaceous borders, and the floor showed granulation tissue with bleeding and yellowish slough. Findings were clinically typical of pyoderma gangrenosum, and biopsy from the edge of the ulcer showed nonspecific findings of dense sterile neutrophilic infiltrate in the dermis [Figure 1]. Peripheral smear had neutrophilic leukocytosis. The patient was started on daily intravenous dexamethasone (8 mg) and oral cyclosporine (100 mg) twice daily.
Figure 1: The patient presented to us with an ulcer of size 20 cm × 15 cm on her abdomen

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There was very minimal improvement in 15 days of the treatmen. The patient was started on dexamethasone pulse therapy, and after a single 3-day pulse therapy, there was remarkable improvement with a reduction of ulcer size (more than 40%), with visible signs of healing as re-epithelialization at the edges of ulcer. Paraffin gauze dressing was applied over the affected area to prevent any secondary bacterial infection and to accelerate the healing process. Care was taken to prevent any tight dressing so that pathergy is not induced. After a total of five dexamethasone pulses, with tapering doses of oral cyclosporine in the pulse interval, the ulcer had healed completely with scar formation and postinflammatory hyperpigmentation. There was complete reduction in the pain and tenderness of the ulcer. At presentation, the patient selected a score of severe pain on the visual analog scale (VAS); at the end of 3 months, the patient was completely free of lesional pain and selected no pain on VAS. [Figure 2] shows the complete healing of ulcer with scarring at 5th month of follow-up. At the end of 6 months, the patient was off treatment; we observed the patient for the next 6 months, but no recurrence was observed. There were no dose-related adverse effects of cyclosporine and steroids, except for weight gain of about 8 kg. Routine investigations were done periodically to administer the safety of both medications.
Figure 2: Ulcer showing complete healing with scarring at 5th month of follow-up

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Our patient did not show any response to daily doses of oral steroids and cyclosporine; however, she showed complete clinical and symptomatic resolution and scar formation with dexamethasone pulse therapy and oral cyclosporine, and there was no recurrence of disease over the next 6 months. Riyaz et al. reported the use of pulse therapy as an adjunct to split thickness grafting, and 40% of the patients in their study did not respond and had to be maintained on oral steroids.[3] In Pasricha's study, patients showed an improvement after four pulses with maintenance on intervening oral steroids.[2] Hinterberger et al. used dexamethasone–cyclophosphamide pulse, but their patients developed adverse effects such as nausea and shortness of breath after a single pulse.[4] In conclusion, this combination of oral cyclosporine and dexamethasone pulse can be considered an alternative in cases of pyoderma gangrenosum not responding to conventional daily dosing of corticosteroids or oral cyclosporine alone.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Ambooken B, Khader A, Muhammed K, Rajan U, Snigdha O. Malignant pyoderma gangrenosum eroding the parotid gland successfully treated with dexamethasone pulse therapy. Int J Dermatol 2014;53:1536-8.  Back to cited text no. 1
    
2.
Pasricha JS. Pulse therapy as a cure for autoimmune diseases. Indian J Dermatol Venereol Leprol 2003;69:323-8.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Riyaz N, Mary V, Sasidharanpillai S, Roshin RA, Snigdha O, Latheef EN, et al. Pyoderma gangrenosum: A clinico-epidemiological study. Indian J Dermatol Venereol Leprol 2017;83:33-9.  Back to cited text no. 3
[PUBMED]  [Full text]  
4.
Hinterberger L, Müller CS, Vogt T, Pföhler C. Adalimumab: A treatment option for pyoderma gangrenosum after failure of systemic standard therapies. Dermatol Ther (Heidelb) 2012;2:6.  Back to cited text no. 4
    


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