Efficacy and safety of spesolimab in resistant pyoderma gangrenosum: a case report and brief review of the literature

Pyoderma gangrenosum (PG) is a rare neutrophilic dermatosis characterized by rapidly progressive painful ulcers, and increasing evidence supports a role for the interleukin-36 pathway in its pathogenesis. We report the case of a 59-year-old woman with idiopathic refractory PG that evolved over 8 years. The patient had an insufficient response to prolonged systemic corticosteroids and azathioprine, with persistent steroid dependency. Spesolimab was initiated as a single 900-mg intravenous infusion in combination with low-dose prednisone (10 mg daily). This led to pain reduction, re-epithelialization and progressive ulcer healing, estimated at 30% after 3 months, 50% after 6 months and 80% after 8 months. No major adverse events were observed, apart from an erysipelas-like reaction around the ulcers 3 months later. Our review of published cases suggests that spesolimab may induce rapid and sustained improvement in refractory PG, although responses appear more heterogeneous in patients with underlying myeloid disorders. Overall, spesolimab appears to be a promising and well-tolerated therapeutic option for refractory PG, but further controlled studies are needed to better define its efficacy and safety, and place in the treatment algorithm.