Adalimumab Treatment for Pyoderma Gangrenosum

A 47-year-old woman was referred to Washington University dermatology clinic for a nonhealing ulcer on her right shin of 8 months’ duration. She reported having had a similar ulcer on her left shin 6 years ago. The patient’s medical history was significant for non–insulin-dependent diabetes mellitus, hypertension, and osteoarthritis. On examination, she was found to have a 23-cm punched-out ulcer with rolled borders on her right shin. Evaluation of a biopsy specimen taken 6 months prior to presentation showed extensive dermal necrosis with ulceration and abscess formation and microangiopathy manifested by thickening of the capillary walls with fibrinous deposits and microthrombi. The overall histologic findings were thought to be most consistent with atrophie blanche. Further evaluations at presentation included a complete bloodcellcountwithdifferentialandrheumatoidfactor,both of which were within normal limits. She had no reaction to purified protein derivative. A routine tissue culture grew rare Enterococcus species. After 1 month of therapy with minocycline, 100 mg orally, twice daily, and Unna wraps with applicationofclobetasol0.05%ointment,asecondbiopsyspecimen showed extensive stasis dermatitis and a full-thickness fibroinflammatory process with no necrobiosis. A diagnosis of pyoderma gangrenosum (PG) was made based on the clinical appearance of the ulcer, absence of a significant infectious pathogen, and histologic findings. The patient was treated with minocycline, 100 mg orally, twice daily, Unna wraps with application of clobetasol 0.05% ointment, and intralesional triamcinolone acetonide injections (Kenalog; Bristol-Myers Squibb, Princeton, NJ). After 3 months of treatment, the patient experienced no improvement. The ulcer was deep, painful, and had increased in size to 33.5 cm (Figure 1). A systemic treatment was needed.