Severe recalcitrant pyoderma gangrenosum treated with infliximab

Conflicts of interest: none declared. Sir, We previously reported a case of a 17‐year‐old gentleman with severe recalcitrant pyoderma gangrenosum (PG), who was successfully treated with a combination of mycophenolate mofetil (MMF) and ciclosporin.1 This is an update on this patient's progress, 6 years later. Following complete healing of the PG ulcers affecting the right posterior thigh, immunosuppression was weaned down over 15 months, with only one relapse. He was off treatment for 16 months before he developed a recurrence of the ulceration on the right thigh and a new area of ulceration on the right posterior calf (Fig. 1). Despite recommencing immunosuppressants including prednisolone 25 mg daily, MMF 2 g daily and ciclosporin 6 mg kg−1 day−1, he developed progressive ulceration and we decided to treat him with infliximab. Repeat screening investigations including comprehensive gastrointestinal investigations failed to reveal any underlying cause for the recurrent PG. A dramatic response was seen following three infusions of infliximab given one month apart, at a dose of 3 mg kg−1 (Fig. 2). This resulted in the complete remission of the PG over a 4‐month period. Following the initial infusion a 50% reduction in the size of the ulcers was achieved within 7 days. Treatment was well tolerated with no adverse reactions noted. Ciclosporin and prednisolone were gradually withdrawn with no signs of recurrence of PG at 6 months follow‐up. He remains on MMF 1·5 g daily. Regular wound examination and swabs revealed no evidence of any secondary infection.