S ir, Pyoderma gangrenosum is a condition characterized by destructive skin ulcers with irregular ragged purple–red margins. These ulcers may enlarge to over 10 cm in diameter, are usually painful and result in severe scarring. Underlying conditions (e.g. Crohn's disease, rheumatoid arthritis and monoclonal gammopathies) are identified in 50–75% of cases. The peak prevalence is between 30 and 50 years with a slight female preponderance. Treatment for pyoderma gangrenosum includes high‐dose systemic corticosteroids, intralesional corticosteroids and a range of other treatments including sulphasalazine, cyclophosphamide, methotrexate, clofazimine, azathioprine, high‐dose intravenous immunoglobulin and, more recently, cyclosporin, tacrolimus1, 2 and mycophenolate mofetil.3 We report the successful use of a combination of oral tacrolimus and topical tacrolimus 0.1% ointment (white soft paraffin 86 g, white beeswax 8 g, cetostearyl alcohol 3 g, lanolin anhydrous 3 g per 100 g) in a 30‐year‐old woman. Her past medical history includes Crohn's disease, insulin‐dependent diabetes mellitus and autoimmune neutropenia. Pyoderma gangrenosum was diagnosed in September 1992, and a range of treatments, including oral prednisolone 25 mg daily, azathioprine 100 mg daily, doxycycline 100 mg twice a day and clofazimine 100 mg twice a day, were tried unsuccessfully over a period of 6 months. A trial of oral cyclosporin (125 mg, twice daily) heralded an initial improvement but, within a matter of months, the disease progressed. In 1994, the patient was admitted to hospital for 9 months because of the severity of the ulcers on her shins. She was unresponsive to oral dapsone and intravenous granulocyte–macrophage colony‐stimulating factor and two attempts at skin grafting failed. In November 1994, oral tacrolimus was commenced at 0.3 mg/kg per day and was well tolerated. Her ulcers improved rapidly over the next 2 months, and she was discharged. The patient remained stable for over 2 years with stable renal function, but her ulcers recurred. She was treated with oral tacrolimus (0.3 mg/kg per day), oral azathioprine (150 mg/day), oral prednisolone (15–60 mg/day, averaging at 15–20 mg/day) and intravenous immunoglobulin, but her disease was slow to come under control. Attempts to increase the dose of oral tacrolimus resulted in impairment of renal function (serum creatinine 164 μmol/L; normal range 55–120 μmol/L). It was decided to prepare a 0.1% tacrolimus ointment, and this was applied under occlusion to the ulcers, while a lower oral dose of 0.3 mg/kg per day tacrolimus was maintained. The patient's renal function remained stable, and the ulcers healed over a period of 3 months. The use of oral tacrolimus has been described previously in this patient and another report.1 However, it may be possible to limit both the cost (approximately $18,000/year) and potential side‐effects using a combination of oral tacrolimus and tacrolimus ointment, which can be made up on an individual basis and a potency selected as required. The use of potent immunosuppression of this nature in therapy‐resistant pyoderma gangrenosum warrants close vigilance for infection, particularly with the use of occlusive dressings. In our patient, a Staphylococcus aureusinfection occurred on the shin and was treated successfully with an oral cephalosporin.
No takes yet. Share an insight, caveat, or question.
Jolles et al. (1999) studied this question.