Clinical Review

Diagnosis and treatment of pyoderma gangrenosum

BMJ 2006; 333 doi: http://dx.doi.org/10.1136/bmj.333.7560.181 (Published 20 July 2006) Cite this as: BMJ 2006;333:181
  1. Trevor Brooklyn ([email protected]), consultant gastroenterologist1,
  2. Giles Dunnill, consultant dermatologist2,
  3. Chris Probert, reader in medicine2
  1. 1 Cheltenham General Hospital, Cheltenham GL53 7AN,
  2. 2 Bristol Royal Infirmary, Bristol BS2 8HW
  1. Correspondence to: T Brooklyn
  • Accepted 20 June 2006

Introduction

Pyoderma gangrenosum is a rare but serious ulcerating skin disease, the treatment of which is mostly empirical. Pyoderma can present to a variety of health professionals and several variants exist that may not be recognised immediately. This can delay the diagnosis and have serious clinical consequences.1 The mainstay of treatment is long term immunosuppression, often with high doses of corticosteroids or low doses of ciclosporin. Recently, good outcomes have been reported for treatments based on anti-tumour necrosis factor α, and infliximab proved effective in a randomised controlled trial. This article reviews the presentation of pyoderma gangrenosum and the therapeutic options available.

Fig 1

Classic pyoderma gangrenosum

Methods

We used the keyword “pyoderma gangrenosum” to search Medline. We also searched the Cochrane database but found no Cochrane review on this disease.

How can pyoderma be recognised?

Several variants exist, but the most common one is classic pyoderma gangrenosum. This presents as a deep ulcer with a well defined border, which is usually violet or blue. The ulcer edge is often undermined (worn and damaged) and the surrounding skin is erythematous and indurated (fig 1). The ulcer often starts as a small papule or collection of papules, which break down to form small ulcers with a “cat's paw” appearance. These coalesce and the central area then undergoes necrosis to form a single ulcer.

Classic pyoderma gangrenosum can occur on any skin surface, but is most commonly seen on the legs. Patients are often systemically unwell with symptoms such as fever, malaise, arthralgia, and myalgia. Lesions are usually painful and the pain can be severe. When the lesions heal the scars are often cribriform. Early diagnosis and prompt treatment reduce the risk of scars, and disfigurement may occur if the diagnosis is missed.1 Pathergy occurs in 25-50% of cases—lesions develop at the site of minor trauma, so surgery or …

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