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Pyoderma Gangrenosum – Causes, Symptoms and Treatment

Pyoderma gangrenosum is a rare, inflammatory skin condition that causes painful ulcers. It belongs to the neutrophilic dermatoses and is frequently associated with underlying systemic diseases.

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Things worth knowing about "Pyoderma gangrenosum"

Pyoderma gangrenosum is a rare, inflammatory skin condition that causes painful ulcers. It belongs to the neutrophilic dermatoses and is frequently associated with underlying systemic diseases.

What is Pyoderma gangrenosum?

Pyoderma gangrenosum (PG) is a rare, non-infectious, inflammatory skin disorder classified among the neutrophilic dermatoses. These are conditions characterized by an excessive infiltration of neutrophilic granulocytes (a type of white blood cell) into the skin, leading to tissue destruction. The disease typically follows a relapsing course and is marked by rapidly progressing, extremely painful skin ulcers.

Causes and Risk Factors

The exact cause of pyoderma gangrenosum remains incompletely understood. It is considered an autoimmune condition in which the immune system attacks the body's own tissue. A genetic predisposition is likely involved.

In approximately 50–70% of cases, pyoderma gangrenosum is associated with an underlying systemic condition, including:

Inflammatory bowel diseases (e.g., Crohn's disease, ulcerative colitis)
Rheumatoid arthritis and other joint disorders
Hematological malignancies such as leukemia or monoclonal gammopathy
Autoimmune diseases such as lupus erythematosus

A key phenomenon in pyoderma gangrenosum is the pathergy reaction: even minor skin injuries or surgical wounds can trigger new ulcers or worsen existing ones.

Symptoms

The typical symptoms of pyoderma gangrenosum often develop rapidly and progress quickly:

Onset as a small red papule, pustule, or blister
Rapid progression to a deep, painful ulcer with undermined, violaceous (bluish-red) wound edges
Severe pain that is often disproportionate to the visible lesion
Most commonly located on the lower legs, but can also affect the trunk, face, and other areas
Occasional systemic symptoms such as fever and general malaise

Several clinical variants exist, including the ulcerative (most common), bullous, pustular, and vegetative forms.

Diagnosis

There is no specific laboratory test for pyoderma gangrenosum. The diagnosis is one of exclusion and is based on:

Clinical presentation and disease course
Skin biopsy with histological examination (to exclude other causes)
Exclusion of infections, vascular disorders, malignancies, and other causes of ulceration
Laboratory tests to identify associated underlying conditions

Diagnostic criteria (e.g., those proposed by Maverakis et al., 2018) can support the diagnostic process.

Treatment

Treatment of pyoderma gangrenosum depends on disease severity and the presence of underlying conditions. The primary goal is to suppress the excessive immune response and promote wound healing.

Local Therapy

Moist wound care and gentle wound management (avoiding aggressive debridement)
Topical corticosteroids or calcineurin inhibitors (e.g., tacrolimus) for mild cases

Systemic Therapy

Corticosteroids (e.g., prednisolone) as first-line therapy in severe cases
Ciclosporin as an alternative or adjunct immunosuppressant
Biologics such as TNF-alpha inhibitors (e.g., infliximab, adalimumab), especially for refractory cases or when inflammatory bowel disease is co-present
Other immunosuppressants including dapsone, azathioprine, or mycophenolate mofetil

Treatment of Underlying Conditions

Managing an associated underlying disease (e.g., Crohn's disease) can positively influence the course of pyoderma gangrenosum and is therefore an essential part of the overall treatment plan.

Prognosis

The course of pyoderma gangrenosum varies greatly between patients. Some respond well to treatment, while others experience a chronic, relapsing course. Even after healing, significant scarring may remain. Close dermatological follow-up and regular monitoring are essential.

References

Maverakis E. et al. - Diagnostic Criteria of Ulcerative Pyoderma Gangrenosum. JAMA Dermatology, 2018.
Bolognia J.L., Jorizzo J.L., Schaffer J.V. - Dermatology. 4th Edition, Elsevier, 2018.
Callen J.P. - Pyoderma gangrenosum. Lancet, 1998; 351(9102): 581–585.

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