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Clinical Research
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Clinical algorithm for the combinatorial treatment of pyoderma gangrenosum Vincent W. Li, MD, MBA, Brigham & WomenÕs Hosp Dept of Dermatology, Harvard Medical School; William W. Li, MD, on behalf of the Wound Healing Cooperative Group (WHCG); The Angiogenesis Foundation, Cambridge, MA Pyoderma gangrenosum (PG) is a non-infectious, neutrophilic inflammatory, ulcerative condition for which there is no standard effective treatment. We developed an algorithm using an incremental, combinatorial therapeutic approach for PG, both in first-line treatment or for salvage therapy in cases recalcitrant to systemic prednisone or cyclosporine. This algorithm focuses on first suppressing inflammation, then stimulating wound healing with an advanced modality that stimulates angiogenesis and promotes healing. Assessment of wound healing velocity guides the treatment pathway. Based on mechanism of action, topical and systemic agents chosen to suppress inflammation include amlexanox paste, cromolyn sodium solution, tacrolimus ointment, clobetasol propionate gel, oral thalidomide, oral low dose doxycycline and niacinamide, oral mycophenolate mofetil, and parenteral infliximab or etanercept. All patients were started on topical agents and incrementally increased to systemic agents in order of lesser to greater toxicity. Concomitant wound bed preparation with cautious sharp debridement to avoid tissue pathergy is utilized. Cell therapy with bioengineered skin (Apligraf) alleviates pain and facilitates wound healing. The algorithms' clinical utility will be shown in a series of thirteen patients, all of whom were successfully treated without using prednisone, cyclosporine, or azathioprine. 10 of 13 cases had been refractory to conventional therapy (ulcer duration: 3 months - 5 years). Multiple interventions were necessary in all patients, ranging from 5-8 drugs. All patients benefited from bioengineered skin to accelerate healing. No patients developed any significant adverse events. Crowson AN, et al. J Cutan Pathol. 2003;30:97 Powell FC, et al. J Am Acad Dermatol. 1996;34:39. |
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