Recognizing and Treating Wounds Caused by Pyoderma Gangrenosum Protection Status
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by Aletha Tippett MD

If you care for wounds and have never encountered pyoderma gangrenosum, count yourself lucky. Drawing from my years of experience and the nearly 20,000 wounds I’ve cared for, pyoderma gangrenosum is the most difficult and most challenging. Fortunately it is rare. It can occur anywhere on the body, but most commonly is seen on the legs. It usually starts as a fairly innocuous injury, such as a nick while shaving the leg, or a chip thrown from weed whacking. Antibiotics are used, which are not effective. The wound continues to worsen and grow in size, and now is referred to a wound center or wound specialist.

By this time, it is a wound covered with slough and necrosis and the first impulse of a wound care provider is to debride the wound, and maybe get a biopsy. I would caution you to do neither, because of a problem known as pathergy that is hallmark of pyoderma gangrenosum. With pathergy, any physical action taken on the wound makes it worse.

How to recognize pyoderma gangrenosum? First, always think - an enlarging painful wound with violaceous borders are the key characteristics. It is extremely painful. Regardless of what is done it gets larger. And, its borders are violet or blue in color. Look for underlying conditions in your patient, too. Pyoderma gangrenosum is an autoimmune disorder and will be found in people over the age of 40 and often in people with other immune problems, such as ulcerative colitis, rheumatoid arthritis, multiple myeloma, polycythemia vera. About half the time no underlying pathology is evident.

What to do if faced with pyoderma gangrenosum? In our clinic we always start the patient on prednisone. We use topical pain relieving wound dressings. If tolerated, we use multi-layer compression wraps. If the wound is still progressing, we add cyclosporine treatment. We sometimes use green clay on the dressing. We always do wound cultures, checking for bacterial and mycobacterial agents, and treat for any infection. And we always treat for pain with appropriate pain medications.

Success with this wound is not guaranteed. Despite every effort, sometimes the wound continues to worsen and there is nothing that can be done. In one case we had, ultimately the patient’s leg was amputated. Most times, however, the above treatment plan is successful, and we have had many more pyoderma gangrenosum patients who healed their wounds. This is, however, a condition to always be taken seriously. In conclusion, it is important to be able to recognize pyoderma gangrenosum so as to be able to treat it appropriately and with the sensitivity it requires.

About The Author
Aletha Tippett MD is a family medicine and wound care expert, founder and president of the Hope of Healing Foundation®, family physician, and international speaker on wound care.

The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.

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Nice review Aletha. I have had the opportunity to see many PG cases usually after they are mismanaged by dabblers. I start with one of the immune modulating drugs such as Protopic which I apply around the wound. I reserve steroids for flareups or wounds that fail to respond to Protopic due to the systemic effects of steroids. I use well soaked hydrogel gauze to the wound to promote autolytic debridement as well as reduce pain. MPM makes a nice lidocaine hydrogel just perfect to help with the pain but I agree, pain patches and orals are almost mandatory. In my experience, though, I think that a confirmatory punch biopsy is needed to confirm PG recognizing the potential for Pathergy due to other etiologies. I biopsy the wound, wound/skin interface and the adjacent skin with a 2mm punch. Surgical debridement after diagnosis is confirmed is of course a No No. I absolutely agree with the compression and do this routinely as there is no question the venous system takes a hit when this flares. Like all unusual wounds or ones that fail to respond to the basics and/or when in doubt ...refer. Happy Holidays!!

What is green clay? Where do you get it? What does it do?
Thanks for discussing pg in your blog. I'm working with a person whose ulcer is identical to the photo.

I found that PolyMem Max works very well for cleaning up and supporting healing of PG wounds. PolyMem is anti-inflammatory and pain relieving, so it addresses the major issues for PG sufferers.

Have you tried Medihoney paste? We have had some success with this. We use it every other day with a good absorbing dressing.

I have PG. Was diagnosed after lung surgery when wound did not heal. Very large scar that itches very bad. Recently developed pimple inner thigh. Wonder if this may turn into ulcer. On dapsone and weaning off prednisone. very fatigued all the time.

I have had pyo 3 times now this time it's been open close to 3yrs. Right now I am only on pain meds and clobetasol only being treated by primary - all kinds of problems -anyway it is bleeding alot more than it has in quite awhile and burning like liquid fire. I use aloecaine gel for the pain but it doesn't seem to be helping much lately can I do something else? (By the way I do drink PHnomenal water it is a PH water that has made more difference then I can say ) Thanks Kathy

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