Pyoderma gangrenosum is a rare, non-infectious neutrophilic dermatosis that results in painful, recurrent necrotizing ulcerations. The condition causes painful ulcerations, with a characteristic appearance of a violaceous undermined border, mainly on the lower extremity. The etiology is poorly understood and there is no defined treatment protocol.
However, a poster I recently co-presented at the American Podiatric Medical Association Annual Scientific Meeting reveals promise for treating pyoderma gangrenosum with porcine small intestine submucosa wound matrix (Oasis, Healthpoint).1
Four patients with chronic leg ulcers due to pyoderma gangrenosum received weekly application of a graft derived from porcine small intestine submucosa extracellular matrix (SIS/ECM). We secured the graft with steri-strips, reconstituted it with super-oxidized water (Microcyn, Quinnova Pharmaceuticals), and covered the graft with a non-adhesive dressing and a subsequent dry sterile dressing. Patients changed outer dressings daily but left the graft untouched. We recorded the size of the wound bed and pain level weekly for eight to 31 weeks.
A 59-year-old Caucasian male presented with a history of ulcerations on the distal aspect of his right lower extremity for over five years. The ulcers were due to pyoderma gangrenosum. We initiated weekly treatment consisting of cleansing the wounds with super-oxidized water with subsequent application of the SIS/ECM graft on the medial malleolus ulcer. (Due to the availability of trial pieces of SIS/ECM graft that we had for evaluation purposes, we only applied this graft to the medial malleolar ulcer.)
Unfortunately, the patient had an aggressive form of pyoderma gangrenosum. As a result, he failed all conventional treatments and his wounds failed to respond to this experimental treatment as well. Throughout the course of this treatment, the patient habitually reported a pain level of 5 to 7/10 on the visual analogue scale (VAS). However, during the course of several visits, he noted a definitive decrease in pain with the application of the SIS/ECM graft versus prior treatments.
A 68-year-old African American male with type 2 diabetes presented with a chronic non-healing ulcer on the posterior aspect of his right lower extremity, superficial to the Achilles tendon. On August 3, 2012, we started the regimen of cleansing the ulcer with super-oxidized water with subsequent application of the SIS/ECM graft. At that time, the ulcer had an area of 8.82 cm2. Just over a month later, the ulcer had decreased to 3 cm2 and by October 5, the ulcer no longer required treatment because it healed as a solid eschar. In total, it took nine SIS/ECM grafts to achieve wound closure.
On January 15, the patient returned with two new ulcerations on his left foot, likely secondary to pathergy to minor trauma. The first ulcer located on the dorsal forefoot had an area of 15 cm2. On April 8, after nine SIS/ECM graft applications, the forefoot ulcer had further decreased to 3.6 cm2 while the third toe ulcer decreased to 0.5 cm2. At the following visit on April 12, the third toe ulcer was healed.
A 69-year-old Caucasian male presented with chronic non-healing ulcerations on his left lower extremity that had previously failed a standard wound care regimen and he was later diagnosed with pyoderma gangrenosum. The treatment with SIS/ECM graft began on June 15, 2012. The ulcer had an overall area of 450 cm2 and was located on the left anterior leg, extending medially and laterally. On August 23, after eight SIS/ECM graft applications, the ulcer had an area of 0.4 cm2. The anterior lateral left leg ulcer had decreased to 8.75 cm2. The patient reported his pain level to be 9/10 on the VAS at the beginning of treatment and this pain decreased over the course of treatment to 3 to 4/10.
A 69-year-old, non-diabetic Caucasian female presented with chronic non-healing ulcerations on the lateral aspect of her right and left lower extremities. She had failed previous standard wound care treatment. Over the course of 15 weeks, the patient had four ulcerations treated with 13 applications of SIS/ECM graft. The two ulcers located on the left lateral leg showed a decrease in area of 31.15 percent and 98.88 percent, the right lateral ulcer decreased 74.65 percent, and the right medial ulcer closed after four applications. The patient reported her pain level to be 8/10 on the VAS at the start of treatment and this pain level reduced to 4/10 over the 15 weeks of treatment.
The results revealed an overall percent decrease in wound surface area as well as lower pain levels, showing that that SIS/ECM graft is a viable treatment option for patients who suffer from pyoderma gangrenosum.
1. Cooney ML, Lazaroff F, Vlahovic TC. Porcine small intestine submucosa wound matrix in the treatment of pyoderma gangrenosum: a case series. Poster presented at the American Podiatric Medical Association Annual Scientific Meeting, July 2013, Las Vegas, NV.