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Perspectives on peristomal pyoderma gangrenosum

DII small banner By Warren R. Heymann, MD
Oct. 28, 2016

Peristomal pyoderma gangrenosum (PPG) is a challenging problem, both physically and emotionally. The diagnosis may be delayed, often being mistaken for an irritant dermatitis or an infection. Barbosa et al have performed an extensive review of their experience in 44 patients with PPG and reported that 93% (41 patients) had inflammatory bowel disease (IBD), notably Crohn disease (CD). The mean time to PPG onset after stoma surgery was 5.2 months (excluding 1 outlier). Systemic therapies included corticosteroids (66%), immunosuppressants (41%), biologics (36%), and a combination of systemic treatments (36%). The mean time to reach a complete response was 10.7 weeks. Stoma closure had the greatest complete response (4 of 4 patients, no recurrences). Recurrence after any treatment was documented in 23 of 38 (61%) patients. Stoma relocation/revision recurred in 10 of 15 (67%) patients. Remission occurred in 29 of 31 (94%) patients. The authors concluded that systemic corticosteroid or combination therapies and surgical closure can be effective treatments. Timely recognition and management are paramount to achieving early remission.

Topical steroids and calcineurin inhibitors were used topically in Barbosa’s study, although they note that “treatment should match the severity of disease”, including systemic treatments (1). Certainly the best approach would be to close the stoma altogether, but that may not be possible. Systemic therapies for pyoderma gangrenosum (PG) include systemic steroids, cyclosporine, IVIG, or biologic agents (mostly TNF inhibitors used in inflammatory bowel disease). How effective are topical therapies?

Thomas et al performed a prospective cohort study of sixty-six patients (22-85 years of age) with PG. Clobetasol propionate 0.05% was the most commonly prescribed therapy, with topical tacrolimus a distant second. Twenty-eight of 66 (43.8%) ulcers healed by 6 months. The median time to healing was 145 days (95% confidence interval, 96 days to ∞). Initial ulcer size was a significant predictor of time to healing (hazard ratio, 0.94 [95% confidence interval, 0.88-1.00); P = .043). Four patients (15%) had a recurrence. The authors concluded that topical therapy is potentially an effective first-line treatment for PG that avoids the possible side effects associated with systemic therapy. It remains unclear whether more severe disease will respond adequately to topical therapy alone (2).
When using topical agents for PPG, it is essential to choose the right vehicle. It is preferable to use foams, lotions, or gels, as opposed to creams or ointments that may prevent proper adhesion of the stoma device resulting in leaks (3). Working with an expert stoma nurse is invaluable.

An ingenious pearl is to use hydrocolloid dressing, such as Duoderm, and cut a hole in the center, as described by Rodenbeck et al (1). This enables the patient to secure the topical agent to the skin and allow the stoma appliance to sit on the dressing. How simple, elegant, and wonderful for these patients, if they must live with a stoma.
In conclusion, PPG can be controlled either by topical therapy, systemic agents, or both. Optimally, the stoma would be removed — if that is not feasible, patients should be encouraged by therapeutic approaches allowing a good quality of life.

1. Barbosa NS, et al. Clinical features, causes, treatments, and outcomes of peristomal pyoderma gangrenosum (PPG) in 44 patients: The Mayo Clinic experience, 1996 through 2013. J Am Acad Dermatol 2016; 75: 931-9.
2. Thomas KS, et al. Clinical outcomes and response of patients applying topical therapy for pyoderma gangrenosum: A prospective cohort study. J Am Acad Dermatol 2016; 75: 940-9.
3. Lyon CC. Stoma Care. In Lebwohl MG, Heymann WR, Berth-Jones J, Coulson I (eds). Treatment of Skin Disease, 4th edition, 2014, pp 728-9.
4. Rodenbeck DL, et al. Peristomal pyoderma gangrenosum (PG): A simple hydrocolloid dressing technique to promote wound healing. J Am Acad Dermatol 2015; 73: e107-8.

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