Acta Dermato-Venereologica 99-2CompleteContent | Page 28

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SHORT COMMUNICATION
Keratin Gel as an Adjuvant in the Treatment of Recalcitrant Pyoderma Gangrenosum Ulcers: A Case
Report
Evy PAULSEN and Anette BYGUM
Department of Dermatology and Allergy Centre, Odense University Hospital, DK-5000 Odense C, Denmark. E-mail: [e-mail]
Accepted Nov 1, 2018; E-published Nov 5, 2018
Classic pyoderma gangrenosum (PG) is an ulcerative
skin disease that belongs to the neutrophilic dermatoses
(1). Although the disease may be idiopathic, it has tra-
ditionally been associated with an array of conditions,
notably inflammatory bowel disease and rheumatoid
arthritis. The pathogenesis of PG is not fully clarified,
but recent research suggests a pivotal role of pro-
inflammatory cytokines, such as interleukin (IL)-1-β
and IL-17 and tumour necrosis factor alpha (TNF-α),
as in the monogenic autoinflammatory diseases (1). IL-
1-β is also an atherogenic cytokine, and, in accordance
with this, a recent clinical study showed evidence of
more generalized inflammation in patients with PG:
Jockenhöfer et al. (3) detected a stronger association
between PG and the occurrence of metabolic syndrome
than between PG and inflammatory bowel disease and
rheumatic conditions (2, 3).
As might be expected from the pathogenesis, topical
and/or systemic immunosuppressive or immunomodu-
lating drugs are necessary for the healing of PG lesions.
Despite this, the ulcers are sometimes quite recalcitrant
to treatment.
A keratin-rich gel has been reported to be an effective
topical treatment in ulcers and wounds of different origin
(4–7). We report here our experience with this gel in a
patient with PG ulcers.
CASE REPORT
A 62-year-old woman was referred to the department of derma-
tology with a suspected PG ulcer on her right shin in July 2014.
Her past medical history was inconspicuous apart from arterial
hypertension and recurrent ulcers. Since 2009, she had had 3 mal-
leolar ulcers without evidence of venous, arterial, or coagulopathic
aetiology. A skin biopsy from the third ulcer had been consistent
with PG, and the patient was treated with topical and systemic
corticosteroids, which resulted in rapid healing.
The present ulcer measured 3×4 cm on referral and despite
treatment with systemic corticosteroids (prednisolone, up to 75
mg daily), supplemented first with cyclosporine 300 mg daily and
later also with methotrexate 15 mg weekly, the ulcer progressed.
Furthermore, a new ulcer developed symmetrically on the cont-
ralateral shin. Extensive blood tests and tumour positron emission
tomography – computed tomography (PET-CT) scanning did not
reveal any associated diseases. In December 2014, it was decided
to discontinue cyclosporine and begin treatment with the TNF-α
antagonist infliximab. After 3 infusions of infliximab, the ulcers
measured 7×6 cm and 6×9.4 cm, respectively, and were covered
with granulation tissue, but showed no sign of epithelialization
(Fig. 1). Instead of diminishing the interval between the inflixi-
mab infusions, a keratin gel (Keragel ® , Keraplast Technologies
LLC, Christchurch, New Zealand) was applied to the ulcers as
doi: 10.2340/00015555-3081
Acta Derm Venereol 2019; 99: 234–235
Fig. 1. Bilateral idiopathic pyoderma ulcers with granulation tissue
in April 2015.
the main topical treatment in May 2015. At the next visit, after 9
days of treatment with the gel, the ulcers were diminished in size,
and the systemic treatment with infliximab, corticosteroids, and
methotrexate in tapering doses was continued along with Keragel ®
as topical treatment. In November 2015, the ulcers were healed
(Figs 2 and 3). The infliximab infusions were not discontinued
until October 2016 in order to prevent a relapse.
DISCUSSION
Although it is often necessary to use multiple anti-
inflammatory drugs to treat PG ulcers, the drugs may
have a negative effect on the final healing process. Thus,
systemic corticosteroids impair wound healing both via
Fig. 2. Regressing pyoderma ulcers in July 2015 after 2 months’
treatment with keratin gel.
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Journal Compilation © 2019 Acta Dermato-Venereologica.