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LETTER TO EDITOR
Year : 2018  |  Volume : 2  |  Issue : 1  |  Page : 41-42

Doxycycline and dapsone in chronic pyoderma gangrenosum: Revisiting the old therapies


1 Department of Dermatology, Sir Ganga Ram Hospital, New Delhi, India
2 Department of Dermatology, Subharti Medical College, Meerut, Uttar Pradesh, India
3 Department of Pathology, Sir Ganga Ram Hospital, New Delhi, India

Date of Web Publication5-Jan-2018

Correspondence Address:
Divya Arora
Department of Dermatology, Subharti Medical College, Meerut, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/CDR.CDR_13_17

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How to cite this article:
Garg S, Arora D, Singh K, Kansal S. Doxycycline and dapsone in chronic pyoderma gangrenosum: Revisiting the old therapies. Clin Dermatol Rev 2018;2:41-2

How to cite this URL:
Garg S, Arora D, Singh K, Kansal S. Doxycycline and dapsone in chronic pyoderma gangrenosum: Revisiting the old therapies. Clin Dermatol Rev [serial online] 2018 [cited 2021 Oct 27];2:41-2. Available from: https://www.cdriadvlkn.org/text.asp?2018/2/1/41/222263



Sir,

Pyoderma gangrenosum is a rare, noninfectious neutrophilic dermatosis[1] characterized by long standing ulcers.

A 48-year-old female presented with painful skin lesions involving both lower legs of 8-year duration. The lesion first appeared on the right lower leg as a painful red raised lesion with pus in the center which progressed to form an ulcer. Thereafter, multiple similar lesions appeared over both lower legs which gradually increased in size and number forming large ulcerated areas. Patient was treated for maggot infestation of the ulcers 6 years back. For 4 years, patient took multiple courses of oral antibiotics will little relief. Patient underwent skin grafting for these nonhealing ulcers; however, the skin continued to ulcerate. Skin biopsy done 3 years back showed features of tuberculosis and patient was started on antitubercular therapy for 2 years to which she did not respond and continued to develop fresh ulceration. There was no history of trauma or drug intake before appearance of lesion. There was no history of joint pains, abdominal pain, diarrhea, constipation, tiredness, abnormal bruising, or weight loss. She was on treatment for hypothyroidism for the past 9 years and uncontrolled type 2 diabetes mellitus for the past 11 years. Her general and systemic examination was within normal limits. Dermatological examination revealed the presence of sclerotic, scarred, depressed plaque with violaceous to black colored raised border with surrounding halo of erythema, with center of the plaque showing areas of both hyperpigmentation and hypopigmentation along with atrophy, measuring 20 cm × 10 cm, present symmetrically, involving lower two-third of anterior surface of both lower legs and encircling it to extend on the posterior aspect of lower one-third of both lower legs. Areas of ulceration covered with crust were present all along the margins of the lesions which oozed pus on compression [Figure 1]a. The lesions were tender on palpation. Differential diagnosis of lupus vulgaris, necrobiosis lipoidica diabeticorum, pyoderma gangrenosum, vasculitis, and mycetoma were made. Bacterial, tubercular, and fungal cultures from the exudate and skin tissue were negative. Skin biopsy from the edge of the ulcer revealed extensively ulcerated epidermis with dense acute fibrinopurulent exudate. Dermis had focal areas of dense inflammatory infiltrate composed of lymphocytes and plasma cells with proliferating capillaries suggestive of pyoderma gangrenosum [Figure 2]. Granulomas were absent, and staining for acid-fast bacilli and fungus was negative. Venous Doppler studies of both lower limb were normal. Antinuclear antibody was negative. Patient was started on tablet dapsone 100 mg at night and capsule doxycycline 100 mg twice a day after a normal glucose-6-phosphate dehydrogenase, complete blood count, and liver function profile. The lesions healed completely with scarring after 45 days of treatment [Figure 1]b after which dapsone was stopped, and doxycycline was continued twice a day for next 2 months and once a day for another 2 months after which it was discontinued. Patient has not developed any fresh lesion in the past 4 months.
Figure 1: (a) Well-defined atrophic plaques with violaceous border and erythematous halo, present symmetrically on lower two-third of both legs. Crust covered ulcers present along the medial border of plaques. (b) Healed lesions with near complete clearance of ulcerations

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Figure 2: Histopathology showing dense lymphocyte, neutrophil, and plasma cell infiltrate (A) around proliferating capillaries (B)

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Pyoderma gangrenosum may be idiopathic or seen in association with systemic diseases such as arthritis, inflammatory bowel disease, hematological dyscrasias, and malignancy. Systemic treatment includes steroids, cyclosporine, mycophenolate mofetil, infliximab,[2] dapsone,[3] clofazimine, and minocycline.[4] Among these, steroids and immunosuppressive modalities are most commonly used.

Our patient had idiopathic pyoderma gangrenosum of 8-year duration. Due to the severity of disease, large area of involvement, and very long-standing nature of the disease, we wanted to start the patient on oral prednisolone. However, in view of her uncontrolled diabetes, adverse effects of cyclosporine on blood pressure and kidney, inconvenience of taking potassium iodide, and biologics being very expensive alternative, we decided to begin the therapy with safer alternatives and hence dapsone and doxycycline were started to which the patient responded very quickly and completely in 45 days and still continues to be in remission. We report an unusually long-standing case of pyoderma gangrenosum and would like to lay emphasis on the fact that older, cost–effective, and relatively safer drugs such as dapsone and doxycycline may be revisited again as first-line therapy for treating pyoderma gangrenosum, especially in patients with comorbidities rather than steroids, immunosuppressives, and biologics which have greater side effects and are very expensive.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Ormerod AD, Hampton PJ. Neutrophilic dermatoses. In: Griffiths C, Barker J, Bleiker T, Chalmers R, Creamer D, editors. Rook's Textbook of Dermatology. 9th ed., Vol. 49. UK: Blackwell; 2016. p. 49.1.  Back to cited text no. 1
    
2.
Gameiro A, Pereira N, Cardoso JC, Gonçalo M. Pyoderma gangrenosum: Challenges and solutions. Clin Cosmet Investig Dermatol 2015;8:285-93.  Back to cited text no. 2
    
3.
Altman J, Mopper C. Pyoderma gangrenosum treated with sulfone drugs. Minn Med 1966;49:22-6.  Back to cited text no. 3
[PUBMED]    
4.
Bhat RM. Management of pyoderma gangrenosum – An update. Indian J Dermatol Venereol Leprol 2004;70:329-35.  Back to cited text no. 4
[PUBMED]  [Full text]  


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