Use of dermal injection of activated protein C for treatment of large chronic wounds secondary to pyoderma gangrenosum.

Abstract

Pyoderma gangrenosum (PG) is a systemic disease that presents with cutaneous necrotizing ulceration, producing deep necrotic ulcers, usually with a raised, undermined, violaceous border. Treatment typically involves high dose immunosuppressive drugs, but more recently anti-tumour necrosis factor and monoclonal antibodies have been used. Activated protein C (APC) stimulates wound healing in patients with treatment-refractory skin ulcers, possibly by stimulating angiogenesis and re-epithelialization, and preventing inflammation. To investigate whether APC may be beneficial as a treatment for ulcers related to cutaneous PG. Two patients were recruited with a clinical history and physical and histopathological evidence of acute PG. A total of 400μg (1.0mL) of APC was injected subcutaneously into the dermal edge of necrotic PG ulcers weekly for a total treatment period of 6weeks. Photographs were taken, and clinical progress, ulcer size and pain score were monitored during this period and after the cessation of treatment, at weeks 8and 12. Over the 12weeks of the trial, APC led to a reduction in wound size from 3.8cm(2) to 0.8cm(2) in patient 1 (78.9% decrease) and from 41cm(2) to 16cm(2) in patient 2 (70.0% decrease, respectively), and a reduction in pain scores from 10 to 0 (100% decrease) in both patients. Although this study has limited because of its small sample size and lack of a true placebo group, it does indicate that APC has potential as a therapeutic option for patients with chronic skin ulcers from PG.