1. Fedorko L. MD PhD, Linden R. MD, Jones W. RN,
Pyoderma Gangrenosum: first line treatment – immunosuppresion or Hyperbaric Oxygen Therapy ?
Fedorko L. MD PhD, Linden R. MD, Jones W. RN,
Depts of Anesthesiology, University Health Network, and Judy Dan Research & Treatment
Introduction
Chronic wounds caused by Pyoderma Gangrenosum (PG) are very painful and difficult to treat. Infiltration of dermis with mature neutrophils, recurrent advancing necrotic ulcers with surrounding erythema are most characteristic. There is strong association with ulcerative colitis and rheumatoid arthritis.
Immunosuppressant agents such as steroids, cyclosporin and more recently anti-TNFα agents such as infliximab have been employed with variable success. Hyperbaric Oxygen Therapy (HBOT) is known to improve chronic wound healing. Some research indicate that it may modulate granulocyte responses to inflammatory/ischemic stimulus . There are several case reports and reviews describing successful resolution of lesions with Hyperbaric Oxygen Therapy (HBOT) prior to introduction of anti-TNFα agents which are now more commonly used as an early choice.
HBOT is still treated as an exotic, last hope approach, even though it has few side effects and is much less expensive than infliximab or adulimumab therapy.
Here we report series of 3 patients – 2 of them are patients with ulcerative colitis who failed previous combined therapy with immunosuppresive and anti-TNFα agents, but responded very well to HBO. 
Methods – Hyperbaric Oxygen Therapy
Case Study 3
Hyperbaric Oxygen Therapy consisted of exposing patient to 100 oxygen under pressure of 2.4 atmospheres (equivalent to a dive to 49 feet in depth) for 90 minutes daily for 5 days a week
A 20 year- old male with history of leg injury with no prior history of inflammatory bowel disease developed a large pyoderma gangrenosum shin wound. He had had this  wound for over 9 years.   After failed medical therapy patient was treated with 68 HBOT treatments.  This patient has not received anti-TNFα therapy. This patient was poorly compliant. Although his treatments were interrupted numerous, times his wound was remarkably improved as of the last visit. He was lost to follow-up *
Conclusion
Significance of our presentation is in demonstration that at least some of the refractory Pyoderma Gangrenosum wounds in patient with Ulcerative Colitis or Rheumatoid Arthritis could benefit from early introduction of Hyperbaric Oxygen. These are patients who are also eligible to receive anti-TNFα agents under current indications.
We propose that HBOT should be used as an adjuvant therapy as soon as it is determined, that the wounds do not respond well to combined steroid/immunosuppressive/anti-TNFα management.
HBOT could be instituted even earlier in patients who have contraindications to, or do not tolerate medical therapy.
Our current experience is that the patients are referred for HBOT usually after very prolonged and unsuccessful medical treatment which in these cases was over a 12 month period.
Raising awareness of the HBOT treatment option for these difficult wounds will hopefully improve patients’ quality of life and will reduce overall cost of treatment , while reducing risks of side effects from high dose steroids, immunosuppresion or anti-TNFα therapy.
A 20 year-old female with a history of asthma and long standing ulcerative colitis had developed a left calf wound for 11 months as well as two wounds on both breasts. These wounds were diagnosed as refractory pyoderma gangrenosum. She was treated with antibiotics, budesonide, and a course of anti-TNFα infliximab, as well as adalimumab, multivitamins and zinc. For wound pain she used ibuprophen, acetaminophen, and meperidine. Despite of these treatments wounds failed to heal and the patient was in signifcant amount of pain. She presented to Judy Dan Research and Treatment Centre where HBOT was initiated with standard wound care. Initiation of HBOT resulted in significant relief of pain within first few treatments. She received in total 119 HBOT treatments over a 6 month period. All three wounds completely healed.
Case Study 2
Case Report 1
A 17year-old female with a history of ulcerative colitis developed
a right leg wound. Her wound was non healing for over one year. At one point she required hospitalization for 8 day to manage .her pain
Her treatmen regimens included IV antibiotics, IVIG,
certolizumab and systemic steroids. Her pain was managed with a morphine infusion.
At the Judy Dan Research and Treatment Centre, her treatment included debridement, antibiotics, systemic prednisone and HBOT.
Treatment with 35 HBO sessions resulted in resolution of
leg lesions.
Results
Both patients with ulcerative colitis presented here have been treated with hyperbaric oxygen after multiple courses of conventional and advanced anti-TNFα agents therapy, in combination with excellent wound care failed to achieve healing and pain reduction. Both patients achieved complete healing of their lesions , one patient after only 7 weeks of treatment and the other after six months period. Of significance was a considerable reduction of pain early on through the course of treatment in both patients.
The third patient had no previous history of UC or RA and had his lesion present for over 9 years. He had a very good initial response to treatment, however he interrupted treatment several times throughout the course and was not compliant with the wound care as well. Although not healed completely his wound has improved dramatically as well from the time of presentation.
Pre Post
References:
Cochrane Database Syst Rev Hyperbaric oxygen therapy for chronic wounds
Ciaravino ME et al. Is hyperbaric oxygen a useful adjunct in the management of problem lower extremity wounds? Ann Vasc Surg (6):
Neuman & Thom. Physiology and medicine of hyperbaric oxygen therapy. Saunders Elsivier © 2008
Tutrone WD et all. Pyoderma gangrenosum: dermatologic application of hyperbaric oxygen therapy. J Drugs Dermatol (12):1214-9