Wound care dressings for pyoderma gangrenosum.

To the Editor: Pyoderma gangrenosum (PG) is a rare ulcerative neutrophilic dermatosis with uncertain pathogenesis. While systemic therapy is required to treat severe cases, local wound therapy is critical to minimize pain, reduce infection risk, and promote wound healing. Despite the importance of local wound care, there are no standardized guidelines specific to PG. The tissue, infection, moisture balance, edge advancement (TIME) approach is a general wound management strategy developed for chronic wounds1Schultz G.S. Sibbald R.G. Falanga V. et al.Wound bed preparation: a systematic approach to wound management.Wound Repair Regen. 2003; 11: S1-S28Crossref PubMed Scopus (891) Google Scholar and has been adapted to PG based on physician's expertise.2Janowska A. Oranges T. Fissi A. et al.A practical approach to the clinical management of pyoderma gangrenosum.Dermatol Ther. 2020; 33: e13412Crossref PubMed Scopus (9) Google Scholar The primary aim of this study is to summarize the most frequent dressings used for wound management of PG. In addition, this study proposes an algorithm and flow chart for wound care dressings for PG ulcers. We conducted a systematic review of the literature to identify articles describing wound care for PG (Supplemental Figure 1 and Supplemental Table I available via Mendeley at https://doi.org/10.17632/gzv2rw3wv6.2). Our search yielded 41 articles, of which 29 met our inclusion criteria of describing the dressing type and time to healing. A total of 59 patients with PG were identified in the 29 articles. The mean age of the cohort was 48.1 (SD = 20.7) years, comprised of 41 (69.5%) females. PG location was reported in 53 cases. Lesions were most commonly located on the torso (n = 30, 56.6%) and lower extremities (n = 17, 32.0%). Of the 33 cases that reported on PG size, 31 (93.9%) were classified as large (>2 cm). Type and phase of PG were infrequently reported. Information on healing was obtained for 53 cases; 44 (83.0%) cases had complete healing. Time to healing was reported in 41 cases with an average time to heal of 113.5 (SD = 93.9) days. Of these, 36 (87.8%) healed within 6 months. The most common successfully used dressings were antimicrobial (n = 15, 25.4%), hyperabsorbent (hydrofiber and alginate) (n = 11, 18.7%), simple (n = 9, 15.3%), collagen (n = 7, 11.9%), foam (n = 6, 10.2%), and wet-to-dry (n = 2, 3.4%) (Table I). Concurrent compression dressings were described in two (3.4%) patients. We also recorded information on number of weekly dressing changes and time to heal (Table I). Similar to results of previous work,3Castillo B. Vera N. Ortega-Loayza A.G. Seminario-Vidal L. Wound care for Stevens-Johnson syndrome and toxic epidermal necrolysis.J Am Acad Dermatol. 2018; 79: 764-767.e1Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar modern dressings needed less frequent changes compared to traditional dressings. Steroids (n = 36, 61.0%) and antibiotics (n = 12, 20.3%) were the most frequently cited concurrent systemic therapies. Steroids were also the most frequently cited concurrent topical therapy (n = 19, 32.3%). Pain scores, cost, and adverse effects from using any of these dressings were not reported.Table IDressing types and average time to healingTypes of DressingsNumber of Successful UsesMean Days to Complete Healing (SD)Mean Dressing Changes/Week (SD)Collagen7138.7 (66.4)3.1 (0.2)Foam6116.2 (74.4)3.8 (3.0)Hyperabsorbent11157.2 (90.1)4.2 (1.9)Simple9102.6 (110.3)7.8 (4.7)Antimicrobial∗The “antimicrobial” category includes silver-impregnated, mafenide acetate, and methylene blue crystal violet dressings.15119.9 (88.5)2.8 (0.4)Wet-to-dry266.0 (8.5)21 (0)Other†The “other” category includes use of hydrocolloid dressings, wound vacuums, dehydrated human amnion/chorion membrane (dHACM) allografts, polymeric membranes, barrier film sprays, dermal regeneration templates, or some combination of the above.27125.5 (114.8)6.9 (5.1)∗ The “antimicrobial” category includes silver-impregnated, mafenide acetate, and methylene blue crystal violet dressings.† The “other” category includes use of hydrocolloid dressings, wound vacuums, dehydrated human amnion/chorion membrane (dHACM) allografts, polymeric membranes, barrier film sprays, dermal regeneration templates, or some combination of the above. Open table in a new tab Our review found antimicrobial dressings and hyperabsorbent dressings to be the most commonly used dressings for management of PG ulcers. These modern dressings required less frequent changes and manipulation. The limitations of this study include those inherent to a retrospective design. Future research should include the evaluation of dressings as a possible secondary outcome in trials in order to develop an optimal management algorithm for PG wound care. In the absence of such a trial, we currently advocate the use of wound care dressings based on our results with stratification of the inflammatory and noninflammatory phases of PG as suggested by the TIME-based approach (Fig 1). None disclosed.