This handout is for pyoderma gangrenosum (neutrophilic ulcerative dermatosis). Your care team identified this based on: rapidly enlarging, exquisitely painful ulcer with a violaceous, undermined, overhanging border (paracelsus — violaceous border in 98% of pg; jockenhöfer br j dermatol 2019 pmid 29388188).
Other reasons your team may use this plan: a papule/pustule/vesicle that ulcerated within ~4 days of appearing (maverakis delphi minor criterion; jama dermatol 2018 pmid 29450466); ulcer that enlarged after surgical debridement, biopsy, or minor trauma — pathergy; commonly misdiagnosed as wound/necrotising infection (pmid 31498172); painful ulcer not responding to antibiotics with sterile cultures — the dominant infective-misdiagnosis entry (shaigany arch dermatol res 2021 pmid 34714405).
Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.
| Medication | Starting dose | How | When | What it does |
|---|---|---|---|---|
| avoid_surgical_debridement_and_aggressive_surgery_pathergy | — | — | — | PMID 31498172 — PG is routinely misdiagnosed as wound/necrotising infection and surgically debrided, which enlarges it catastrophically via pathergy. NO debridement / aggressive surgery. This rule precedes all therapy. |
| exclusion_workup_tissue_culture_edge_biopsy_associated_disease | — | — | — | Maverakis Delphi (PMID 29450466) — PG has no confirmatory test: 1 major (edge-biopsy neutrophilic infiltrate, supportive only) + 8 minor, ≥4/8 → Sn 86% / Sp 90%. Biopsy EXCLUDES mimics; it does not confirm. Mandatory associated-disease workup (IBD/heme/arthritis). |
| meticulous_moist_nonadherent_wound_care_and_analgesia | — | — | — | Partridge Br J Dermatol 2018 (PMID 29478243) — gentle moist non-adherent dressings + adequate analgesia (pain is severe and out of proportion) in parallel with immunosuppression; autolytic, NOT surgical, debridement only. |
Plan: Pyoderma gangrenosum — exclusion-first immunosuppressive ladder by extent/tempo (Maverakis Delphi PMID 29450466; STOP GAP PMID 26071094; Partridge PMID 29478243)
Contact your care team if any of the following happen:
Call 911 or go to the nearest emergency room right away if you have:
Chronic surveillance: continued meticulous moist non-adherent wound care + analgesia, slow steroid taper with steroid-sparing maintenance, recurrence vigilance (PG recurs in ~28-30% — STOP GAP), pathergy education (avoid elective surgery/debridement; flag PG to any future surgeon; perioperative immunosuppressive cover if surgery unavoidable), cribriform-scar counselling, and ongoing associated-disease monitoring (repeat heme screen if new cytopenia; IBD/arthritis activity). Dermatology continuity for any systemic agent.
Guideline: Maverakis et al, Diagnostic Criteria of Ulcerative Pyoderma Gangrenosum — Delphi consensus (JAMA Dermatol 2018; PMID 29450466; DOI 10.1001/jamadermatol.2017.5980) + Jockenhöfer et al PARACELSUS diagnostic score (Br J Dermatol 2019; PMID 29388188; DOI 10.1111/bjd.16401) + Ormerod/Thomas STOP GAP ciclosporin-vs-prednisolone RCT (BMJ 2015; PMID 26071094; DOI 10.1136/bmj.h2958) + Brooklyn et al infliximab RCT (Gut 2006; PMID 16188920; DOI 10.1136/gut.2005.074815) + Partridge et al systematic review of systemic therapy (Br J Dermatol 2018; PMID 29478243; DOI 10.1111/bjd.16485)