Use of TIME Concept for Treatment of Pyoderma Gangrenosum

Pyoderma gangrenosum
Pyoderma gangrenosum
An algorithm based on the TIME features is outlined for the treatment of pyoderma gangrenosum.

Successful use of a treatment algorithm in the non-inflammatory and inflammatory phases of pyoderma gangrenosum (PG) based on the TIME (Tissue; Infection; Moisture Balance; Epithelization) concept was described by researchers from the University of Pisa in Italy in a paper published in Dermatologic Therapy.

The researchers retrospectively identified 52 patients with PG who visited a university dermatology department in Italy from 2008 to 2018. The mean age for women was 68 years, whereas the mean age for men was 72 years. Medical records were reviewed to collect information about the clinical features of PG, duration, and evolution of lesions. Areas were measured at baseline and until healing. The investigators also assessed all patients’ skin biopsies.

The researchers suggested 2 approaches for local treatment in the noninflammatory and inflammatory phases based on the TIME concept. Recommended local treatment for bullous, pustular, and vegetative PG included binding bacteria dressings or non-adherent moist dressings on the wound bed. The aim of this approach was to prevent secondary infections and the use of local corticosteroids on perilesional skin. Treatment of the inflammatory phase of PG and non-inflammatory healing phase were 2 approaches for the local treatment for the ulcerative type.

Approximately 82.6% (n=43) of patients had ulcerative PG, whereas 9.6% (n=5) of patients had pustular PG. Vegetative PG, bullous PG, and peristomal PG was observed in 1.9% (n=1), 1.9% (n=1), and 3.8% (n=2) of cases, respectively. The lower leg was affected by PG in 90.4% (n=47) of cases. Epidermal ulceration and a dermal neutrophilic infiltrate or aspecific inflammation were observed on histologic examination of ulcerative PG.

In contrast, sterile dermal and subcorneal/subepidermal neutrophilic infiltration was observed in pustular PG. Vegetative PG demonstrated dermal neutrophilic, eosinophilic, and histocytic infiltrate with corresponding subepidermal granulomatous inflammation. In addition, bullous PG had superficial dermal necrosis.

Oral glucocorticosteroids were used as the first-line treatment for all patients. Complete healing was observed in 17.3% of patients approximately 3 weeks after treatment with 0.5-1 mg/kg/die of methylprednisolone. An incomplete response was observed in the 82.7% of patients (n=43); these patients who did not achieve complete healing subsequently received long-term maintenance therapy comprising either oral glucocorticosteroids or other systemic treatments. Complete healing was achieved in 25% of patients (n=13) with 2 to 6 months of low-dose and escalating doses of oral glucocorticosteroids.

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During the inflammatory phase, enzymatic debridement or autolytic debridement covered by either a binding bacteria dressing or non-adherent dressing was used to reduce necrosis and fibrin on the wound bed. Local corticosteroids and lidocaine 5% cream was used for the inflammatory edges, which ultimately resulted in reduced inflammation and pain.

Limitations of this study included its retrospective design as well as the inclusion of a small number of patients.

The researchers’ findings suggest that the combination of “local and systemic treatments with correct wound management can help physicians to achieve a better clinical result in refractory PG.”

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Janowska A, Oranges T, Fissi A, et al. PG-TIME: a practical approach to the clinical management of pyoderma gangrenosum [published online April 14, 2020]. Dermatol Ther. doi: 10.1111/dth.13412