Onset of Pyoderma Gangrenosum in Patients on Biologic Therapies: A Systematic Review

Abstract

OBJECTIVE:To summarize clinical outcomes of paradoxical pyoderma gangrenosum (PG) onset in patients on biologic therapy. METHODS:The authors conducted MEDLINE and EMBASE searches using PRISMA guidelines to include 57 patients (23 reports). RESULTS:Of the included patients, 71.9% (n = 41/57) noted PG onset after initiating rituximab, 21.1% (n = 12/57) noted tumor necrosis factor α (TNF-α) inhibitors, 5.3% (n = 3/57) reported interleukin 17A inhibitors, and 1.8% (n = 1/57) reported cytotoxic T-lymphocyte-associated protein 4 antibodies. The majority of patients (94.3%) discontinued biologic use. The most common medications used to resolve rituximab-associated PG were intravenous immunoglobulins, oral corticosteroids, and antibiotics, with an average resolution time of 3.3 months. Complete resolution of PG in TNF-α-associated cases occurred within an average of 2.2 months after switching to another TNF-α inhibitor (n = 1), an interleukin 12/23 inhibitor (n = 2), or treatment with systemic corticosteroids and cyclosporine (n = 3), systemic corticosteroids alone (n = 1), or cyclosporine alone (n = 1). CONCLUSIONS:Further investigations are warranted to determine whether PG onset is associated with underlying comorbidities, the use of biologic agents, or a synergistic effect. Nevertheless, PG may develop in patients on rituximab or TNF-α inhibitors, suggesting the need to monitor and treat such adverse effects.

Pyoderma Gangrenosum: An Updated Literature Review on Established and Emerging Pharmacological Treatments

“…Conversely, a recent systematic review demonstrated that rituximab may be associated with the onset of vulvovaginal PG [ 137 ]. In fact, rituximab appears to be responsible for the majority of new-onset PG cases reported during biologic therapies [ 138 ].…”

Pyoderma Gangrenosum: Treatment Options

“…In an analysis of all case reports in which PG was thought to have been triggered by the administration of biological therapy, 57 patients were identified. Here, 41 cases involved rituximab, 12 cases involved TNF-α inhibitors, 3 cases involved interleukin 17A and one case involved cytotoxic T-lymphocyte-associated protein 4 antibodies [ 31 ]. It is hypothesised that in these paradoxical reactions, there is a shift of the cytokine balance towards a molecular pattern typical of the respective induced disease.…”