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   Introduction
   Case Report
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CASE REPORT
Year : 1992  |  Volume : 58  |  Issue : 3  |  Page : 210-212

Minocycline in pyoderma gangrenosum




Correspondence Address:
Thomas Koshy


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Source of Support: None, Conflict of Interest: None


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  Abstract 

A case of pyoderma gangrenosum resistant to the usual modes of treatment was successfully treated with minocycline. The drug was well tolerated without any side effects.


Keywords: Pyoderma gangrenosum, Minocycline


How to cite this article:
Koshy T, Binitha M P. Minocycline in pyoderma gangrenosum. Indian J Dermatol Venereol Leprol 1992;58:210-2

How to cite this URL:
Koshy T, Binitha M P. Minocycline in pyoderma gangrenosum. Indian J Dermatol Venereol Leprol [serial online] 1992 [cited 2020 Feb 29];58:210-2. Available from: http://www.ijdvl.com/text.asp?1992/58/3/210/3798



  Introduction Top


Pyoderma gangrenosum is a relatively uncommon dermatosis characterised by chronic, recurring ulcerations with distinctive clinical features. Despite it's association with numerous systemic diseases in 50 percent of cases, the pathogenesis is still uncertain and the treatment, a challenge. A case of pyoderma gangrenosum is reported, which was refractory to the usual modes of treatment but healed completely with oral minocycline hydrochloride.


  Case Report Top


A 46-year-old house wife reported with a large, non-healing painful ulcer on the postero lateral aspect of right elbow of 1 1/2 years duration. The lesion started as a small pustule which ulcerated and healed within 2 weeks with treatment. Then, 6 months later, the ulcer, recurred and had been slowly enlarging in size. The lesion was diagnosed as pyoderma gangrenosum at a local hospital, and was confirmed by biopsy. She had been on high doses of corticosteroids for 5 months without much response, hence referred to this hospital.

Dermatological examination showed a large, shallow, well defined tender ulcer 7 x 5 cm in size, on the posterolateral aspect of the right elbow, with bluish, oedematous, undermined borders, a red granular base and a seropurulent discharge [Figure - 1]. There was - no regional lvmr hadenoDathv.

Detailed clinical examination of other systems revealed no abnormalities. Routine laboratory investigations were all normal, except for an elevated ESR. Repeated pus cultures showed consistent growth of Stapoh. aureus and Pseudomonas aeruginosa. Sigmoidoscopy and rectal biopsy were normal.

The presentation was suggestive of idiopathic pyoderma gangrenosum. The steroids which she was already on, were gradually tapered off and stopped. She was started on 100mg of dapsone daily, and stopped after a few days, due to acute cyanosis, dyspnoea and psychosis. Further treatment with clofazimine in a dose of 200mg daily for 2 months showed only a partial response. She also had several courses of antibiotics in between, depending on the pus culture and antibiotic sensitivity reports.

Concomitant topical therapy in the form of metronidazole compresses, fusidic acid cream, silver sulfadiazine cream, sofratulle dressings and supportive measures like B complex, vitamin C and oral zinc were also given.

Due to lack of response even after 3 months, oral minocycline was introduced, in a dose of 100mg twice daily, along with continuation of the previous topical therapeutic measures and clofazimine. Within 10 days, the ulcer showed an appreciable healing with development of granulation tissue. In 2 months, the ulcer had healed completely with fine pink scar tissue [Figure - 2]. Clofazimine was stopped and minocycline continued in a lower dose of 100mg daily for one month, then 50mg daily for one more month, and stopped. Follow-up for the past 5 months has revealed no recurrence of the ulcer.


  Comments Top


The treatment of pyoderma gangrenosum includes that of any associated disorders if present. Such a disease was ruled out in our patient by sufficient investigations. Local therapy of the ulcer with compresses, topical antibiotics and gentle debridement were reported to be helpful in some cases. [1]

Several systemic agents have been tried in the treatment of pyoderma gangrenosum, though none has been found to be consistently effective. These include high doses of systemic steroids, sulfasalazine, sulfapyridine, dapsone, clofazimine, [2] rifampicin [3] and immunosuppressants like azathioprine [4] and cyclophosphamide. Sulfasalazine is broken down by intestinal bacteria into 5-amino­salicyclic acid and sulfapyridine. The mechanism of action of sulfones and sulfapyridine in pyoderma gangrenosum is by its anti-inflammatory effect, by inhibiting the myeloperoxidase - H202 halide mediated cytotoxic effect on neutrophils, and not through the antibacterial effect. [5] Dapsone also inhibits the generation of reactive oxygen intermediates by leucocytes. [6] Clofazimine enhances neutrophil phagocytosis and stimulates macrophage function.

Several reports have indicated good results with minocycline hydrochloride in the treatment of pyoderma gangrenosum. [7],[8] It has an anti-bacterial activity several times more potent than tetracycline, especially against gram negative bacteria, meningococci and staphylococci. Pharmacologically, minocycline is 7­dimethylamine-6-deoxy-6-dimethyl­tetracycline. As with other tetracyclines, the anti-inflammatory and immunosuppressive properties of minocycline are thought to be responsible for the beneficial effect in pyoderma gangrenosum. [9] Eventhough minor side­effects like giddiness, nausea, vomiting [10] and pigmentary changes have been reported, our patient tolerated the drug very well without any side effects.

In the present case, there was no satisfactory response to any of the drugs conventionally used in the treatment of pyoderma gangrenosum. Minocycline was found to be extremely effective in healing the ulcer, with no side-effects. The agents commonly used in the treatment of pyoderma gangrenosum are associated with significant morbidity and mortality, especially the cytotoxic drugs and immunosuppressants. Hence, we recommend the use of minocycline as a first-line drug in the treatment of pyoderma gangrenosum.


  Acknowledgement Top


We express our thanks to M/s. Cynamid India Limited for the liberal supply of Cynomycin brand of minocycline capsules.

 
  References Top

1.Moschella S L. Pyoderma gangrenosum: A patient successfully treated with intralesional injections of steroid. Arch Dermatol 1967;95:121.  Back to cited text no. 1    
2.Michaelsson G, Molin L, Ohman S, et al. Clofazimine: A new agent for the treatment of pyoderma gangrenosum. Arch Dermatol 1976;112:344.  Back to cited text no. 2    
3.Tay CH. Pyoderma gangrenosum and leukemia. Arch Dermatol 1973;108:580.  Back to cited text no. 3  [PUBMED]  
4.Byrne JPH, Hewitt M, Summerly R. Pyoderma gangrenosum associated with active chronic hepatitis. Arch Dermatol 1976;112:1297.  Back to cited text no. 4    
5.Wyhinny PP, Malkinson FD. Pyoderma gangrenosum. In: Clinical Dermatology (Demis DJ. ed), Vol.1. Philadelphia: Harper and Row, 1985;Unit 5-12:1-7.  Back to cited text no. 5    
6.Miyachi Y, Niwa Y. Effects of potassium iodide, colchicine and dapsone on the generation of polymorphonuclear leucocyte- derived oxygen intermediates. Br J Dermatol 1982;107:209.  Back to cited text no. 6  [PUBMED]  
7.Lynch WS, Bergfeld WF. Pyoderma gangrenosum responsive to minocycline hydrochloride. Cutis 1978;21:535.  Back to cited text no. 7  [PUBMED]  
8.Davies MG, Piper S. Pyoderma gangrenosum: Successful treatment with minocycline. Clin Exp Dermatol 1981;6':219.  Back to cited text no. 8    
9.Reynolds NJ, Peachey RDG. Response of atypical pyoderma gangrenosum to oral minocycline hydrochloride and topical steroids. Acta Derm Venereol 1990;70:538-9.  Back to cited text no. 9    
10.Jaran VO, Shah BH, Dixit CV. Pyogenic infections of skin treated with minocycline. Ind J Derm Venereol 1971;37:99-103.  Back to cited text no. 10    


    Figures

[Figure - 1], [Figure - 2]



 

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