P054 Topical ciclosporin eyedrops for recalcitrant pyoderma gangrenosum: report of two adult cases

Abstract

Pyoderma gangrenosum (PG) is an uncommon inflammatory skin disease characterized by painful ulceration. Treatment options include topical corticosteroids and calcineurin inhibitors, or systemic therapies including corticosteroids, ciclosporin and mycophenolate mofetil. We present two cases of recalcitrant PG successfully treated with ciclosporin eyedrops. Patient 1 was a 77-year-old man with a painful 11 × 9-cm enlarging ulcer on his left calf, with violaceous borders and undermined edges. Histology showed active chronic inflammation and granulation tissue extending from the epidermis to the subcutis, which is in keeping with PG. Treatment with clobetasone ointment and oral prednisolone showed minimal improvement. Oral ciclosporin impaired his kidneys. Consequently, he was trialled on topical ciclosporin eyedrops, applied directly to the ulcer, and covered with an occlusive dressing. Almost complete resolution was achieved after 4 weeks of daily application of ciclosporin drops. Patient 2 was a 48-year-old woman with a pan-proctocolectomy for management of ulcerative colitis, with formation of a stoma. She developed two painful shallow ulcerations around her colostomy site, one 1.5 cm and the other 5 mm in diameter. Histology revealed nonspecific inflammation and ulceration, and a clinical diagnosis of peristomal PG was made. She was treated with beclometasone spray, fluocinolone acetonide gel and triamcinolone injection, with little response. She was subsequently commenced on topical ciclosporin eyedrops once daily for 4 weeks, resulting in near-complete healing of her PG. Her treatment continued for another month before being tapered. We remind colleagues of this effective topical treatment, which may reduce the need for systemic agents for the treatment of PG.