P055 Real-world experience using guselkumab for pyoderma gangrenosum: rapid responses in three patients

Abstract

Pyoderma gangrenosum (PG) is a rare neutrophilic dermatosis characterized by painful ulceration and significant morbidity. Management is challenging, particularly in refractory disease or in patients with complex comorbidities. Increasing evidence implicates the interleukin (IL)-23/T helper 17 axis in PG pathogenesis, supporting the use of targeted biologic therapies. We report three cases of refractory PG treated with guselkumab, a monoclonal antibody targeting the p19 subunit of IL-23. Case 1 involved a 71-year-old man with multiple comorbidities, including prior treated spinal tuberculosis and paraplegia, who developed multifocal painful ulceration of the lower limbs. Histology demonstrated neutrophilic inflammation consistent with PG. Following failure of local wound care measures, potent topical corticosteroid therapy and minocycline, guselkumab was initiated. Rapid initial improvement was observed, with near-complete ulcer resolution by 12 weeks. Case 2 describes an 18-year-old woman who developed painful, nonhealing breast ulcers following reduction mammoplasty. Biopsies demonstrated a neutrophilic dermatitis. Disease persisted despite systemic immunosuppression with corticosteroids, mycophenolate mofetil, ciclosporin and topical therapy. Guselkumab led to symptomatic improvement within 1 week and sustained healing at 8 weeks. Case 3 involved a 65-year-old woman with an 11-year history of recurrent lower-limb ulceration, presenting with a near-circumferential ulcer demonstrating classical features of PG. Histology confirmed neutrophilic inflammation. She did not respond to systemic corticosteroids and antibiotics and required significant analgesia. Marked clinical improvement was observed 4 weeks after guselkumab initiation. IL-23 is overexpressed in PG lesions and plays a key role in maintaining T helper 17-mediated neutrophilic inflammation. Our cases add to emerging evidence supporting guselkumab as an effective and well-tolerated therapeutic option for refractory PG. Ongoing clinical trials will further clarify its role within treatment algorithms. Guselkumab represents a promising targeted therapy for refractory PG, offering rapid and sustained clinical benefit in complex cases.