Management of peristomal pyoderma gangrenosum

PURPOSE: This study was designed to evaluate the presentation, management, and outcome of peristomal pyoderma gangrenosum at a specialist colorectal unit and develop a strategy for therapy. METHODS: Patients with peristomal pyoderma gangrenosum were identified from a prospectively accrued Institutional Review Board-approved stoma database. Data were collected regarding demographics, disease status, history of illness, time to heating, and treatments used from the database and by chart review. RESULTS: Sixteen patients presented between 1997 and 2002 with peristomal ulceration consistent with a diagnosis of peristomal pyoderma gangrenosum. Diagnosis was predominantly clinically based on a classic presentation of painful, undermined peristomal ulceration. The underlying diagnosis was Crohn's disease in 11 patients, ulcerative colitis in 3, indeterminate colitis in 1, and posterior urethral valves in 1. At the time of development of peristomal pyoderma gangrenosum, the underlying disease was active in 69 percent of patients. Stoma care, ulcer debridement with unroofing of undermined edges, and intralesional corticosteroid injection was associated with a 40 percent complete response rate and further 40 percent partial response rate. Of five patients who received infliximab, four (80 percent) responded to therapy. Complete response after all forms of therapy, including stoma relocation in seven patients, was 87 percent. CONCLUSIONS: Local wound management and enterostomal therapy are extremely important for patients with peristomal pyoderma gangrenosum. Infliximab may provide a useful option for those failing other forms of medical therapy. Relocation of the stoma is reserved for persistent ulceration failing other therapies, because peristomal pyoderma gangrenosum may recur at the new stoma site.