title: Severe pyoderma gangrenosum unresponsive to etanercept and adalimumab.
abstract: BACKGROUND
  A 74-year-old female with severe and therapy-resistant pyoderma gangrenosum (PG) was treated for more than 40 years with topical antibacterial ointments, topical and systemic corticosteroids, dapsone and azathioprine. Generally, immunosuppression is the mainstay of treatment of PG, but in our patient cyclosporine had to be discontinued because of significant serious side effects. An attempt was made to decrease the amount of steroids, but tapering of the prednisone dose resulted in relapses of PG.
  
  
  METHODS
  Off-label use of etanercept resulted in a temporary limited clinical improvement. After 6 months, initial clinical improvement reduced and adalimumab was started. Unfortunately, after 6 months of adalimumab no clinical improvement was seen. Therefore, systemic corticosteroids had to be continued with very good clinical results.
  
  
  CONCLUSIONS
  In concordance with previous results of several other studies, reviews and case reports, we presume that possibly both etanercept and adalimumab could be excellent therapeutic alternatives in the treatment of PG. Unfortunately, the effectiveness of both etanercept and adalimumab were very limited in our case. Literature research revealed no other successful studies on the off-label use of other immunomodulators as an alternative treatment option for PG. However, infliximab or ustekinumab could be alternative treatment options.
authors.affiliation: Department of Dermatology , Radboud University Nijmegen Medical Centre, The Netherlands. M.Kleinpenning@derma.umcn.nl
authors.forename: Marloes M
authors.initials: MM
authors.lastname: Kleinpenning
authors.forename: Annechien M G
authors.initials: AM
authors.lastname: Langewouters
authors.forename: Peter C M
authors.initials: PC
authors.lastname: Van De Kerkhof
authors.forename: Rens J
authors.initials: RJ
authors.lastname: Greebe
mesh_terms: D000068879:Adalimumab; D000368:Aged; D000893:Anti-Inflammatory Agents / Q000627:therapeutic use*; D061067:Antibodies, Monoclonal, Humanized / Q000627:therapeutic use*; D000068800:Etanercept; D005260:Female; D006801:Humans; D007074:Immunoglobulin G / Q000627:therapeutic use*; D007166:Immunosuppressive Agents / Q000627:therapeutic use*; D011241:Prednisone / Q000627:therapeutic use; D017511:Pyoderma Gangrenosum / Q000188:drug therapy*; D018124:Receptors, Tumor Necrosis Factor / Q000627:therapeutic use*; D017211:Treatment Failure
chemical_list: D000893:Anti-Inflammatory Agents; D061067:Antibodies, Monoclonal, Humanized; D007074:Immunoglobulin G; D007166:Immunosuppressive Agents; D018124:Receptors, Tumor Necrosis Factor; D000068879:Adalimumab; D000068800:Etanercept; D011241:Prednisone