Autologous platelet rich plasma in pyoderma gangrenosum - two case reports.

Sir,

Pyoderma gangrenosum (PG) is an idiopathic, inflammatory, ulcerative disease of undetermined cause. Both topical and systemic formulations of corticosteroids and cyclosporine are commonly used for the ulcers of PG, but these ulcers are often intractable despite treatment.[1] Platelet-rich plasma (PRP) is a volume of autologous plasma that has a platelet concentration above baseline i.e., 5 times more than normal platelet counts.[2] PRP enhances wound healing by promoting healing process by growth factors present in it. They are platelet derived growth factors, fibroblast growth factor, vascular endothelial growth factor, epidermal growth factor, and transforming growth factor. These growth factors are important in modulating mesenchymal cell recruitment, proliferation and extra-cellular matrix synthesis during the healing process.[123] We have used PRP for two cases of PG with significant improvement.

A 50-year-female presented with an ulcer measuring about 3.5 × 4.8 cm with well-defined margins, punched out edges covered by red granulation tissue associated with pain over the posterior aspect of left leg for two and half months duration. There was history of similar ulcers over both legs for the past 6 months, which healed spontaneously without treatment in two to three months. She had been treated with systemic antibiotics, regular cleaning and dressing of the ulcer previously without significant improvement. Second case was a 60-year-old male presented with an ulcer measuring about 7.8 cm × 5 cm in size covered by healthy granulation tissue over his left shin for one month. In both the cases, pathergy test was negative. Routine investigations were within normal range. Skin biopsy taken from the edge of the ulcer showed features of neutrophilic infiltrate in the dermis. Culture did not grow any organisms. Mantoux test and antinuclear-antibodies (ANA) titers were negative. Hence with exclusion of other causes, a diagnosis of PG was made.

The ulcers were treated with autologous PRP using double-centrifugation method. Before applying onto the ulcer, PRP was activated with 10% calcium chloride which turns into gel form.[3] Activated PRP should be used immediately as 70% of growth factors are released within 10 minutes. Therefore, clinicians should only clot (activate) PRP when they are ready to use it and not in advance.[4] The ulcer was covered with non-adherent dressing. The procedure was repeated weekly once. Patient ‘1’ showed improvement by 20 days. Patient ‘2’ showed improvement in five weeks requiring four sittings of PRP application. [Figures 1 and 2] During this treatment, patients were not put on topical antibiotics, or oral steroids/dapsone or any systemic drugs.

Figure 1

Before and after photograph of PG with one sitting of PRP

Figure 2

Before and after photograph of PG treated with four sittings of PRP

PRP is a safe, easy and cost-effective method in the management of chronic non-healing ulcers.[2] Higher the concentration of platelets, the efficacy is increased. PRP can be prepared by using PRP kit but it is quite expensive. Manual technique is found to be more of a cost-effective method in the preparation of PRP. Some conventional recombinant-growth factor products like becaplermin [recombinant-platelet derived growth factor] is Food and Drug Administration (FDA) approved for the treatment of chronic wounds.

Toyozawa et al., reported a case of PG treated with allogenic cultured dermal substitute followed by skin grafting.[1] Kang MC et al., reported a case of PG with combination therapy of cyclosporine and PRP.[5] This is the only case reported till now.

We report two cases of PG that was treated successfully with PRP without any systemic or topical drugs. PRP is a safe and inexpensive method of treating ulcers, which provides necessary growth factors. Hence, PRP can be used as an effective substitute to becaplermin and culture dermal substitutes that are expensive and cumbersome to use.