Biologic agent sparing potential of fish skin grafts in treatment resistant pyoderma gangrenosum: a case study

Introduction: Pyoderma gangrenosum (PG) is an ulcerative skin disorder that is caused by neutrophil dysfunction, genetic function, and systemic inflammation, best known as a complication of inflammatory bowel disease. Ulcerative or classic PG is the most common variant typically begins as a tender, inflammatory papule, pustule, or vesicle on normal-appearing skin or at a site of trauma.

Treatment is with systemic steroids and/or cyclosporine. If these measures along with traditional would care fail, patients are candidates for an anti-TNF biologic agents which can be extremely costly along with their invasive nature and inherent risks. In this case study the feasibility of fish skin for PG wound management was assessed.

Methods: A 78 year old female patient presents to the dermatological department for treatment with infliximab. A non-responsive PG ulcer in the lower abdominal area that has been present for more than 1 year. Various wound dressing have been tried without success, as well as local and injectable steroids. It was decided that fragmented fish skin graft would be used to attempt to fill the wound. The patient received one application of the fragmented fish skin graft and a subsequent three applications of intact fish skin graft a week apart.

Results: The first application of fish skin was 19. of March. At the follow up visit there was good granulation not seen previously, thus after a discussion with the patient the management with the fish skin continued. The patient achieved complete wound closure at 21st of March, in 5 weeks, without the need to initiate infliximab therapy.

Discussion: The application of fish skin graft prevented a potentially costly intervention with infliximab for the patients wound. Generally, the requirement for infusion and the high cost of infliximab makes it a less favorable for patients. Fish skin grafts are a safe option virtually free of physical and systemic side effects while the use of biologics include infusion reactions, infections, demyelinating disease and heart failure. The use of fish skin graft is a novel approach worth considering in patients with unresponsive PG wounds.