Alternative Therapy for Pyoderma Gangrenosum

Problem:  T.R.,  41 y/o male, admitted to our facility with peristomal pyoderma gangrenosum(PG).  The patient had been suffering with PG for several months but recently became a larger ulceration and very painful (10 on the 0-10 scale) approximately 10 days prior to his arrival.  His double-barreled ileostomy was directly in the middle of the ulceration, which measured 15x17.5x1cm. The wound was beefy-red with partial and full-thickness tissue loss.  T.R. was pouching the stoma over moist raw tissue. As a result, he was not achieving a good seal, changing the appliance several times per day due to leakage of stool.

Solving the problem:  Our chief colorectal surgeon summoned the CWOCNs to the patient’s bedside to assess the wound. We chose aggressive treatment since T.R. wanted to return home.  We covered the wound bed with petrolatum-impregnated gauze, applied one cohesive ring around base of the stoma, another cohesive ring cupping the stoma, then applied negative pressure wound therapy (NPWT).  Black foam (we later switched to saline impregnated white foam for patient comfort) was cut to fit the ulceration and surround the stoma.  We covered the cohesive rings with stoma paste.  NPWT drape was applied.  We applied a moldable convex large wafer with a drainable pouch and ostomy belt after the NPWT pump was turned on with a good seal.  NPWT was set to continuous -125mmHg and dressing was changed three times per week.

Results:  Patient was hospitalized for 20 days, wound measurements on discharge  decreased to 13x16x0.3cm and pain had decreased.  Patient refused to be admitted to LTAC for continued NPWT and elected to go home.  NPWT is not approved by FDA for home use around a stoma.  Treatment protocol at home consisted of silver-impregnated calcium alginate and thin hydrocolloid.  T.R. achieved 2 days wear time.