Case Report: Triple Combination Therapy for Recalcitrant Perineal Pyoderma Gangrenosum

Pyoderma gangrenosum (PG) is a destructive ulcerative process, which is usually idiopathic or associated with underlying systemic disease. Its pathogenesis remains unknown. A 30-year-old male with a history of Crohn's disease presented with an advanced perineal and inguinal ulcer consistent with pyoderma gangrenosum, which only partially responded to oral and intralesional corticosteroids and adalimumab 80mg biweekly. The patient was started on adjunct combination cyclosporine and thalidomide, which resulted in prompt relief and profound healing. Treatment of pyoderma gangrenosum is often challenging with no standardized treatment protocols. Combination therapy should be considered in patients with refractory disease, especially with failure of monotherapy. J Drugs Dermatol. 2019;18(3):307-310.

Economic Costs Avoided by Diagnosing Melanoma Six Months Earlier Justify >100 Benign Biopsies.

New melanoma drugs bring enormous benefits but do so at significant costs. Because melanoma grows deeper and deadlier over time, deeper lesions are costlier due to increased sentinel lymph node biopsy, chemotherapy, and disease-associated income loss. Prior studies have justified pigmented lesion biopsies on a "value per life" basis; by contrast we sought to assess how many biopsies are justified per melanoma found on a purely economic basis. We modeled how melanomas in the United States would behave if diagnosis were delayed by 6 months, eg, not biopsied, only observed until the next surveillance visit. Economic loss from delayed biopsy is the obverse of economic benefit of performing biopsy earlier. Growth rates were based on Liu et al. The results of this study can be applied to all patients presenting to dermatologists with pigmented skin lesions suspicious for melanoma. In-situ melanomas were excluded because no studies to date have modeled growth rates analogous to those for invasive melanoma. We assume conservatively that all melanomas not biopsied initially will be biopsied and treated 6 months later. Major modeled costs are (1) increased sentinel lymph node biopsy, (2) increased chemotherapy for metastatic lesions using increased 5-yr death as metastasis marker, and (3) income loss per melanoma death at $413,370 as previously published. Costs avoided by diagnosing melanoma earlier justify 170 biopsies per melanoma found. Efforts to penalize "unnecessary" biopsies may be economically counterproductive.

J Drugs Dermatol. 2016;15(5):527-532.