P024 Anakinra for recalcitrant pyoderma gangrenosum with Achilles tendon exposure

Abstract Pyoderma gangrenosum (PG) is an ulcerative autoinflammatory neutrophilic dermatosis associated with systemic disorders. It often has a chronic relapsing course characterized by rapidly enlarging painful ulcers, which may be challenging to manage. A 61-year-old man with a history of non-insulin-dependent diabetes, hypertension, chronic kidney disease, atrial fibrillation and heart failure, presented initially to the vascular team with bilateral nonhealing painful ulcers that developed following an episode of cellulitis. Initial punch biopsy showed neutrophilic infiltrate in keeping with PG, which prompted dermatology referral. Repeat incisional biopsy by dermatology from the ulcer edge showed venous stasis, granulation tissue with neutrophilic infiltrate and no evidence vasculitis or a thrombus. Investigations for underlying malignancy and inflammatory bowel disease were negative. Unfortunately, there was rapid progression of his lower-limb ulceration with exposure of the left Achilles tendon. He was commenced on ciclosporin with initial improvement, but uptitration was limited to 3 mg kg−1 per day due to the development of significant renal impairment, which required medical admission. Treatment was switched to adalimumab fortnightly. His ulcers progressed aggressively despite an increased dose up to 80 mg weekly. The ulcers were also unresponsive to oral steroids (1 mg kg−1 per day), which were poorly tolerated in the context of his comorbidities. He was commenced on anakinra (100 mg daily), a recombinant interleukin-1 inhibitor, and initial monthly monitoring of neutrophils was carried out. Combined with ongoing lower-limb wound care and high-grade compression, anakinra has resulted in significant ulcer improvement and gradual healing, and has been well tolerated. After 14 months of treatment, all areas of ulceration are almost completely healed with one area of mild overgranulation, currently being treated with topical clobetasol propionate. This case highlights the difficulties in treating PG, as side-effects of medications must be balanced with systemic comorbidities. It also reveals the importance of regular wound care and lower-limb compression in the setting of ulcers at this site. Anakinra represents a potentially effective treatment option with a relatively low side-effect profile.