Use of Becaplermin for nondiabetic ulcers: pyoderma gangrenosum and calciphylaxis

Abstract

Large difficult to heal ulcers of various etiologies carry a high morbidity and mortality rate. Becaplermin is a recombinant platelet-derived growth factor approved for treatment of diabetic ulcers. In this two-case series, we report the use of becaplermin in the treatment of ulcers due to (i) calciphylaxis, an often fatal condition resulting from systemic calcification and thrombosis of vessels and (ii) pyoderma gangrenosum (PG), a neutrophilic dermatosis. We also report that topical collagenase worsened PG ulcers, consistent with pathergy. Becaplermin can be used to help treat ulcers resulting from calciphylaxis and PG. These encouraging results lend support for the utilization of becaplermin in the treatment of nondiabetic chronic ulcers of various etiologies.

Keywords: becaplermin; calciphylaxis; pyoderma gangrenosum.

FIG. 1

Histopathology of right knee. 40 × magnification, H&E stain of edge of ulcer with underlying mixed acute and chronic inflammatory infiltrate with neutrophils and eosinophils consistent with chronic pyoderma gangrenosum. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]

FIG. 2

Pyoderma gangrenosum gross photographs. A) Location of pyoderma gangrenosum lesions on right lower leg and left dorsal foot. B) Right lower leg flaring at the beginning of the patient’s last hospitalization showing a large ulcer with undermined borders and granulation tissue. C, D) Improvement in the size and extent of the ulceration over time at 3 and 7 weeks post-treatment as patient was treated with prednisone and becaplermin, with progression to pink atrophic plaques and hyperpigmented cribiform scars. E) Left dorsal foot with a large ulcer with undermined borders and crust. F, G) Resolution of left dorsal foot ulcer at 3 and 7 weeks post-treatment showing replacement with pink atrophic plaque. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]

FIG. 3

Calciphylaxis gross photographs and pathology. A) Retiform purpura visible on left anterior shin as well as large ulcer of the left medial calf. B, C) Left medial calf after 3 and 8 weeks of daily therapy with 0.01% becaplermin gel. D) Histopathology of ulcer at 40 × magnification, von Kossa stain highlights calcium deposition within medium-sized vessel walls, consistent with calciphylaxis. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]