Treatment of Erythema Nodosum, Aphthous Stomatitis, and Pyoderma Gangrenosum in Patients with IBD

The only remedy necessary for most extraintestinal symptoms of inflammatory bowel disease (IBD) is to treat the underlying bowel disease. However, extraintestinal disorders may persist despite resolution or improvement in the bowel symptoms, even those that usually respond promptly such as erythema nodosum and peripheral arthritis. A course of prednisone 1-1.5 mg/kg/day in divided doses is an option, but some patients do not tolerate steroids and some do not respond. Here are some other options for selected IBD-associated disorders. Of all the extraintestinal manifestations, this one is the most responsive to treatment of the bowel, and persistence of the lesions indicates inadequate control of the IBD. For steroid-refractory patients with mild to moderate gut symptoms, azathioprine is my first choice and if not tolerated, then subcutaneous methotrexate. For severely active, steroid-refractory disease, I favor colectomy for ulcerative colitis and resection for limited Crohn's disease, such as segmental colon resection or resection of limited distal ileal disease. I would discuss intravenous cyclosporine as an alternative to surgery. Thalidomide, available as an investigational drug in the United States, is rapidly effective for erythema nodosum leprosum and is associated with a decrease in serum concentrations of tumor necrosis factor (TNF)-α (1), so perhaps it would be effective for EN in IBD. Whether TNF-α antibody therapy is effective for EN remains to be seen. These do not parallel the activity of the bowel disease and often warrant direct therapy. Intralesional steroid injections are sometimes effective when high-dose oral prednisone has failed. Nicotine gum is an unproved option in the patient with ulcerative colitis. Whether immune modulator therapy is effective for oral lesions above and beyond treatment of the bowel disease is unknown but worth a try if corticosteroids fail. Thalidomide 200 mg/day for 14-28 days induces dramatic healing of aphthous ulcers related to human immunodeficiency virus infection (2) and could be tried for lesions in IBD patients. These lesions can develop and respond to therapy without any relation to the activity of the bowel disease. High-dose oral prednisone and intralesional injections of corticosteroids are often effective. Oral cyclosporine 5 mg/kg/day completely healed pyoderma lesions in 2-3 months in the majority of patients in an uncontrolled series (3). Pyoderma adjacent to an ileostomy is best treated medically and with modifications of the appliance under the supervision of an enterostomal therapist: Surgical relocation of the stoma to an uninvolved site is a last resort, because the lesions may recur at the new stoma.