Nicotine for pyoderma gangrenosum.

A 35-year-old man with no past medical illness developed bloody diarrhea with up to 12 loose stools per day and abdominal pain in February 1984. He had smoked 1 pack of cigarettes per day for 16 years until he stopped smoking 2 months prior to the onset of his illness. In March 1984, he was hospitalized because of toxic dilatation of the colon (toxic megacolon). Treatment consisted of intravenous fluids and electrolytes, broadspectrum antibiotics, and corticosteroids. After the condition had slowly improved, he was released on a daily dosage of 40 mg of prednisone, 4 g of sulfasalazine, and 800 mg of cimetidine. Findings of colonoscopic and sigmoidoscopic examinations with biopsies were inconclusive, and he was diagnosed as having active nongranulomatous colitis similar to inflammatory bowel disease, without being able to differentiate between ulcerative colitis and Crohn disease. He subsequently had short remissions with only minimal activity and many relapses with severe symptoms. He was treated with 1.5 to 3 g/d of sulfasalazine, and 50 to 100 mg/d of azathioprine, as well as intermittent courses of prednisone. Cimetidine, iron, and vitamins were also administered. We first saw the patient in July 1985 for 2 multiloculated necrotic ulcers on both legs surrounded by a raised, thickened, undermined bluish edge. The diagnosis of pyoderma gangrenosum was made clinically. Therapy with 60 mg/d of prednisone was started and gradually reduced to 25 mg/d of prednisone over 1 year, after which the ulcers healed. In July 1992, he again developed pyoderma gangrenosum on 1 leg and underwent a similar treatment and course over nearly 1 year until the ulcer had completely healed. In August 1995, there was an exacerbation of his bowel symptoms together with pyoderma gangrenosum on his left leg. Therapy consisted of blood transfusions and 30 mg/d of prednisone, in addition to the sulfasalazine and azathioprine regimens. His bowel symptoms but not his cutaneous lesions improved gradually, and prednisone was slowly tapered within 5 months to 12.5 mg/d. In March 1996, azathioprine was stopped on his request. However, the pyoderma gangrenosum did not respond to this treatment; rather, the cutaneous situation in August 1996 was about the same as it had been 1 year earlier.