Treatment of Oral Lesions of Pyoderma Gangrenosum

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I saw a patient today with pyoderma gangrenosum for a Palliative Care consult. She has a very rare presentation of occasionally having mucosal lesions that are located in her throat that are quite painful. Her daughter said that the Mayo Clinic has only seen one other case with the oral lesions. I was told that the only thing that has worked was when an ENT surgeon passed a needle through her open mouth to inject a steroid solution directly into the lesion located somewhere in her throat. Fortunately this patient does not currently have any mucosal lesions. Is there any information on the use of Magic Mouthwash for treatment of such an unusual problem?

Feb 23, 2022 by David L. Dugan, MD

1 replies

Elaine Horibe Song
MD, PhD, MBA

Hi Dr Dugan,

Thank you for sharing this unusual case. The literature on the use of magic mouthwash for oral pyoderma gangrenosum (PG) is scarce, but there are some case reports and interesting information, summarized below:

Magic mouthwash refers to a number of mixed medication formulations used to prevent or treat oral mucositis. There is no fixed formulation, and these mixtures are compounded differently by individual pharmacies, with no set formula.[1] Commonly, these mouthwashes consist of anticholinergic agents (eg, diphenhydramine), antacids and/or mucosal protective agents (eg, sucralfate, aluminum hydroxide), anesthetics (eg, lidocaine), and sometimes antibacterials, antifungals, opioids, and steroids.[1]

PG is an uncommon dermatological condition with very rare oral involvement. Few reports of oral lesions have been documented. In general, management consists of systemic corticosteroids as the first line of immunosuppressive therapy.[2] In addition to systemic corticosteroids, local ulcer care is suggested to enhance patient comfort and prevent secondary microbial or fungal infections. Chlorhexidine 0.12% mouth rinse can be used to achieve this in oral PG. Topical clobetasol propionate (Dermovate 0.05%) or Tacrolimus (Protopic 0.1 or 0.03%) can be used as adjuvants to systemic therapy to relieve symptoms.[2]

Published cases of oral involvement in patients with PG are summarized in this article https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5677063/' target='_blank'>https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5677063/ [2] Below are 3 cases that included mouthwash in their therapy. Yco et al [3] described a case solely managed with magic mouthwash.

- Yco et al. [3]: Symptomatic therapy: kaolin, pectin, lidocaine and Benadryl mouthwash 2 wks after biopsy, the lesion steadily healed and the palatal mucosa eventually returned to normal
- Chariatte et al. [4]. Prednisone 50 mg/d with topical protopic 0.1% application (with sterile gauze)
- Curi et al. [5]. Oral lesions managed with Chlorhexidine 0.12% mouth-wash and topical corticosteroids. Prednisolone PO 40 mg/d + mesalazine 800 mg/d, oxacillin 2 g/d. Rapid and complete resolution of the mucocutaneous lesions after a week of treatment

The components of the magic mouthwash used by Yco et al are similar to the magic mouthwash commonly administered at Mayo Clinic sites [6]

More on PG: https://woundreference.com/app/topic?id=pyoderma-gangrenosum-treatment

[1] https://pubmed.ncbi.nlm.nih.gov/30453313/ (see attached)
[2] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5677063/' target='_blank'>https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5677063/
[3] https://pubmed.ncbi.nlm.nih.gov/3386383/
[4] https://www.jomos.org/articles/mbcb/abs/2011/03/mbcb110016/mbcb110016.html
[5] https://www.scirp.org/journal/paperinformation.aspx?paperid=32024
[6] https://www.medscape.com/viewarticle/869314

Feb 25, 2022

* Information provided without clinical evaluation and is not intended as a replacement for in-person consultation with a medical professional. The information provided through Curbside Consult is not a substitute for proper training, experience, and exercising of professional judgment. While every effort has been made to ensure the accuracy of the contents, neither the authors nor the Wound Reference, Inc. give any guarantee as to the accuracy of the information contained in them nor accept any liability, with respect to loss, damage, injury or expense arising from any such errors or omissions in the contents of the work.

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