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.