What is the evidence that infliximab offers superior remission rates compared with adalimumab in refractory pyoderma gangrenosum

What is known

- Infliximab is the only agent tested in a randomised, double-blind, placebo-controlled trial, demonstrating superiority over placebo for PG. ^1,2 - A retrospective analysis of 52 PG patients reported complete remission in 63.6% with infliximab versus 57.1% with adalimumab, but this is uncontrolled and not a direct comparative trial. ² - Adalimumab has achieved healing in refractory PG, including in patients who lost response to or had reactions with infliximab, but its evidence base is case series and observational data. ^3–5 - Reviews and case reports assert infliximab is 'more effective' or 'more superior' to adalimumab and label it first-choice, but these are opinion-based, not head-to-head results. ^6,7

What is unknown / caveats

- Retrospective series shows only a small numerical remission gap (63.6% vs 57.1%) between infliximab and adalimumab - Assertions of infliximab superiority derive from indirect comparison and pharmacokinetic reasoning, not a comparative trial - No randomized head-to-head infliximab vs adalimumab trial in refractory PG - Adalimumab data are case series/observational, not RCT-level - Whether infliximab truly yields higher remission than adalimumab cannot be established without a direct comparative study.

## References

1. Brooklyn TN, Dunnill MG, Shetty A, Bowden JJ, Williams JD, Griffiths CE, Forbes A, Greenwood R, Probert CS. Infliximab for the treatment of pyoderma gangrenosum: a randomised, double blind, placebo controlled trial. Gut. 2006. PMID: 16188920.

2. Meier K, Schloegl A, Poddubnyy D, Ghoreschi K. Skin manifestations in spondyloarthritis. Ther Adv Musculoskelet Dis. 2020. PMID: 33343725.

3. Sagami S, Ueno Y, Tanaka S, Nagai K, Hayashi R, Chayama K. Successful Use of Adalimumab for Treating Pyoderma Gangrenosum with Ulcerative Colitis under Corticosteroid-tapering Conditions. Intern Med. 2015. PMID: 26328641.

4. Fousekis FS, Mpakogiannis K, Karampinis E, Mastorogianni IN, Christodoulou DK, Papoutsaki M, Zampeli E, Katsanos KH. Pyoderma Gangrenosum in a Patient with Crohn's Disease Treated with Adalimumab: A Case-Based Review and Systematic Review of the Current Literature. Clin Pract. 2025. PMID: 40136593.

5. Yamamoto T, Tanizaki H, Yamasaki K, Matsubara N, Nakayama M, Iwashita E, Yamanaka K. Safety and Effectiveness of Adalimumab for the Treatment of Pyoderma Gangrenosum: A 52-Week Real-World Prospective Observational Study. Dermatol Ther (Heidelb). 2026. PMID: 42107018.

6. Lee HC, Kwon Y, Kim ES, Ahn S, Choe YH, Kim MJ. Dual Biological Therapy for Ulcerative Colitis with Intractable Pyoderma Gangrenosum. Ann Dermatol. 2023. PMID: 37853879.

7. Arivarasan K, Bhardwaj V, Sud S, Sachdeva S, Puri AS. Biologics for the treatment of pyoderma gangrenosum in ulcerative colitis. Intest Res. 2016. PMID: 27799888.

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_Draft, generated by the IBDology RAG and not yet clinician-reviewed. Answers are grounded in the retrieved literature listed above; a high faithfulness score means the answer matches its sources, not that the sources are correct._