Title: Topical tacrolimus for pyoderma gangrenosum
Abstract: Richard Powell and colleagues (Dec 13, p 1720)1Powell RJ Holbrook RJ Stevens A Pyoderma gangrenosum and its treatment.Lancet. 1997; 350: 1720-1721Summary Full Text Full Text PDF PubMed Scopus (32) Google Scholar discuss the requirements for successful management of pyoderma gangrenosum, including appropriate local and systemic treatment. Whereas high-dose systemic glucocorticosteroids represent the mainstay of therapeutic strategies, non-steroidal immunosuppressive agents such as the macrolide lactones cyclosporin A (CsA) and tacrolimus (FK506) have been increasingly used as adjunctive or alternative therapy.2Chow RKP Ho VC Treatment of pyoderma gangrenosum.J Am Acad Dermatol. 1996; 34: 1047-1060Summary Full Text PDF PubMed Scopus (221) Google Scholar, 3Abu-Elmagd K Jegasothy BV Ackerman CD et al.Efficacy of FK 506 in the treatment of recalcitrant pyoderma gangrenosum.Transpl Proc. 1991; 23: 3328-3329PubMed Google Scholar However, long-term systemic administration of these compounds may be limited by severe adverse effects. Therefore, we assessed the efficacy of topical tacrolimus as add-on medication for treatment of pyoderma gangrenosum. A 32-year-old woman developed a rapidly growing ulcer on her right calf after an insect bite. On admission, the painful lesion (diameter 10 cm) showed the typical features of pyoderma gangrenosum with purplish margins. Laboratory findings revealed an acute inflammatory response and transient proteinuria, but systemic diseases associated with pyoderma gangrenosum were excluded. Although initial treatment with oral prednisolone (100 mg daily) stopped further enlargement, healing of the ulcer was not seen before starting daily topical applications of tacrolimus (0·5% solution; Prograf) after 2 weeks. Subsequently, the dose of prednisolone was then tapered and treatment with topical tacrolimus alone under hydrocolloidal wound dressings led to complete resolution of the skin lesion after 12 weeks. Apart from a burning sensation during application, there were no side-effects to tacrolimus or systemic uptake of the drug. Topical tacrolimus exerts important immunosuppressive effects during induction of contact hypersensitivity.4Homey B Schuppe H-C Assmann T et al.A local lymph node assay to analyse immunosuppressive effects of topically applied drugs.Eur J Pharmacol. 1997; 325: 199-207Crossref PubMed Scopus (20) Google Scholar Moreover, a recent study showed that tacrolimus ointment is highly effective in the treatment of atopic dermatitis.5Ruzicka T Bieber T Schöpf E et al.A short-term trial of tacrolimus ointment for atopic dermatitis. European Tacrolimus Multicenter Atopic Dermatitis Study Group.N Engl J Med. 1997; 337: 816-821Crossref PubMed Scopus (506) Google Scholar Our observation indicates that the destructive skin inflammation characterising pyoderma gangrenosum may also be successfully treated with topical tacrolimus. This approach allows reduction of severe adverse effects associated with systemic administration of immunosuppressants, including the complications of prolonged glucocorticosteroid treatment.