Topical Tacrolimus for Parastomal Pyoderma Gangrenosum: A Report of Two Cases
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The treatment regimen is based on individual response and can be local, systemic, or in some refractory cases, surgical. Local treatment includes wound care, topical agents, and local injection of medications. Local wound care including debridement, curettage, and deroofing the ulcer complex is often insufficient. Unsuccessful treatment can result in stoma relocation.6 Use of topical agents including antibiotics, corticosteroids, Desitin ointment (Pfizer, Inc., New York, NY), and 0.5% nicotine cream has been described and provides variable efficacy.7 Systemic therapy such as dapsone, prednisone, cyclosporine, mycophenolate mofetil, and intravenous infliximab remain the mainstay of treatment.7-10 In refractory cases or in patients with inactive or resected disease, topical tacrolimus can be beneficial.
Tacrolimus (FK506) is a potent member of the macrolide family of immunosuppressive antibiotics. It acts by blocking the IL-2 transcription, thereby inhibiting T-lymphocyte proliferation and activation. Systemic therapy with tacrolimus has been shown to be effective in a variety of lymphocyte-driven inflammatory dermatoses, although adverse effects of the systemic treatment such as hypertension, neurotoxicity, and nephrotoxicity have been shown.11 In order to circumvent the adverse effects of systemic therapy, topical treatment strategies have been evaluated in multiple case studies. Studies19,20 using 0.3% tacrolimus ointment report rare adverse reactions, such as burning, pruritis, flu-like symptoms, allergic reactions, and skin erythema. Manufacturer contraindications for the use of tacrolimus include a known allergy to tacrolimus or one of the components of the preparation. Tacrolimus should not be used in the pediatric population or on any lesion of infectious origin.
Applied topically, tacrolimus penetrates skin effectively and has been used in a wide array of inflammatory dermatoses, such as graft versus host disease, vitiligo, contact dermatitis, and alopecia.12-15 Results of case series16,17 indicate that topical tacrolimus has been one of the more effective local agents in the treatment of PG.16,17 Schuppe et al16 reported a case of a 32-year-old woman who developed a rapidly growing ulcer on her right calf. On admission, the ulcer had a 10-cm diameter and showed typical features of PG. Although ulcer enlargement ceased with standard treatment with oral prednisolone (100 mg daily), healing was achieved after 2 weeks of daily topical applications of tacrolimus (0.5% solution). The authors used topical tacrolimus alone under a hydrocolloidal wound dressing. The skin lesion completely resolved at 12 weeks after discontinuation of the steroids. No adverse effect other than a burning sensation was noted. Reich et al17 described two cases where patients with PG were treated successfully with tacrolimus ointment alone and in combination with systemic cyclosporine. The first case involved a 48-year-old man with recurrent ulcerative lesions. Although previous lesions had responded to traditional treatment comprising systemic prednisolone and low-dose cyclosporine, the recurrent lesions failed to respond. When the patient developed a 2-cm lesion over the clavicle, the authors started monotherapy consisting of twice-daily application of tacrolimus ointment (0.1%). The lesion healed in 3 weeks. The second patient, a 27-year-old woman with a 4-year history of ulcerative colitis, presented with several lesions ranging from 5 cm to 10 cm in diameter. This patient was treated with systemic cyclosporine at 5 mg/kg/day, which was tapered, and 0.1% tacrolimus ointment applied once daily with a hydrocolloid dressing for 3 weeks. The authors concluded that the addition of tacrolimus accelerated lesion healing.