Cath Lab Digest

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D’Inca et al¹⁸ described oral tacrolimus as an effective and safe treatment for highly destructive cyclosporine-resistant PG. In this case, oral therapy with tacrolimus (0.1 mg/kg per day) was started following an unsuccessful course of cyclosporine and antibiotics in the attempt to treat a 15-cm area of necrotic tissue.

  To compare treatment with topical tacrolimus and clobetasol propionate, Lyons et al¹⁹ followed 30 patients with PPG. Topical tacrolimus 0.3% in Orabase (ConvaTec Ltd., Uxbridge, Middlesex, UK) was given to six patients who had failed to respond to topical corticosteroids, systemic corticosteroids, or cyclosporine. In five of the six patients, PPG healed within 6 weeks following application and the last patient was controlled with systemic tacrolimus. The authors concluded that tacrolimus is an effective treatment in ulcers >2 cm. Furthermore, based on the results observed in 11 patients, they found that treatment with tacrolimus in concentrations less than 0.3% was ineffective.

  This article presents two cases in which topical tacrolimus 0.1% was used successfully in the treatment of PPG.

Case Report 1

  Ms. A, a 59-year-old woman with a medical history unremarkable other than for pan-ulcerative colitis, underwent a colonoscopy that revealed multiple polyps. The majority of the biopsies performed revealed chronic colitis without dysplasia. One 4 cm x 5cm polyp in the region of the sigmoid and descending colon was described as a dysplasia-associated lesion or mass (DALM). A total proctocolectomy with end ileostomy was performed. Postoperatively, Ms. A recovered well and did not require any further post-resection medical treatment but 11 months later, Ms. A noticed two small ulcers on the right side of the stoma. These developed into an irregular shaped 2 cm x 2 cm painful ulcer with raised edges and a violet hue in one area of the wound border (see Figure 1). The lesion was clinically identified as PPG.

  Ms. A was prescribed daily appliance changes and application of topical tacrolimus 0.1 % ointment. No special parastomal skin care preparations were used and the ointment was placed directly under the adhesive pouch. Six weeks later, the lesion had markedly improved with new skin forming on the lower edge of the parastomal ulcer and a healthy stoma (see Figure 2). Ms. A’s treatment was altered to tacrolimus ointment 0.03% ointment and every-other-day appliance changes. The dosage was lowered and appliance changes were performed in this frequency to ensure use of the minimal concentration tacrolimus and to reduce parastomal trauma from frequent appliance changes. Two months later, the PPG had improved substantially and itching and pain had resolved (see Figure 3). Ms. A experienced a brief resurgence of her symptoms and skin changes with an unintended hiatus in her therapy. She was restarted on topical tacrolimus 0.1% ointment and after a few weeks of therapy, her symptoms resolved.

Case Report 2

  Ms. B, a 62-year-old woman with a history of chronic ulcerative colitis who underwent a total proctocolectomy and ileostomy due to pan-colitis, DALM, and poor sphincter function presented with pain, bleeding, and ulceration around her right lower quadrant ileostomy after trauma to her stoma. Her medical history was otherwise unremarkable. Examination revealed a healthy ileostomy with a tender, 1 cm x 1 cm ulcerated skin lesion on the right side of the stoma with raised edges clinically consistent with PG (an infectious etiology was not found). Therapy with topical triamcinolone 0.5% and daily appliance changes was initiated. However, this treatment was unsuccessful and the ulcerative process progressed. After 1 month, Ms. B’s lesion had enlarged to a 3-cm ulceration with excoriation of the left lateral and left inferior parastomal skin.