Cyclosporine and tacrolimus in dermatology

Nanoscale Topical Pharmacotherapy in Management of Psoriasis: Contemporary Research and Scope

Psoriasis is a typical dermal condition that has been anticipated since prehistoric times when it was mistakenly implicit in being a variant of leprosy. It is an atypical organ-specific autoimmune disorder, which is triggered by the activation of T-cells and/or B-cells. Until now, the pathophysiology of this disease is not completely explicated and still, many research investigations are ongoing. Different approaches have been investigated to treat this dreadful skin disease using various anti-psoriatic drugs of different modes of action through smart drug-delivery systems. Nevertheless, there is no ideal therapy for a complete cure of psoriasis owing to the dearth of an ideal drug-delivery system for anti-psoriatic drugs. The conventional pharmacotherapy approaches for the treatment of psoriasis demand various classes of anti-psoriatic drugs with optimum benefit/risk ratio and insignificant untoward effects. The advancement in nanoscale drug delivery had a great impact on the establishment of a nanomedicine-based therapy for better management of psoriasis in recent times. Nanodrug carriers are exploited to design and develop nanomedicine-based therapy for psoriasis. It has a promising future in the improvement of the therapeutic efficacy of conventional anti-psoriatic drugs. The present manuscript aims to discuss the pathophysiology, conventional pharmacotherapy, and contemporary research in the area of nanoscale topical drug delivery systems for better management of psoriasis including the significance of targeted pharmacotherapy in psoriasis.

Utility of dermoscopy for evaluating the therapeutic efficacy of tacrolimus ointment plus 308-nm excimer laser combination therapy in localized vitiligo patients

The aim of the present study was to assess the function of dermoscopy in evaluating the therapeutic efficacy of tacrolimus ointment plus 308-nm excimer laser combination therapy in patients with localized vitiligo. A total of 147 patients with localized vitiligo (progressive disease, n=92; stable period, n=55) were enrolled and received combination therapy for 12 weeks. The condition of the skin lesions was monitored by dermoscopy and visual observation. At the initial visit, skin lesions were observed in 61 progressive and 19 stable patients. Residual perifollicular pigmentation was more abundant in progressive-stage patients than in stable-stage patients, whereas the presence of perilesional hyperpigmentation was obviously lower in patients with progressive vitiligo. After 12 weeks of combination therapy, marked differences in residual perifollicular pigmentation were identified between the progressive- and stable-stage patients. Dermoscopy and visual observation indicated that the 12-week treatment efficacy in patients with progressive disease was significantly higher than in those with stable disease and that assessment by dermoscopy was superior to visual observation at 8 or 12 weeks of treatment. Binary logistic regression analysis revealed that the disease stage, vitiliginous areas and disease course were risk factors associated with the treatment efficacy of the combination therapy. In conclusion, dermoscopy may be used as an effective means of vitiligo therapy assessment to provide an accurate and scientific evaluation of treatment efficacy for localized vitiligo patients.

Treatment of acute kidney injury associated with cyclosporine overdose in a dog using hemodialysis and charcoal hemoperfusion

OBJECTIVE

To describe the management of cyclosporine overdose using hemodialysis and hemoperfusion in a dog.

CASE SUMMARY

A 6-year-old, spayed female Australian Shepherd was presented for treatment of cyclosporine overdose and acute kidney injury. Five days prior to presentation, the dog had been diagnosed by its referring veterinarian with immune-mediated thrombocytopenia. Treatment was initiated with prednisone, but since no response was noted, azathioprine (50 mg PO q 24 h) and cyclosporine (6 mg/kg IV q 24 h) were added. On day 4, an overdose of cyclosporine (33 mg/kg IV) was administered accidentally. Upon presentation, serum biochemistry panel revealed azotemia [creatinine, 521.6 μmol/L (5.9 mg/dL); BUN, 59.3 mmol/L (166 mg/dL)], increased activities of liver enzymes, and hyperbilirubinemia. Due to the presumed diagnosis cyclosporine overdose and acute kidney injury, a combined hemodialysis and charcoal hemoperfusion treatment was planned. Hemosorba CH-350 charcoal hemoperfusion cartridge was placed in series upstream in the extracorporeal circuit from the hemodialyzer. A 3-hour treatment was performed and a total of 0.74 L/kg of blood was processed. Pretreatment blood cyclosporine concentration was 960 nmol/L (1154 ng/mL) and decreased to 440 nmol/L (529 ng/mL) posttreatment (54% fractional reduction, 18% per hour). Thirty-one hours following treatment, blood cyclosporine concentration was 220 nmol/L (265 ng/mL; 1.5% decrease per hour). Twelve days following presentation to our hospital, the dog was euthanized due to lack of response to medical management.

NEW OR UNIQUE INFORMATION PROVIDED

Combined hemodialysis and charcoal hemoperfusion treatment can significantly reduce blood cyclosporine concentrations following acute intoxication or overdosage, and should be considered as an option for decontamination in such cases.

Topical Tacrolimus Therapy for Pyoderma Gangrenosum

Pyoderma gangrenosum (PG) is a type of neutrophilic disorder with a chronic clinical course. Immunosuppressive agents have been used for its management. Among them, corticosteroid is known as the most effective. However, other immunosuppressants including cyclosporine A have been selected for patients with PG who were refractory to systemic steroids. Herein we report a case of PG resistant to systemic steroids, who was successfully treated with topical tacrolimus. A fifty-four year-old male had a 14-year history of PG. In 2002, necrotic ulcers appeared on his right leg that were refractory to oral prednisolone (30 mg/day). The application of topical tacrolimus to the border of the ulcers hastened epithelization of the ulcers and allowed for reduction of the oral prednisolone. Topical tacrolimus therapy may be an effective alternative for PG when the lesion is poorly controlled by corticosteroid.

Life-long diseases need life-long treatment: long-term safety of ciclosporin in canine atopic dermatitis

Ciclosporin (Atopica; Novartis Animal Health) has been licensed for canine atopic dermatitis (AD) since 2002. Adverse events (AEs) have been reported in 55 per cent of 759 dogs in 15 clinical trials, but are rare in pharmacovigilance data (71.81 AEs/million capsules sold). Gastrointestinal reactions were most common, but were mild and rarely required intervention. Other AEs were rare (≤1 per cent in clinical trials; <10/million capsules sold). Hirsutism, gingival hyperplasia and hyperplastic dermatitis were rarely significant and resolved on dose reduction. Ciclosporin decreases staphylococcal and Malassezia infections in AD, and at the recommended dose is not a risk factor for other infections, neoplasia, renal failure or hypertension. The impact on glucose and calcium metabolism is not clinically significant for normal dogs. Concomitant treatment with most drugs is safe. Effects on cytochrome P450 and MDR1 P-glycoprotein activity may elevate plasma ciclosporin concentrations, but short-term changes are not clinically significant. Monitoring of complete blood counts, urinalysis or ciclosporin levels is not justified except with higher than recommended doses and/or long-term concurrent immunosuppressive drugs. Ciclosporin is not a contraindication for killed (including rabies) vaccines, but the licensed recommendation is that live vaccination is avoided during treatment. In conclusion, ciclosporin has a positive risk-benefit profile for the long-term management of canine AD.

Relationship of body weight to maintenance cyclosporine a dose in canine atopic dermatitis

Cyclosporine A (CsA) is a commonly prescribed and effective therapy for canine atopic dermatitis. The purpose of this study was to investigate the potential relationship between patient body weight and CsA dosing. Seventy-seven cases of canine atopic dermatitis managed between 2000 and 2011 were evaluated retrospectively. Duration of CsA therapy was at least 16 wk. Groups analyzed included the study population as a whole, those treated with only CsA, and those treated with both CsA and metoclopramide. The division between small and large dogs was set at 15 kg. Descriptive analysis, two-way analysis of variance, Pearson correlations, and a Student t test were used to analyze data. There were no significant differences between CsA dose and body weight regardless of method of analysis. Concurrent corticosteroid use, other medication use, and pruritus score were also analyzed over the study period. There was a significant decrease in CsA dose, corticosteroid dose, medication score, and pruritus score between the time points for all patients, but no significant relationship between those changes and body weight. These study findings suggest that differential CsA dosing is not warranted based on body weight.

A multicentre placebo-controlled clinical trial on the efficacy of oral ciclosporin A in the treatment of canine idiopathic sebaceous adenitis in comparison with conventional topical treatment

Canine idiopathic sebaceous adenitis (ISA) is an inflammatory reaction of sebaceous glands, potentially resulting in their complete loss. It is considered a T-cell-mediated disease, but its precise pathogenesis is still unknown. Topical treatment with oil soaks, humectants and shampoos is effective but laborious. Ciclosporin A (CsA), an immunomodulatory drug, has recently been shown to ameliorate the clinical picture of ISA and to reduce inflammation greatly. It is, however, an expensive treatment option. The objective of this multicentre, partly double-blinded, randomized controlled study was to evaluate the efficacy of ciclosporin A, either alone or with topical therapy, in comparison to conventional topical treatment alone, as measured by the primary end-points alopecia and scaling, and multiple histopathological secondary objectives. Thirty-four dogs with an established diagnosis were treated for 4-6 months and were evaluated before, during and after therapy. Both CsA and topical therapy demonstrated efficacy in this study. Differences between the treatment protocols were marginal. Topical treatment, both alone and in combination with CsA, appeared to reduce scaling more effectively than CsA alone. Both therapies reduced alopecia. There is evidence of a synergistic benefit on both scaling and alopecia, if both treatment options are combined. Inflammation of the sebaceous glands is also best reduced by a combination of both CsA and topical therapy. There is evidence that regeneration of sebaceous glands is best achieved by CsA, either given alone or in combination with topical treatment.

The use of cyclosporine in dermatology: part II

Cyclosporine is highly effective in the treatment of a multitude of dermatoses. Concern over its side effect profile has limited its use in dermatology. Adverse effects are, for the most part, dose dependent and related to duration of therapy. Using the recommended monitoring protocols results in a significant decrease in the incidence of cyclosporine-related toxicities. This article provides a comprehensive review of the pharmacokinetics of cyclosporine, potential drug interactions, adverse effects, and recommendations for monitoring in patients treated with cyclosporine. The use of cyclosporine in pregnancy and in the pediatric population is also addressed.

LEARNING OBJECTIVES

After completing this learning activity, participants should be familiar with the monitoring guidelines of cyclosporine, its contraindications, its possible drug interactions, its adverse effect profile, and its use in pregnancy and the childhood and adolescent populations.

Systemic ciclosporin and tacrolimus in dermatology

Ciclosporin and tacrolimus are calcineurin inhibiting immunosuppressant agents useful in the treatment of immune-mediated inflammatory dermatoses. Available data and clinical experience demonstrate ciclosporin's efficacy in treating psoriasis, atopic dermatitis, pyoderma gangrenosum, lichen planus, autoimmune bullous disease (in combination with corticosteroids), recalcitrant chronic idiopathic urticaria, and chronic dermatitis of the hands and feet. Although the role of topical tacrolimus in atopic dermatitis is well established, such experience with the oral formulation of tacrolimus has been limited. However, there are several case studies and anecdotal reports of the successful use of oral tacrolimus in various dermatoses. In this article we discuss the utility of systemic ciclosporin and tacrolimus in dermatology.

Psoriasis in the elderly

Psoriasis is one of the most common chronic skin diseases, and unprecedented increases in the elderly population will make diagnosis and management of geriatric psoriasis increasingly important. Management of psoriasis in the elderly requires consideration of several important factors. Many commonly prescribed drugs can precipitate psoriasis or aggravate pre-existing psoriasis. In addition, elderly patients are at increased risk of adverse drug reactions due to polypharmacy, adverse drug–drug interactions, adverse drug–disease interactions, incorrect use of medication and concomitant comorbidities. Psoriasis is a highly variable disease that requires individualized treatment. The major classes of topical medications include topical corticosteroids, coal tar preparations, calcipotriol, tazarotene and salicylic acid. Phototherapy, including narrowband ultraviolet B, photochemotherapy, psoralen ultraviolet A and excimer laser treatment, can be effective in properly selected patients. Systemic therapy for psoriasis in the elderly should be reserved for severe, extensive cases that have failed to respond to topical treatment, and may include methotrexate, systemic retinoids and immunotherapy.

Steroids versus other immune modulators in the management of allergic dermatoses

PURPOSE OF REVIEW

The classic role of topical and systemic corticosteroids for allergic dermatoses is discussed, with special attention to the impact on the current clinical treatment paradigm by newer systemic and topical therapies. These products are reviewed and recommendations presented on how to effectively assimilate them into clinical practice.

RECENT FINDINGS

Current knowledge about the etiopathogenesis of atopic dermatitis has resulted in drug development focused on agents with less toxicity than current topical and systemic corticosteroids. Some agents with ceramide/cholesterol/acid combinations demonstrate efficacy in restoring the dysfunctional skin barrier of atopic patients. Concerns resulting from the recent Federal Drug Administration announcement regarding a theoretical risk of cancer associated with topical calcineurin inhibitors are also addressed. Novel therapeutic entities are presented.

SUMMARY

Patients seeking relief from atopic dermatitis have historically had few really effective and safe therapeutic options. Topical calcineurin inhibitors represent an exciting new therapy for atopic dermatitis without the side-effect profile associated with topical corticosteroids. Nonsteroidal formulations incorporating glycyrrhetinic acid/telmesteine/Vitis vinifera extract and palmitoylethanolamide as 'active' ingredients recently entered the market, stressing antipruritic, antiinflammatory, and skin barrier repair. This confabulates against previously designed topical therapy paradigms. These new products may be used as monotherapy or alternatives to steroid agents.

Pyoderma gangrenosum: uncommon presentations

Pyoderma gangrenosum (PG) is a rare, inflammatory, noninfective, nonneoplastic skin disorder, which is often associated with systemic diseases. These include inflammatory bowel disease, rheumatoid arthritis, paraproteinaemia, or hematologic malignancy, which can be found in up to 50% of patients with some variants of PG. Brunsting et al (Arch Dermatol 1930;22:655-80) first described PG as a disease entity in 5 patients who had painful, enlarging necrotic ulcers with bluish undermined borders surrounded by advancing zones of erythema. Four of these patients had chronic ulcerative colitis. They felt that the condition might be associated with bacterial infection (pyoderma) and considered it as linked to the underlying bowel disease. Although the cause of PG remains obscure, bacterial infection seems to be unrelated to its causation, rendering the term pyoderma redundant. In addition, the number of conditions reported in association with PG has markedly expanded in recent years, showing clearly that this is not solely a cutaneous manifestation of inflammatory bowel disease. The clinical concept of PG has also been broadened, and certain clinical variants of PG have been linked with different types of associated disease seen in these patients.

FK506 promotes melanocyte and melanoblast growth and creates a favourable milieu for cell migration via keratinocytes: possible mechanisms of how tacrolimus ointment induces repigmentation in patients with vitiligo

BACKGROUND

Vitiligo is an acquired pigmentary disorder characterized by depigmentation of skin and hair. As the pathogenesis of this disease is still obscure, the treatment of vitiligo has generally been unsatisfactory and often disappointing. Topical tacrolimus (FK506) ointment has recently been added to the armamentarium against this pigmentary disorder. Despite its clinical efficacy, the underlying mechanisms of how topical tacrolimus induces repigmentation in vitiligo have rarely been investigated. As tacrolimus ointment is applied directly to the skin, its impact on keratinocytes (KCs) requires thorough investigation.

OBJECTIVES

To investigate the effects of FK506 on melanocyte (MC) and melanoblast (MB) growth via KCs.

METHODS

Cultured MCs and MBs were treated with supernatant of KC cultures conditioned with various concentrations of FK506. The impact of supernatant on MCs and MBs was assessed in terms of its effect on MC/MB proliferation, melanin formation and cell migration. The activities of matrix metalloproteinase (MMP)-2 and MMP-9, known for their influence on cell migration, were evaluated. The concentrations of MC/MB growth factors in the KC supernatant were also determined.

RESULTS

Results demonstrated that proliferation of both MCs and MBs was significantly enhanced by FK506-treated KC supernatant. In addition, the concentration of stem cell factor in KC supernatant increased dose-dependently with FK506 treatment. The supernatant from FK506-treated KC culture showed a significant increase in MMP-9 activity.

CONCLUSIONS

Our study provides in vitro evidence demonstrating that direct interaction between FK506 and KCs creates a favourable milieu for MC growth and migration. Furthermore, our findings provide a possible mechanism explaining how tacrolimus ointment induces repigmentation in patients with vitiligo.

Efficacy of cyclosporin in the treatment of atopic dermatitis in dogs--combined results from two veterinary dermatology referral centres

OBJECTIVE

To evaluate the efficacy of cyclosporin in controlling the clinical signs associated with atopic dermatitis in dogs under Australian field conditions.

DESIGN

A multicentre prospective clinical investigation of the use of cyclosporin in 41 dogs with atopic dermatitis.

PROCEDURE

Dogs were treated with cyclosporin (5 mg/kg orally once daily with food) for 6 weeks. Four clinical parameters of severity of atopic dermatitis were measured on Day 0 and on Day 42 using a 0 to 4 scoring system. Individual variables were then combined to form a Global Score. Both client and clinician observed pruritus scores were combined to form a Pruritus Score. Pre- and post-treatment scores were statistically analysed. The difference in results between the two investigators was also recorded and analysed.

RESULTS

All dogs showed a marked reduction in pruritus and erythema during the 6-week treatment period. All dogs showed a significant (P < 0.001) improvement in clinical lesion scores and Global Score (P < 0.001). The mean percentage improvement in Global Score from Day 0 to Day 42 was 83.9%. The mean percentage improvement in Pruritus Score from Day 0 to Day 42 was 83%. The medication was well tolerated. Side effects such as vomiting, diarrhoea and soft stools were observed in four dogs. Another four dogs developed bacterial pyoderma during the trial period. There was no significant difference in results between the two centres.

CONCLUSION

Cyclosporin was well tolerated and efficacious in the symptomatic treatment of atopic dermatitis in dogs attending two veterinary dermatology referral centres in Australia, under Australian field conditions, when administered at 5 mg/kg/day for 6 weeks.

Effects of cyclosporine A on clinical and histologic abnormalities in dogs with sebaceous adenitis

OBJECTIVE

To evaluate the effects of cyclosporine A in the treatment of sebaceous adenitis in dogs.

DESIGN

Open-label clinical trial.

ANIMALS

12 dogs with sebaceous adenitis.

PROCEDURE

Dogs were treated with cyclosporine A at a dosage of 5 mg/kg/d (2.3 mg/lb/d), PO, for 12 months and reevaluated every 4 months. A clinical score was calculated by grading the extent of alopecia and severity of follicular casts as absent, mild, moderate, or severe in each of 17 body regions. Biopsy specimens were obtained and examined histologically and by means of immunohistochemical staining.

RESULTS

Mean clinical score was significantly decreased, compared with baseline score, after 4 months of treatment and remained low after 8 and 12 months. Histologically, the severity of inflammation was significantly decreased, as were numbers of macrophages, CD3+ T cells, and major histocompatibility complex class II-expressing cells. The percentage of hair follicles with sebaceous glands increased, suggesting regeneration of sebaceous glands. Clinical signs recurred when cyclosporine administration was discontinued.

CONCLUSIONS AND CLINICAL RELEVANCE

Results suggest that administration of cyclosporine A at a dosage of 5 mg/kg/d may reduce the inflammation associated with sebaceous adenitis in dogs. Long-term treatment appears to be neccessary to control the disease.

Changing paradigms in dermatology: topical immunomodulators within a permutational paradigm for the treatment of atopic and eczematous dermatitis

The first formulation of a class of products called topical immuno modulators (TIMS) was approved for clinical use in December 2000 and released in February 2001. This product is tacrolimus in an ointment base, prescribed under the Protopic. The next TIM, pimecrolimus cream, was FDA approved in December 2001 and launched February 2002 in a cream vehicle under the Elidel. TIMs are becoming a significant component in the topical treatment paradigm for atopic dermatitis, introducing a useful alternative to, or complement for, high- and low-potency topical steroid therapy.

Optimal treatment of pyoderma gangrenosum

The optimal treatment of pyoderma gangrenosum includes a combination of local wound care and systemic medications. Oral and pulse intravenous corticosteroids have traditionally been the most commonly recommended first-line systemic therapies. Cyclosporine, with or without corticosteroids, has more recently emerged as a first-line systemic treatment. A multitude of immunosuppressive and immune-modulating medications, as well as antimicrobial agents with anti-inflammatory properties have also been widely prescribed. Often, it is difficult to achieve control of aggressive cases of pyoderma gangrenosum, necessitating administration of a combination of systemic therapies. Furthermore, patients recalcitrant to one or many medications are frequently reported. Concomitant disease, intolerance to a class of medications, and the patient's response to prior therapies can help guide a practitioner in choosing the optimal treatment of pyoderma gangrenosum.

Hypopigmentary Skin Disorders

Alterations of skin and hair pigmentation are important features that have warranted treatment from ancient history on up to modern time. In some cultures, even today patients with vitiligo are regarded as social outcasts and are affected considerably both emotionally and physically. This article presents current options and future directions for the treatment of hypopigmentary disorders. Whereas with congenital disorders, such as albinism and phenylketonuria, no causal therapy has been established up to now, several treatment options for acquired hypopigmentary disorders have been investigated. In particular, in vitiligo, one of the most prevalent hypopigmentary disorders, a number of treatment modalities have been employed in the past 30 years. However, most of them are only able to palliate, not cure, the disease. Depending on the distribution of the hypopigmented lesions (localised or generalised) and the state of the disease (active or stable), several therapeutic options, for example phototherapy, surgical skin grafts, autologous melanocyte transplantation and immunomodulators, can be applied alone or in combination. For phototherapy, because of unfavourable results and adverse effects, ultraviolet (UV) A has been largely replaced by narrow-band UVB for repigmentation of generalised vitiligo. Although immunomodulators, such as corticosteroids, have been used both topically and systemically over the past 3 decades for the treatment of disseminated vitiligo, they are only suitable for the treatment of acrofacial and localised forms because of adverse effects. Hence, new immunomodulatory agents, such as calcineurin antagonists, have recently been introduced as new promising tools to treat acquired hypopigmentary disorders. However, all therapeutic approaches are hampered by the fact that the pathophysiology of hypopigmentary disorders is still poorly understood.

Review of the pharmacokinetics, interactions and adverse reactions of cyclosporine in people, dogs and cats

Cyclosporine is being increasingly used in veterinary medicine. Oral formulations of the drug have found many therapeutic uses, but topical formulations have met with only limited success, probably owing to their poor penetration through the stratum corneum. The concurrent use of ketoconazole to inhibit cyclosporine metabolism has been shown to reduce the required dose and hence the cost of cyclosporine therapy. In human medicine, adverse reactions to the drug, especially nephrotoxicity, are common but in dogs given the commonly used oral dose of 5 mg/kg per day there have been few adverse reactions. However, no toxicity studies lasting longer than 12 months have been carried out in this species. This paper reviews the pharmacokinetics, drug and procedural interactions, contraindications and the adverse reactions to cyclosporine, with particular reference to its use in the treatment of dermatological conditions in dogs, cats and people.

Cyclosporin: applications in small animal dermatology

Cyclosporin has been increasingly used for the treatment of skin diseases in small animals. Reported uses include the treatment of atopy, cutaneous lupus erythematosus, feline acquired alopecia resembling pseudopelade of humans, pemphigus erythematosus, pemphigus foliaceus, perianal fistulae and sebaceous adenitis. In addition, cyclosporin has been used anecdotally for several other skin diseases. Few side effects have been noted at doses therapeutic for dermatologic diseases. Current suggestions for monitoring, and the value of trough cyclosporin serum concentrations for prediction of toxicity and efficacy are discussed.

Practical management of psoriasis in the elderly: epidemiology, clinical aspects, quality of life, patient education and treatment options

Psoriasis in the elderly will constitute a significant challenge for the practising physician in this new millennium. Special considerations for the elderly include drug-induced or drug-aggravated psoriasis, especially for patients receiving polypharmacy or with recent worsening or poor response to conventional therapy. Other frequently encountered forms of psoriasis in the elderly include psoriatic arthritis and its complications, inverse psoriasis and potentially life-threatening complications such as erythrodermic or acute pustular psoriasis, where early recognition and systemic therapy is critical. Faced with an array of topical and systemic drug therapy options, it is of paramount importance that the physician remains focused on the holistic management of the patient, in order to achieve optimal compliance and benefit. This can be achieved through careful attention to quality-of-life issues, especially since many elderly patients may have other medical, social and economic comorbidities that can further negatively affect their overall quality of life. It is also essential that the severity of psoriasis be assessed on a more balanced, holistic scale that incorporates both physical and psychological parameters, such as the Salford Psoriasis Index. The patient and caregiver education should be multi-faceted, regularly conducted and practically orientated. Treatment goals should be kept simple and individualised for each patient, based on concomitant comorbidities, potential adverse effects, existing quality of life, self-care capability, drug history, caregiver situation, financial needs, feasibility for follow-up and patient's preferences. Topically applied medications, such as topical corticosteroids, salicylic acid, tar and dithranol preparations, calcipotriol and tazarotene, are the favoured first-line therapeutic options in the elderly. Narrowband ultraviolet B phototherapy is also well established as a standard therapy for psoriasis. Systemic therapy with agents such as methotrexate, acitretin and cyclosporin should be judiciously reserved for severe, extensive cases in view of their lower therapeutic index in the elderly. The ambulatory psoriasis treatment centre is an integral part of the overall cost-effective management of patients with psoriasis that can function as a 'one-stop' treatment and resource centre for the elderly patient.

Important drug interactions and reactions in dermatology

A constantly expanding pharmacological armamentarium increases the concern for serious drug interactions. This article discusses drug metabolism and how the cytochrome P-450 family facilitates drug biotransformation. Clinically significant drug interactions involving antifungal drugs, antibiotics, retinoids, and immunosuppressive agents, as well as topical anesthetics and various foods, are included.

Novel therapies for psoriasis

The T cell-driven immunopathogenesis of psoriasis has been well recognized since cyclosporine first revolutionized the treatment of psoriasis 20 years ago. Almost all investigative and clinical research subsequently, has concentrated on elucidating the specifics of antigen presentation, T cell interaction and the production of specific cytokines. The role of the keratinocyte, previously thought to be the primary target cell in psoriasis pathogenesis, has been relegated to a secondary role and the mechanism of action of systemic methotrexate in psoriasis has been challenged, the primary role of the T lymphocyte is now well known. While psoriasis has traditionally been treated "ab initio" with topical medications (corticosteroids, vitamin D(3), and retinoid derivatives), either singly, in combination, or with ultraviolet B (UVB) or psoralens and ultraviolet A (PUVA) therapy, the role of systemic medications has assumed greater prominence. Thus, three systemic medications currently are approved worldwide for the treatment of moderate to severe forms of psoriasis, namely cyclosporine, methotrexate and acitretin. The first two are likely to give significant clearing (greater than 75%) in the majority of cases, whereas acitretin is significantly less effective as monotherapy, but may approach methotrexate and cyclosporine in efficacy, if combined with PUVA or UVB phototherapy. The main limitations of these three drugs remain organ toxicity, especially hepatic toxicity with methotrexate, hypertension and nephrotoxicity with cyclosporine, and teratogenicity and mucocutaneous toxicity with acitretin. Thus, the need for more specific systemic therapy, targeting the T lymphocyte. This has become the major area of clinical research interest over the past 5 years, with the promise of longer-term disease control (improved remissions) and less organ toxicities. Currently, there are over 15 of these "biologic" drugs in various stages of development and clinical trials, either by the subcutaneous, intramuscular or intravenous route. The three main variables are the rapidity of onset, percentages of improvement and remission rates. Without exception, these new systemic agents appear to be remarkably free of systemic organ toxicities (liver, renal, bone-marrow, etc.), with adverse effects being limited to mild flu-like symptoms with the anticipated increase in infections (e.g., herpes simplex) being either equal to placebo or only marginally increased. Not all these agents under evaluation give clinical responses equal to methotrexate or cyclosporine (75% or greater clearing in 75% of cases). In addition, response rates may be slower with some therapies versus others. However, the need for intermittent administration even by the injectable route, longer remissions, lack of systemic organ toxicities and the potential for safer usage in females of child-bearing age, make a compelling argument for widespread acceptance by both patients and the dermatological community. Other modalities under clinical evaluation include vitamin D and retinoid drugs, topically and systemically, with effects on nuclear receptors, as well as more specific wavelengths (308 to 311 nm) of UVB phototherapy with application for more localized forms of psoriasis. For the 2 to 3% of the worldwide population of patients with psoriasis the future has never looked brighter.

Sweet's syndrome: a review of current treatment options

Sweet's syndrome was originally described in 1964 by Dr Robert Douglas Sweet as an 'acute febrile neutrophilic dermatosis'. The syndrome is characterized by pyrexia, elevated neutrophil count, painful red papules, nodules, plaques (which may be recurrent) and an infiltrate consisting predominantly of mature neutrophils that are diffusely distributed in the upper dermis. In addition to skin and mucosal lesions, Sweet's syndrome can also present with extra-cutaneous manifestations. Sweet's syndrome can be classified based upon the clinical setting in which it occurs: classical or idiopathic Sweet's syndrome, malignancy-associated Sweet's syndrome and drug-induced Sweet's syndrome. Systemic corticosteroids have been considered the 'gold standard' for the treatment of patients with Sweet's syndrome; in addition, treatment with topical and/or intralesional corticosteroids may be effective as either monotherapy or adjuvant therapy. However, spontaneous resolution of the symptoms and lesions has occurred in several patients with Sweet's syndrome for whom disease-specific therapeutic intervention was not initiated and in some of the patients with drug-induced Sweet's syndrome after withdrawal of the dermatosis-causing medication. Oral therapy with either potassium iodide or colchicine typically results in rapid resolution of Sweet's syndrome symptoms and lesions; therefore, in patients with Sweet's syndrome who have a potential systemic infection or in whom corticosteroids are contraindicated, it is reasonable to initiate treatment with these agents as a first-line therapy. Indomethacin, clofazimine, dapsone, and cyclosporine have also been effective therapeutic agents for managing Sweet's syndrome. However, indomethacin and clofazimine appear less effective than corticosteroids, potassium iodide, and colchicine. Appropriate initial and follow-up laboratory monitoring is necessary when treating with either dapsone or cyclosporine because of the potential for severe adverse drug-associated effects. Systemic antibacterials with activity against Staphylococcus aureus frequently result in partial improvement of Sweet's syndrome lesions when they are impetiginized or secondarily infected. In some patients with dermatosis-associated bacterial infections, organism-sensitive specific systemic antibacterials have been helpful in the management of their Sweet's syndrome. Although patients with hematologic malignancy-associated Sweet's syndrome often receive cytotoxic chemotherapy agents and antimetabolic drugs for the treatment of their underlying disorder, these agents are seldom used solely for the management of the symptoms and lesions of Sweet's syndrome. The treatment of patients with Sweet's syndrome with either etretinate or interferon-alpha have been reported as single case reports; both patients had improvement of not only their Sweet's syndrome lesions, but also their associated hematologic disorder.

Safety of the new macrolide immunomodulators

With the wide acceptance of cyclosporine in the treatment of skin disease, there has been an effort to find new immunomodulating agents with superior safety profiles for use in dermatology. Among the most promising of the classes are the new macrolide immunomodulators, including tacrolimus and pimecrolimus. Of these, only tocrolimus has had widespread use for nondermatologic indications, primarily solid organ transplantation. Both of these agents have been studied for inflammatory diseases of the skin. In this article, we review the systemic and topical toxicities of these macrolide immunomodulators.