Severe refractory chronic actinic dermatitis successfully treated with tacrolimus ointment

Chronic actinic dermatitis with leonine facies and iatrogenic adrenal insufficiency successfully treated with topical tacrolimus

Chronic actinic dermatitis is a chronic photosensitivity disorder characterized by severe eczematous lesions on sun-exposed skin areas. We report a case of chronic actinic dermatitis presenting with leonine facies and secondary adrenal insufficiency, which was successfully treated with topical tacrolimus. The facial lesions dramatically improved after sun avoidance and topical tacrolimus application. After almost 20 years of oral corticosteroid therapy complicated with secondary adrenal insufficiency, we were able to switch treatment from systemic corticosteroids to topical tacrolimus to control the patient's symptoms.

[Chronic actinic dermatitis: treatment with topical tacrolimus (two cases)]

BACKGROUND

Chronic actinic dermatitis is usually controlled under systemic immunosuppressive drugs. We report herein two patients successfully treated with topical tacrolimus.

CASE REPORTS

Two men aged 60 and 70 years were treated for chronic actinic dermatitis for two years using systemic immunosuppressive drugs. Due to drug intolerance and treatment resistance, systemic treatment was substituted by topical tacrolimus. Cutaneous lesions improved dramatically within two months but withdrawal of daily application was immediately followed by recurrence of the lesions.

DISCUSSION

Our cases, together with the 10 others reported in the literature, confirm the efficacy of topical tacrolimus in the treatment of chronic actinic dermatitis. Since tacrolimus chiefly targets activated T lymphocytes, it has been successfully deployed in various inflammatory dermatoses and its use is logical in the treatment of chronic actinic dermatitis. While dramatic improvement is achieved within a few weeks in this indication with twice-daily applications of tacrolimus ointment 0.1%, symptoms recur rapidly on dosage reduction, and extremely long-term, or even lifelong, treatment is thus probably needed. Topical tacrolimus application has been shown to be safe for periods of three years. However, the peculiar mechanism of chronic actinic dermatitis with a pronounced imbalance in T-cell subsets raises the question of theoretical risk of carcinogenicity of tacrolimus applications, and this, together with the prolonged duration of treatment, calls for long-term follow-up of chronic actinic dermatitis patients.

Successful Treatment of Nodular Actinic Reticuloid with Tacrolimus Ointment

Actinic reticuloid (AR) is the severest clinical variant of chronic actinic dermatitis (CAD) and describes a persistent photoinduced skin disorder often associated with delayed-type hypersensitivity reactions. Histopathologically, AR resembles pseudolymphoma and may also show features of cutaneous lymphoma. In contrast to other UV-induced skin diseases, AR patients show persistent photosensitivity to UV radiation and visible light parallel to permanent changes of skin texture with infiltrated papules and thickened plaques. Therapeutically, CAD is a problematic condition. Daily application of sun protection has to be combined with local or systemic immunosuppression. However, various therapeutic approaches including systemic corticosteroids and other systemic immunosuppressive agents are limited by severe side effects. Tacrolimus, a Streptomyces-derived immunosuppressive macrolide antibiotic and inhibitor of calcineurin, has been proven successful in various inflammatory skin diseases including atopic eczema, allergic contact dermatitis and photodermatoses without undesired side effects. We present a case of severe recalcitrant and nodular chronic actinic dermatitis responding to topically applied tacrolimus (Protopic). To avoid further relapses we continued this therapy twice a day over a period of 2 years.

A case of chronic actinic dermatitis treated with topical tacrolimus

INTRODUCTION

The treatment of chronic actinic dermatitis (CAD), a sun-induced disorder characterized by a persistent eczematous eruption, involves photoprotective measures, topical corticosteroid therapy and, in more severe cases, systemic immunosuppression. The potential side effects of systemic immunosuppressant drugs prompted us to evaluate the efficacy of topical tacrolimus for treatment of CAD. PATIENT AND TREATMENT: A 58-year-old man with CAD, resistant to previous treatment with topical and systemic corticosteroids, oral cyclosporine and PUVA-photochemotherapy, was treated with tacrolimus ointment 0.1% once a day.

RESULTS

Tacrolimus ointment led to significant improvement of pruritus and severe eczematous skin lesions after 20 days of treatment.

CONCLUSIONS

Tacrolimus shows a beneficial effect on CAD; this could be attributed to the fact that CAD is characterized by a lymphohistiocytic infiltrate producing a chronic eczema and that tacrolimus blocks the activation of lymphocytes and other immune system cells, also inhibiting the release of mediators from cutaneous mast cells and basophils.

Successful Treatment of Recalcitrant Chronic Actinic Dermatitis with Tacrolimus

Therapeutically, chronic actinic dermatitis is a problematic condition. Frequently applied sunscreen usually fails to mitigate the clinical symptoms, and steroids--while efficient--exert many undesired side-effects with prolonged usage. We present a case of chronic actinic dermatitis responding well to topically applied tacrolimus (Protopic) in combination with chemical and physical UV protection.

Chronic actinic dermatitis: A retrospective analysis of 44 cases referred to an Australian photobiology clinic

A retrospective study was performed to analyse the clinical and photobiological features and therapeutic outcomes of 44 patients with chronic actinic dermatitis who were evaluated over an 8.3-year period. The study population comprised 37 men and seven women with a mean age of 62.7 years (range 26-85 years). The most common abnormal phototest results were decreased minimal erythema doses to both UVA and -B (73.8%), and to UVA alone (14.3%). Twenty-six patients (78.8%) had at least one allergic, photoallergic or combined allergic/photoallergic reaction. A total of 139 positive contact or photocontact reactions were recorded (mean 4.2 per patient). Most commonly, treatment consisted of photoprotection, topical corticosteroids and episodic use of systemic agents, in particular azathioprine.