[FK 506 ointment 0.1 % - A new therapeutic option for atopic blepharitis. Clinical trial with 14 patients]

Therapeutic effects of topical 0.03% Tacrolimus ointment in children with refractory vernal keratoconjunctivitis in Middle East

OBJECTIVE

The purpose of this paper is to review the efficacy and safety profile in children treated with topical 0.03% Tacrolimus ointment for vernal keratoconjunctivitis in Middle East and to propose a treatment posology. According to recent studies, a complex non-IgE dependent mechanism plays a relevant role in the pathogenesis of vernal keratoconjunctivitis. Numerous cells and mediators have been found in the serum, conjunctiva and tears of patients with Vernal keratoconjunctivitis.

DESIGN

This case series included 10 patients from a single centre, pediatric department of a tertiary hospital with active symptomatic vernal keratoconjunctivitis. All the patients had proliferative lesions and corneal involvement despite conventional medications, including topical steroids. All other medications, systemic and topical: steroids, antihistamines and cyclosporine, were unsuccessful. Patients were treated with topical 0.03% Tacrolimus ointment twice daily for 8 weeks and then once a day for the next two month followed by thrice a week for two months. The changes in symptoms and signs after treatment were evaluated, also the development of possible complications was assessed.

RESULTS

The results showed a significant reduction in signs and symptoms after 4 weeks of the treatment. Clinical resolution of giant papillae and corneal lesions were seen within eight weeks and no additional drug was required during that period, except tear substitutes. Treatment was continued for period of two months and then slowly reduced.

CONCLUSION

The use of 0.03% Tacrolimus ointment is safe and effective in children refractory to conventional treatment of vernal keratoconjunctivitis even in high temperature climate as Middle East. Due to the effectiveness of the treatment, the dosage used may be proposed for conventional use.

[Ocular involvement in atopic dermatitis : Clinical aspects and therapy]

Patients with atopic dermatitis frequently complain of ocular symptoms. The general dermatitis can directly affect the periocular skin and patients often present with chronic atopic blepharokeratoconjunctivitis. Early diagnosis of the characteristic ophthalmological alterations, such as blepharitis, allergic conjunctivitis, keratoconjunctivitis sicca, conjunctival scarring with formation of symblepharon and lid malpositioning, filiform keratitis, corneal plaques, (persistent) epithelial defects, corneal ulcers and keratoconus as well as appropriate stage-adapted treatment, including lid hygiene with preservative-free lubricants, topical and sometimes systemic anti-inflammatory therapy and surgical treatment are important for patients to prevent long-term damage of the ocular surface leading to severe visual impairment.

Long-term use of 0.003% tacrolimus suspension for treatment of vernal keratoconjunctivitis

PURPOSE:

To evaluate the safety and efficacy of 0.003% tacrolimus suspension for the treatment of refractory vernal keratoconjunctivitis (VKC).

MATERIALS AND METHODS:

This prospective study included 40 eyes of 20 patients with severe VKC. After discontinuing all other medications, patients were treated with varying doses of 0.003% tacrolimus suspension. All were followed for at least 24 months. Changes in signs and symptoms after treatment were evaluated; adverse events were assessed. The clinical response to the treatment was the most important measurement to achieve the conclusion.

RESULTS:

The mean age of the patients was 15.7 ± 1.4 years. Two patients discontinued treatment due to severe burning sensation and were excluded from the study. Significant improvements in all signs and symptoms, including itching, foreign body sensation, papillae, and Trantas dots, were seen in all patients 6 weeks after starting topical tacrolimus. Itching was the first symptom to improve. Treatment was gradually reduced, and intervals were increasing between applications. Recurrence occurred in all patients who attempted to discontinue treatment. No additional medications were required to provide relief, and no significant changes in visual acuity or refraction were seen.

CONCLUSIONS:

The safety and efficacy of 0.003% Tacrolimus suspension treatment for refractory VKC were achieved and it can be considered a useful option instead of steroids, despite the poor compliance in few patients due its adverse effects.

[Treatment options for chronic blepharitis considering current evidence]

The goal of the treatment of chronic blepharitis lies in the reduction of inflammation, which can be achieved by warming, mechanical, and immunomodulatory measures as well as acaricide medication in cases with pathogenetically relevant demodicosis.

Tacrolimus Ointment for Treatment of Vernal Keratoconjunctivitis

Purpose:

To evaluate the safety and efficacy of tacrolimus 0.1% ointment for the treatment of refractory vernal keratoconjunctivitis (VKC).

Materials and Methods:

This prospective, nonrandomized case series enrolled 20 patients (40 eyes) with severe VKC, who were treated with tacrolimus 0.1% ointment. The mean age of the patients was 18.25 ± 4.2 years (range, 9–31 years). Each patient completed a follow-up period of at least 24 months. The main outcome measure was the clinical response to treatment.

Results:

Significant improvements in clinical signs and symptoms were achieved in all patients 6 weeks after starting treatment with topical tacrolimus. Treatment was gradually reduced, with increasing intervals between applications. VKC recurred in all patients who attempted to discontinue treatment. No additional medications were required and no significant changes in visual acuity or refraction were documented. Five patients discontinued treatment due to a severe burning sensation and were excluded from the study.

Conclusions:

Tacrolimus, 0.1% ointment, is a safe and effective treatment for VKC refractory to standard treatment and may be used as a substitute for steroid treatments used to controlled disease activity. However, adverse effects could cause poor patient compliance.

Therapeutic effect of 0.1% Tacrolimus Eye Ointment in Allergic Ocular Diseases

INTRODUCTION

Allergic Ocular Diseases (AODs) like Atopic Keratoconjunctivitis (AKC) and Vernal Keratoconjunctivitis (VKC) are chronic forms of ocular allergy that can cause severe visual complications. Pathogenesis of AODs is uncertain and treatment has been a challenge for ophthalmologists. Tacrolimus, a 23-member cyclic macrolide lactone derived from [streptomyces tsukubaensis] now in ointment form has been successfully used in AODs.

AIM

To study the therapeutic effect of 0.1% Tacrolimus eye ointment in patients with Allergic Ocular Diseases (AODs).

MATERIALS AND METHODS

This prospective observational study was conducted on 36 patients with severe AOD and moderate cases not responding to conventional treatment. They were treated with 0.1% tacrolimus eye ointment twice daily for minimum three months in addition to conventional treatment and observed for a period of 6 months. Symptoms and signs after treatment were evaluated. Grades of clinical signs were assessed based on slit lamp clinical photographs; development of possible complications was assessed and analysed by Wilcoxon signed rank test.

RESULTS

Mean age of patients was 9.3±4.3 years and mean duration of AODs was 3.1±1.8 years. The scores on both the four point scales for signs and symptoms decreased significantly (p<0.0001) after 1 month of 0.1% Tacrolimus eye ointment treatment. Itching was the first symptom to show dramatic relief and conjunctival hyperaemia was the first sign to show improvement. 88.88% of patients were successfully weaned off topical steroids in 6 months into Tacrolimus treatment. Even in patients unresponsive to 0.1% topical Cyclosporine, symptoms and signs scores decreased significantly (p<0.0001). The most common adverse reaction was a transient burning sensation (36.11%).

CONCLUSION

Topical 0.1% Tacrolimus eye ointment was found to be a safe and effective treatment in cases of AODs and also worked as steroid sparing and replacing agent. It was also found effective in patient's refractory to topical Cyclosporine.

Long-term follow-up of tacrolimus ointment for treatment of atopic keratoconjunctivitis

PURPOSE

To evaluate the long-term clinical outcomes of 0.1% tacrolimus dermatologic ointment (Protopic) in cases of refractory atopic keratoconjunctivitis (AKC).

DESIGN

Prospective, nonrandomized, noncontrolled case series.

METHODS

Twenty-two eyes from 11 patients with severe AKC who were treated with 0.1% tacrolimus ointment were followed prospectively. The mean age of the patients was 32.27 ± 12.7 years (range, 19-61 years). Each patient completed a follow-up period of at least 48 months, during which the signs and symptoms of AKC were assessed. Changes in the total scores of signs and symptoms from baseline were recorded at each visit, and the main outcome measure was the clinical response to topical tacrolimus treatment.

RESULTS

Dramatic improvements in clinical signs and symptoms were achieved 1 week after starting topical tacrolimus treatment, and complete clinical resolution was observed in almost all patients 6 weeks after starting treatment. Treatment was gradually reduced, with increasing intervals between applications. Eight patients remained asymptomatic for up to 3 years, although recurrence occurred in 3 patients who attempted to discontinue treatment. All patients complained of a mild burning sensation upon application of the ointment. No additional medications were required to provide relief, and no patient discontinued treatment because of adverse drug effects. No drug-related ocular complications were encountered, and no significant changes in visual acuity or refraction were documented.

CONCLUSIONS

Tacrolimus dermatologic ointment is a potentially safe and effective treatment for AKC cases refractory to standard treatment and may substitute for steroid treatments aimed at controlling disease activity.

Topical 0.005% tacrolimus eye drop for refractory vernal keratoconjunctivitis

PURPOSE

To evaluate the efficacy and safety of topical 0.005% tacrolimus eye drop for treatment of refractory vernal keratoconjunctivitis (VKC).

METHODS

This prospective study included 20 eyes of 10 patients with refractory VKC, who had active symptomatic disease despite conventional medications including topical steroids. After discontinuing all other medications, patients were treated with topical 0.005% tacrolimus eye drop four times a day. Changes in subjective symptoms and objective signs after treatment were evaluated, and development of possible complications was assessed.

RESULTS

Mean age of patients was 21.3±7.4 years and mean duration of VKC was 12.1±5.8 years. After starting tacrolimus eye drop, patients were followed for a mean duration of 10.7±3.7 months (range, 6-15 months). All symptoms including itching, redness, photosensitivity, foreign body sensation, and mucus discharge improved after the treatment; itching was the first symptom to show dramatic relief. In addition, there was improvement in objective signs including conjunctival hyperaemia, conjunctival papillary hypertrophy, giant papillae, limbal hypertrophy, corneal punctate epithelial erosions, and corneal pannus; conjunctival hyperaemia was the first sign to show improvement. No patient required addition of other medications including steroids for further relief. Any attempt to discontinue tacrolimus eye drop was associated with recurrence of patients' symptoms and signs, necessitating continued use of the medication during the entire follow-up time. No ocular complication related to tacrolimus was noted.

CONCLUSION

Topical 0.005% tacrolimus eye drop seemed to be a safe and effective treatment for steroid-resistant refractory VKC; however, long-term use was needed to control the disease.

The Use of Topical Tacrolimus 0.1% Skin Ointment for Anterior Segment Conditions: A Case Series

Tacrolimus (FK 506) is a macrolactam derivative with immunomodulatory and anti-inflammatory activity. Topical tacrolimus 0.03% has been used for inflammatory conditions of the anterior segment. This article adds to the literature on the off-license application of tacrolimus ointment, by describing the safe and effective use of the higher strength of 0.1% topical tacrolimus skin ointment in four patients. To our knowledge this is the first report of topical tacrolimus 0.1% ointment applied to the conjunctival sac for the treatment of atopic keratoconjunctivitis, vernal keratoconjunctivitis and the post-operative management of trabeculectomy and graft rejection in steroid responders.

[Treatment of chronic blepharokeratoconjunctivitis with local calcineurin inhibitors]

Topical calcineurin inhibitors (cyclosporin A 1%, FK506, pimecrolimus) can be useful for treating chronic blepharokeratoconjunctivitis in addition to lid hygiene and lubricants. This treatment leads to an improvement of dry eye symptoms and reduces inflammation.

Preliminary study of the effect of FK506 nanospheric-suspension eye drops on rejection of penetrating keratoplasty

OBJECTIVE

The aim of this study was to investigate the effect of a topical FK506 nanospheric suspension in a rat model of penetrating keratoplasty.

METHODS

FK506 nanospheres were prepared by using a biodegradable poly (lactic-co-glycolic acid) copolymer (PLGA). Its distribution in the eye and blood after a single instillation was examined in rabbits. Sprague-Dawley (SD) rats received corneal heterografts and were topically treated with phosphate-buffered saline (PBS), PLGA, FK-506 0.01% (nanospheres), or dexamethasone 0.05% solutions twice a day for 28 days. Rejection index and graft-survival time were recorded and compared between the four groups. Three grafts were collected at different time points for immunohistochemical studies.

RESULTS

In the cornea, the FK-506 concentration reached its peak within 1 h of a single eye-drop instillation and then decreased by half (1667.85 +/- 611.87 ng/g) at 8 h. FK-506 cannot be detected in rabbit blood. There were significant differences in the graft-survival time between the FK-506 nanosphere group (15.09 +/- 4.81 days) and the other three groups [PBS (7.90 +/- 1.20, t = -4.594, P < 0.001), PLGA (8.44 +/- 0.88, t = - 4.074, P = 0.001) and dexamethasone (10.44 +/- 1.42, t = -2.790, P = 0.012)]. The rejected corneas in the FK506 nanosphere group showed significantly fewer CD4, CD8, CD68, CD79, vascular endothelial growth factor, ICAM, and tumor growth factor-beta(1)-positive cells than those in the other groups.

CONCLUSIONS

FK506 0.01% nanospheric-suspension eye drops delayed the occurrence of corneal allograft rejection and prolonged allograft survival time. The FK506 nanospheres may be valuable in suppressing corneal graft rejection.

Therapeutic Effects of Tacrolimus Ointment for Refractory Ocular Surface Inflammatory Diseases

PURPOSE

To investigate the therapeutic effects of topical tacrolimus ointment on refractory ocular surface inflammatory diseases.

DESIGN

Retrospective interventional consecutive case series.

PARTICIPANTS

Ten consecutive patients with severe ocular surface inflammatory diseases who were suspected to be steroid responders (elevation of intraocular pressure [IOP]) or were refractory to standard steroid therapy were studied. One patient had peripheral ulcerative keratitis with impending corneal perforation, 1 had a Mooren's ulcer, 2 had scleroperikeratitis, 5 had atopic keratoconjunctivitis, and 1 had vernal keratoconjunctivitis.

METHODS

The clinical findings and therapeutic responses after treatment with 0.02% topical tacrolimus ointment were determined by conventional ophthalmological examinations.

MAIN OUTCOME MEASURES

Resolution of the ocular surface diseases (e.g., decrease of hyperemia, ulceration, size of papillae) and IOP. The necessity to use steroids was also assessed.

RESULTS

In all cases, marked to moderate improvement was obtained, including suppression of the melting reaction of the inflamed cornea, remission of scleroperikeratitis, and reduction of a giant papilla and corneal epithelial defect in severe atopic keratoconjunctivitis. The elevated IOP was reduced in steroid responders after successful cessation of steroid therapy. No adverse side effect was noted for 2 to 26 months of continuous treatment.

CONCLUSIONS

Topical tacrolimus ointment is effective in treating refractory ocular surface inflammatory diseases and should be considered as an alternative to higher doses, steroid supplementation, or surgical intervention.

Uses and safety profile of ciclosporin in ophthalmology

Ciclosporin is a calcineurin inhibitor that acts by primarily inhibiting the action of T cells. Clinical trials in the early 1980s demonstrated that systemic ciclosporin was a promising steroid-sparing agent and was also effective in patients who are refractory to treatment with corticosteroids. However, recent years have witnessed the emergence of safer immunosuppressive agents due to the poor side-effect profile of systemic ciclosporin. Topical ciclosporin, however, has a much improved safety profile and is still used to treat a variety of ocular surface disorders including dry eye syndrome, vernal and atopic keratoconjunctivitis, severe blepharitis and high-risk corneal graft patients. This article reviews the uses and safety profile of systemic and topical ciclosporin in ophthalmology, as well as discussing alternative therapeutic agents available.

Chronische Blepharitis

Chronic blepharitis is one of the most common diseases of the eyelids, but surprisingly, it is not often recognized. Frequently, a skin disease such as seborrheic dermatitis, atopic dermatitis, or acne rosacea is the underlying cause of chronic blepharitis. Bacterial pathological lipase, cholesterylesterase production, and bacterial lipopolysaccharides are pathogenetically relevant. Only rarely do genuine bacterial infections play a role. Collarettes occur at the base of the eye lashes, and the Meibomian glands show either abundant fluid secretion or inspissated secretion with obstruction of the orifices. Chronic blepharitis can include sequelae including dry eye and corneal and lid contour changes. The basic treatment comprises attendance of the underlying dermatological disease and lid hygiene. In addition, preservative-free tear film substitutes, antibiotics, immunomodulatory agents, or even surgical intervention may become necessary.

Tacrolimus ointment vs steroid ointment for eyelid dermatitis in patients with atopic keratoconjunctivitis

AIMS

The main objective of this explorative study was to evaluate if tacrolimus ointment could be safer than corticosteroid ointment, with special reference to the intraocular pressure in the treatment of eyelid eczema in patients with atopic keratoconjunctivitis (AKC). Secondary aims were to compare the effects of the treatments on eyelid eczema and their potential impact on ocular surface inflammation.

METHODS

Tacrolimus 0.1% ointment and clobetasone butyrate 0.05% ointment were compared in a double-masked explorative crossover study. In total, 25 AKC patients were included. Each ointment was applied twice daily for 3 weeks, with 2 weeks of washout before, between, and after treatments. Efficacy was determined by eye examination and the patients' own symptom scoring. Cytology and cytokine measurements were performed on tear samples. Safety parameters were intraocular pressure, presence of bacteria and fungi, and the patients' reports of adverse events. The validity of the crossover design was explored with analysis of variance, and the effect of each medication was calculated with paired t-test and Wilcoxon paired test.

RESULTS

A total of 20 patients completed the study. Both treatments were effective in reducing signs and symptoms of eyelid eczema, with a near superior benefit for tacrolimus in terms of eczema (total skin score) signs (P=0.05). No serious adverse events occurred and interestingly, intraocular pressure was not evidently affected by either treatment.

CONCLUSION

Tacrolimus 0.1% ointment is a promising alternative therapy for eyelid eczema in AKC patients. Long-term studies are needed to further determine the value of tacrolimus in this patient group.

Lokale Immunsuppressiva nach perforierender Keratoplastik

Topical steroids are routinely used in the postoperative treatment following penetrating keratoplasty. Due to the known side effects such as steroid-response glaucoma, cataract, and surface disorders, a broader armamentarium of topical immunomodulating drugs with comparable efficacy, better tolerance and less side effects is desirable. Cyclosporine A and FK506 eye drops are a promising alternative. A new approach involves subconjunctival drug delivering implants and locally applied antiangiogenic substances, which still have to be tested in clinical studies.

Effect of 0.03% tacrolimus ointment on conjunctival cytology in patients with severe atopic blepharoconjunctivitis: a retrospective study

PURPOSE

To evaluate the efficacy and effect of tacrolimus ointment on conjunctival cytology in patients with atopic blepharoconjunctivitis or keratoconjunctivitis.

METHODS

Ten patients with severe atopic blepharoconjunctivitis treated with 0.03% tacrolimus ointment once daily as an intermittent treatment were analysed retrospectively. The main outcome measures were clinical response to topical tacrolimus, adverse events and changes in the inflammatory cells obtained from conjunctival brush samples.

RESULTS

Marked clinical responses in blepharitis and conjunctivitis symptoms were seen after a mean follow-up time of 6 weeks. Clinical scores decreased by 67% in blepharitis and 74% in conjunctivitis symptoms. No severe adverse events or signs of immunosuppression such as herpes simplex infections occurred. No significant changes occurred in visual acuity, refraction, anterior chamber, retina or intraocular pressure. Median decreases were 85% (p =0.01) in conjunctival eosinophils, 50% (p = 0.01) in neutrophils and 58% (p = 0.02) in lymphocytes.

CONCLUSIONS

Tacrolimus ointment is potentially a safe and effective treatment for atopic blepharoconjunctivitis. Regular treatment of the eyelids once daily may also lead to clinical and cytological improvement of the conjunctivitis.

Traitement d’une localisation oculaire de pemphigoïde cicatricielle par tacrolimus topique

BACKGROUND

Ocular involvement in cicatricial pemphigoid often occurs from the onset. Certain forms are seen only in this condition.

OBSERVATION

A 31-year-old woman presented highly inflammatory conjunctivitis for several months associated with bilateral symblepharons and superficial punctuate keratitis around the left eye refractory to treatment. The patient had a history of mouth ulcers and sores on the scalp. Examination showed scalp lesions with crusts. Histological examination of these lesions revealed dermal-epidermal cleavage. Direct immunofluorescence showed sub-membrane deposits. Anti-basal membrane antibodies were positive. Immunotransfer confirmed the presence of circulating antibodies. This condition was controlled following administration of three courses of cyclophosphamide as a bolus. However, the symblepharons persisted in both eyes. Improvement lasted 4 years. The patient again consulted for inflammatory conjunctivitis and superficial punctate keratitis resulting in invalidating loss of visual acuity, associated with hypereosinophilia. Cortisone eye drops alone resulted in no improvement. Treatment was initiated with topical tacrolimus (Protopic) 0.03% comprising once-daily application to the conjunctiva in the evening. This therapy was well tolerated, and 2 daily applications could be given, followed by a dosage of 0.1%. Improvement was rapid and spectacular, with frank amelioration of visual acuity and resolution of the patient's keratitis. Treatment was continued for 4 months and gradually reduced to the 0.03% dosage level, with increasingly wide intervals between applications. There has been no relapse within the 12 months following the end of treatment.

DISCUSSION

Standard treatment of pharmacological cicatricial pemphigoid involves systemic immunosuppression since topical anti-inflammatories are ineffective. The mortality associated with this disease is due to iatrogenic complications. Tacrolimus exhibits extremely good penetration of the conjunctiva. Following administration at a concentration of 0.06% 3 times daily in 15 patients with inflammatory disease of the conjunctiva or the cornea, improvement was seen in 10 of these patients at 26 weeks. Tacrolimus appears to act through immunomodulatory and anti-inflammatory mechanisms. It induces local inhibition of T lymphocyte activation and reduces production of pro-inflammatory lymphokines. Oral tacrolimus cannot be used to control cicatricial pemphigoid refractory to standard immunomodulators. However, 3 three other cases involving topical treatment of cicatricial pemphigoid showed marked efficacy of treatment given for 2 to 6 months, with complete tolerability. Thus, topical tacrolimus appears to constitute an interesting alternative treatment in cicatricial pemphigoid.

Topical tacrolimus ointment for treatment of refractory anterior segment inflammatory disorders

PURPOSE

To report 4 cases of patients treated with topical tacrolimus ointment 0.03% for ocular inflammatory conditions refractory to traditional treatment.

METHODS

Four patients were treated topically with tacrolimus 0.03% ointment twice daily: 2 patients with blepharokeratoconjunctivitis, 1 patient with severe atopic keratoconjunctivitis, and 1 patient with chronic follicular conjunctivitis.

RESULTS

Three patients had a dramatic improvement of their ocular condition as early as 2 weeks after starting tacrolimus ointment. One patient developed a herpes simplex virus dendrite after 1 week of tacrolimus use.

CONCLUSION

Tacrolimus ointment appears to be an effective alternative for certain ocular inflammatory conditions refractory to traditional treatments. There may be an increased risk of herpes simplex virus keratitis associated with topical use. Our results support previous literature of patients benefiting from topical tacrolimus use.

Immunomodulatory Therapy in Ophthalmology – Is There a Place for Topical Application?

Topical corticosteroids, although effective in the treatment of ocular immune-mediated diseases, are well known for their ocular side-effects. Not surprisingly, a variety of alternative immunomodulatory agents have been tested for topical use including cyclosporin A (CsA), mycophenolate mofetil (MMF), tacrolimus (FK506), rapamycin (sirolimus) and leflunomide. Local application bears the possibility to avoid the severe side-effects of systemic therapy. The effect of topical therapy is naturally restricted to local immune response mechanisms, such as antigen presentation by Langerhans and dendritic cells. Moreover, many immunomodulatory agents (e.g. CsA) are lipophilic and thus have low water solubility and penetrate insufficiently intra-ocularly, often being stored in the lipophilic corneal epithelial barrier. Therefore, the therapeutical success is limited for intra-ocular immune-mediated diseases like anterior uveitis. However, a multitude of strategies have been introduced to circumvent these problems including complexing substances such as cyclodextrins (CDs) and liposomes. In the prevention and treatment of transplant rejection after keratoplasty, many attempts to introduce topical immunomodulatory therapy have failed; on the other hand, further therapeutic options not primarily expected are being evaluated today such as treatment of severe keratoconjunctivitis sicca. In our own studies, we investigated the pharmacokinetics of topical treatment with different agents including MMF and evaluated the efficacy of topical treatment in animal models for uveitis and keratoplasty. Taken together, topical immunomodulatory therapy will not replace systemic therapy but further treatment options can be expected.

Treatment of Atopic Eyelid Disease Using Topical Tacrolimus Following Corticosteroid Discontinuation in a Patient With Open-Angle Glaucoma

PURPOSE

To report a case of atopic eyelid disease treatment using topical tacrolimus in a patient with open-angle glaucoma following corticosteroid discontinuation.

DESIGN

Interventional case report.

METHODS

A 59-year-old white man with a history of treated open-angle glaucoma (latanoprost 0.005%) was referred to our department for atopic eyelid disease. The patient had received previous treatment with topical corticosteroid ointments (hydrocortisone acetate 1%/dexamethasone 0.1% ointments) that, even though they were effective in controlling atopic eyelid disease, were complicated by markedly elevated intraocular pressure (IOP) (steroid responder). Topical steroids were discontinued while other treatment modalities (such as eyelid hygiene, artificial tears, topical antihistamine drugs, topical mast cell stabilizers, or topical/oral antibiotics) were proven ineffective.

RESULTS

Topical tacrolimus 0.03% ointment (Protopic; Fujisawa, Dublin, Ireland) was applied to the eyelid skin twice daily. An improvement of eyelid inflammation was observed while eczematous skin lesions and erosions were resolved within 15 days. After 6 months of continued topical tacrolimus treatment, there was no evidence of atopic dermatitis recurrence. During this period IOP remained controlled without any evidence of deregulation.

CONCLUSIONS

Treatment of atopic eyelid disease with topical tacrolimus, following corticosteroid discontinuation in a steroid responder patient with open-angle glaucoma, seems to be an effective alternative treatment to corticosteroids without the risk of IOP increase.

[Antipruritic effects of pimecrolimus and tacrolimus]

The development of topical calcineurin inhibitors resulted in a significant improvement in the treatment of inflammatory skin diseases such as atopic dermatitis. In addition, an excellent amelioration of pruritus could be observed. Other itchy dermatoses such as chronic irritative hand dermatitis, rosacea, graft-versus-host-disease, renal pruritus, lichen sclerosus, prurigo simplex, prurigo nodularis, scrotal eczema, and inverse psoriasis also have been treated successfully with pimecrolimus and tacrolimus. The antipruritic effect currently is believed to be related to the inhibition of inflammatory cytokines. Furthermore, recent investigations indicate a release of neuropeptides from sensory nerve fibers and degranulation of mast cells mediated by pimecrolimus and tacrolimus. Similar effects have been observed during capsaicin treatment. These findings may provide a possible explanation for initially observed calcineurin inhibitors related side-effects such as burning and pruritus. Moreover, the antipruritic potency may be related to a direct effect on nerve fibers leading to suppression of itch mediated by unknown mechanisms.

Topical tacrolimus treatment of atopic eyelid disease

PURPOSE

To describe the effects of topical tacrolimus treatment of severe atopic eyelid disease.

DESIGN

Interventional consecutive case series.

METHODS

A description of clinical findings and therapeutic response for five consecutive adult patients (mean age, 56.2 years; range 44-62) treated with topical tacrolimus for severe atopic eyelid disease at one institution.

RESULTS

Five patients with bilateral atopic eyelid disease that was refractory to treatment with topical corticosteroids were treated with tacrolimus 0.03% ointment, applied to the affected eyelid skin of both eyes twice daily. Eyelid induration, erythema, and eczematous changes were substantially improved within 1 to 3 weeks after initiation of topical tacrolimus treatment in all patients. There was an associated decrease in ocular surface irritation and inflammatory signs in each of four patients who also had atopic keratoconjunctivitis. No adverse effect associated with tacrolimus treatment was noted during continued treatment for 5 to 14 months. All patients were able to discontinue longstanding use of topical corticosteroid drugs.

CONCLUSIONS

Application of topical tacrolimus on eyelid skin may be effective for treatment of severe atopic dermatitis of the eyelids, and may have secondary benefits for atopic keratoconjunctivitis. Topical tacrolimus may be used for at least 1 year without apparent adverse reaction in some patients, although the rate of adverse reaction cannot be determined from this small series.