Successful treatment with topical tacrolimus for oral psoriasis

Safety and Efficacy of Topical Calcineurin Inhibitors in the Treatment of Facial and Genital Psoriasis: A Systematic Review

Facial and genital psoriasis impairs quality of life and is challenging to treat because of increased percutaneous penetration and, consequently, increased risk of adverse effects. Topical calcineurin inhibitors are recognized as a valid off-label treatment for these sensitive skin areas, but data on safety and efficacy are limited. This systematic review of the literature included 24 of 3,322 studies (5 randomized controlled trials, 9 open-label studies, 2 case series and 8 case reports). All studies demonstrated positive efficacy; 11 studies found statistically significant reductions in psoriasis severity. Local stinging, burning and itching were the most common short-term adverse effects and were reported in 18 studies. Topical calcineurin inhibitors appear to have an important role in the treatment of facial and genital psoriasis. The drugs are effective and generally well-tolerated with few adverse effects.

Tacrolimus for the management of psoriasis: clinical utility and place in therapy

Psoriasis affects 1%-3% of the population in the United Kingdom and can convey significant detriment to the physical and mental health of sufferers. Plaques of psoriasis typically affect the extensor skin surfaces and scalp. Less frequently inverse psoriasis can affect more sensitive skin such as the face, genitals, and intertriginous areas. Psoriasis is incurable, but there are a range of treatment modalities that can be used to manage the condition. Treatment options include topical preparations, phototherapy, systemic therapy, and biological agents. Tacrolimus is a macrolide calcineurin inhibitor licensed for immunosuppression in transplant patients and topical administration in atopic dermatitis. Tacrolimus administered orally and in topical form has been shown to produce successful outcomes in patients with psoriasis. Topical tacrolimus is particularly effective for inverse psoriasis, which is likely to be due to the reduced level of induration seen in these psoriatic lesions, which allows greater skin penetrance, compared with hyperkeratotic plaques of psoriasis on the body. It is also notable that the areas affected by inverse psoriasis are more susceptible to adverse effects of topical corticosteroid therapy, and thus a topical preparation without the risk of skin atrophy, telangiectasia, and striae could be a valuable addition to current topical treatment options. Oral tacrolimus has shown efficacy in the treatment of severe, refractory psoriasis. Compared to ciclosporin, systemic tacrolimus may be more suited to a patient population with increased cardiovascular risk. This review will draw together the current literature on topical and oral tacrolimus for the treatment of psoriasis. Efficacy and safety have been evaluated by case reports and randomized controlled trials and comparisons have been made between tacrolimus therapy and standard treatment.

Oral Psoriasis: An Overlooked Enigma

Although cutaneous psoriasis is common, the existence of its manifestations in the oral cavity has been questioned. The definitive diagnosis of oral psoriasis can be challenging due to the variability of presentations, and overlapping clinical and histological features with a number of other conditions as well as the lack of consensus. We review oral psoriasis, noting its variable clinical appearance, delineate the differential diagnosis, and discuss management strategies.

Efficacy of topical calcineurin inhibitors in psoriasis

BACKGROUND

Topical calcineurin inhibitors (tacrolimus and pimecrolimus) are indicated for the treatment of atopic dermatitis but have also been studied in the treatment of psoriasis.

OBJECTIVE

To define the efficacy of topical calcineurin inhibitors in the treatment of psoriasis.

METHODS

We searched for English-language articles published since 1990 in PubMed, Ovid/Cochrane, and Embase using "tacrolimus," "pimecrolimus," or "topical calcineurin inhibitors" and "psoriasis."

RESULTS

Nine double-blind and 13 open studies demonstrated the efficacy of topical tacrolimus in psoriasis, especially for facial, genital, and intertrigious psoriasis, and four double-blind and one open study demonstrated the efficacy of topical pimecrolimus.

CONCLUSIONS

The evidence (double-blind and open studies) is strong that topical tacrolimus and, to a lesser extent, pimecrolimus have efficacy in the treatment of psoriasis. Since these agents do not cause cutaneous atrophy, they likely have a special role in facial, genital, and intertriginous psoriasis. Further studies would help define their roles in psoriasis.

Calcineurin inhibitors suppress cytokine production from memory T cells and differentiation of naïve T cells into cytokine-producing mature T cells

T cells have been classified as belonging to the Th1 or Th2 subsets according to the production of defining cytokines such as IFN-γ and IL-4. The discovery of the Th17 lineage and regulatory T cells shifted the simple concept of the Th1/Th2 balance into a 4-way mechanistic pathway of local and systemic immunological activity. Clinically, the blockage of cytokine signals or non-specific suppression of cytokine predominance by immunosuppressants is the first-line treatment for inflammatory T cell-mediated disorders. Cyclosporine A (CsA) and Tacrolimus (Tac) are commonly used immunosuppressants for the treatment of autoimmune disease, psoriasis, and atopic disorders. Many studies have shown that these compounds suppress the activation of the calcium-dependent phosphatase calcineurin, thereby inhibiting T-cell activation. Although CsA and Tac are frequently utilized, their pharmacological mechanisms have not yet been fully elucidated.

In the present study, we focused on the effects of CsA and Tac on cytokine secretion from purified human memory CD4⁺T cells and the differentiation of naïve T cells into cytokine-producing memory T cells. CsA or Tac significantly inhibited IFN-γ, IL-4, and IL-17 production from memory T cells. These compounds also inhibited T cell differentiation into the Th1, Th2, and Th17 subsets, even when used at a low concentration. This study provided critical information regarding the clinical efficacies of CsA and Tac as immunosuppressants.

Topical immunomodulators for management of oral mucosal conditions, a systematic review; part I: calcineurin inhibitors

IMPORTANCE OF THE FIELD

Topical immunomodulators have been used for the management of oral mucosal diseases. Topical immunomodulating preparations may have utility in local management of oral disease which is resistant to topical steroids and oral findings of an immunologic-mediated systemic disease with primary or persisting, oral mucosal involvement.

AREAS COVERED IN THIS REVIEW

This paper is the first part of a systematic review of topical immunomodulators for the management of various oral indications focused on calcineurin inhibitors. The literature search revealed that data are available for cyclosporine, tacrolimus and pimecrolimus. In addition to the review of scientific evidence, this paper presents the potential market, the mechanism of action, the competitive environment and future development options.

WHAT THE READER WILL GAIN

The reader will find weighted conclusions for the topical use of the calcineurin inhibitors in the management of oral diseases.

TAKE HOME MESSAGE

Topical calcineurin inhibitors may be useful as a second-line treatment in several oral diseases, particularly oral lichen planus.

Management of childhood psoriasis

Treating children with psoriasis represents one of the most rewarding yet constantly challenging endeavors in dermatology. These patients require time, energy, enthusiasm, empathy, and current, comprehensive knowledge of the unique clinical presentations in children and available therapies, including clinical action spectrum, mechanism of action, potential toxicity, and monitoring. Longitudinal trials examining the epidemiology and natural history of psoriasis, as well as the safety and efficacy of current and emerging treatments, are desperately needed in the pediatric population. Partner with the patient, family, and other multidisciplinary providers to form an educational and therapeutic alliance. Early in the course of disease, schedule frequent visits for reinforcement of the therapeutic plan, education, clinical and treatment monitoring, and support. As the disease and the patient's physical, psychosocial and emotional level of functioning evolve, so too will the requirement for follow-up and monitoring. Patient advocacy and education groups, such as the National Psoriasis Foundation (www.psoriasis.org; 800-723-9166) are excellent resources and can serve as an extension of your comprehensive care.