Topical tacrolimus in the treatment of atopic dermatitis

Anti-inflammatory effect of Centella asiatica phytosome in a mouse model of phthalic anhydride-induced atopic dermatitis

BACKGROUND

Centella asiatica phytosome (CA phytosome) has potent antioxidant and anti-inflammatory properties. However, its anti-dermatitic effect has not yet been reported.

PURPOSE

We investigated the effects of CA phytosome on inflammatory reponses by macrophages in an atopic dermatitis (AD) mouse model.

STUDY DESIGN

The effects of CA phytosome on atopic dermatitis were examined by using phthalic anhydride (PA)-induced AD mouse model and RAW 264.7 murine macrophages.

METHODS

An AD-like lesion was induced by a topical application of 5% phthalic anhydride (PA) to the dorsal skin or ear of HR-1 mice. After AD induction, 100 µl (20 µl/cm²) of 0.2% and 0.4% CA phytosome was spread on the dorsal skin and ear of the mice three times a week for four weeks. We evaluated histopathological changes and changes in protein expression by Western blotting for iNOS and COX-2; NF-κB activity was determined by EMSA. We also measured TNF-α, IL-1β, and IgE concentration in the blood of AD mice by ELISA.

RESULTS

Histological analysis showed that CA phytosome inhibited infiltration of inflammatory cells. CA phytosome treatment inhibited the expression of iNOS and COX-2, activity of NF-κB, and release of TNF-α, IL-1β, and IgE. In addition, CA phytosome (5, 10, and 20 µg/ml) potently inhibited LPS (1 µg/ml)-induced NO production as well as iNOS and COX-2 expression in RAW 264.7 macrophage. Furthermore, CA phytosome inhibited LPS-induced DNA binding activities of NF-κB, and this was associated with the discontinuation of IκBα degradation and subsequent decreases in the translocation of p65 and p50 into the nucleus.

CONCLUSION

From our data, CA phytosome application, which operates via NF-κB signaling inhibition, seems to be a promising AD treatment. Herein, we investigated the effects of Centella asiatica phytosome (CA phytosome) on inflammatory responses by macrophages in an atopic dermatitis (AD) mouse model. An AD-like lesion was induced by the topical application of 5% phthalic anhydride (PA) to the dorsal skin or ear of HR-1 mice. After AD induction, 100 µl (20 µl/cm²) of 0.2% and 0.4% CA phytosome was spread on the dorsal skin and ear of the mice three times a week for four weeks. We evaluated dermatitis severity, histopathological changes, and changes in protein expression by Western blotting for iNOS and COX-2; NF-κB activity was determined by gel electromobility shift assay (EMSA). We also measured TNF-α, IL-1β, and IgE concentration in the blood of AD mice by enzyme-linked immunosorbent assay (ELISA). CA phytosome attenuated the development of PA-induced AD. Histological analysis showed that CA phytosome inhibited hyperkeratosis, proliferation of mast cells, and infiltration of inflammatory cells. Furthermore, CA phytosome treatment inhibited the expression of iNOS and COX-2, activity of NF-κB, and release of TNF-α, IL-1β, and IgE. In addition, CA phytosome (5, 10, and 20 µg/ml) potently inhibited lipopolysaccharide (LPS) (1 µg/ml)-induced NO production as well as iNOS and COX-2 expression in RAW 264.7 macrophage cells. Furthermore, CA phytosome inhibited LPS-induced DNA binding activities of NF-κB, and this was associated with the discontinuation of IκBα degradation and subsequent decreases in the translocation of p65 and p50 into the nucleus. From our data, CA phytosome application, which operates via NF-κB signaling inhibition, seems to be a promising AD treatment.

Efficacy and Safety of Tacrolimus versus Pimecrolimus for the Treatment of Atopic Dermatitis in Children: A Network Meta-Analysis

OBJECTIVE

Using a network meta-analysis, we aimed to compare the efficacy and safety of tacrolimus and pimecrolimus as treatment options for children with atopic dermatitis (AD).

METHODS

Randomized controlled studies with a modified Jadad score >3 using tacrolimus or pimecrolimus in pediatric patients with AD were studied.

RESULTS

Out of 163 articles, 19 studies enrolling a total of 6,413 pediatric patients were selected. Pooled analysis revealed that tacrolimus 0.03% or 0.1% and pimecrolimus 1% were better at reducing eczema compared with vehicles. No significance was found between tacrolimus and pimecrolimus in improving the severity of eczema. More patients tended to withdraw in the vehicle groups compared to the tacrolimus and pimecrolimus groups. No significant difference existed between total adverse events and withdrawals in the tacrolimus and pimecrolimus groups.

CONCLUSIONS

Pimecrolimus was similar to tacrolimus in both efficacy and safety for AD in children, but both were better than vehicles.

Macrolide therapy in chronic inflammatory diseases

Macrolides are a group of antibiotics with a distinctive macrocyclic lactone ring combined with sugars (cladinose, desosamine). The action of macrolides is to block protein synthesis by binding to the subunit of 50S ribosome of bacteria. Prototype macrolide was erythromycin, which came into clinical practice in the 50s of the 20th century. Its antimicrobial spectrum covers the scope of the penicillins but is extended to the impact of atypical bacteria. In the 90s more drugs of this group were synthesized—they have less severe side effects than erythromycin, extended spectrum of Gram-negative bacteria. Macrolides are effective in treating mycobacterial infections especially in patients infected with HIV. It is now known that in addition to antibacterial abilities, macrolides have immunomodulatory effects—they inhibit the production of proinflammatory cytokines (TNF, IL1, 6, and 8) affect transcription factors (NF-κB) as well as costimulaton (CD 80) and adhesion molecules (ICAM). This review article focused not only on the their antimicrobial abilities but also on efficacy in the treatment of several inflammatory disorders independent of the infectious agent. Their wider use as immunomodulators requires further study, which can lead to an extension of indications for their administration.

[Pruritus and dryness of the skin in chronic kidney insufficiency and dialysis patients - a review]

The uremic pruritus is a very painful symptom suffered by chronic haemodialysis patients and is observed in 22 to 74% of the subjects. The causes of uremic pruritus have not yet been clarified. During the last 20 to 30 years it has been focused on altogether 5 different pathophysiological hypotheses: stimulating influences (e.g. calcium phosphate deposits in the epidermis), stimuli (e.g. secondary hyperparathyroidism), neuropathic injuries (e.g. disturbance of the cutaneous innervation in patients with uremic peripheral neuropathy), and central nervous changes (e.g. accumulation of endorphins in uremic patients which is associated with increasing pruritus), and immunologic conditions. The last mentioned immunological hypothesis has increasing importance, not at least based on the fact that the application of a topical calcineurin inhibitor (tacrolimus) improves the uremic pruritus. However, this fact could not be confirmed in a recent prospective placebo-controlled study from the USA. Only after kidney transplantation with a functioning transplant the uremic pruritus is stopped. That is why no causal therapy exists so far. Actually, the uremic pruritus has to be treated by topical and systemic means in a symptomatic and polypragmatic way only. Urea represents one of the most important "natural moisturizing factors" which are responsible for the hydration of the skin. It has been demonstrated that older patients have decreased urea levels within the stratum corneum of the epidermis, whereas in patients with terminal kidney insufficiency - despite dryness of the skin - as a paradox finding elevated levels of urea have been assessed in the stratum corneum. Because of this reason, the meaning of urea as part of the "natural moisturizing factors" system is not understood, until now. However, there are very promising results of clinical phase II studies showing a significant effect of topical application of 2.5% L-arginine hydrochlorid ointment - a semi-essential amino acid - on improvement of dryness and, in particular, on improvement of pruritus in haemodialysis patients.

Topical application with a new NF-kappaB inhibitor improves atopic dermatitis in NC/NgaTnd mice

Growing evidence has demonstrated the crucial role of NF-kappaB activation on disease severity in allergic disorders. In this study, we examined the clinical relevance of a novel NF-kappaB inhibitor, IMD-0354, for atopic dermatitis (AD) by its topical application. To investigate the in vivo efficacy, 1% IMD-0354 ointment was applied daily to NC/NgaTnd mice with severe dermatitis, which served as a model for human AD. During 2 weeks of treatment, scratching behavior decreased and severity of dermatitis reduced in mice treated with IMD-0354 as well as FK506 without diverse effects. Based on histological examinations, the hyperplasia of keratinocytes and infiltration of inflammatory cells were significantly reduced in the skin of IMD-0354-treated mice. The expressions of T-helper 2 cytokines and tumor necrosis factor-alpha at the affected skin sites were downregulated in IMD-0354-treated mice. Furthermore, IMD-0354 suppressed the proliferation of various immunocompetent cells, neurite outgrowth of nerve growth factor-stimulated pheochromocytoma cells, IgE production from splenic B cells, and IgE-mediated activation of mast cells in vitro. IMD-0354 effectively reduced the allergic inflammation in NC/NgaTnd mice in vivo. Thus, a drug that interferes with NF-kappaB activity may provide an alternative therapeutic strategy for the treatment of AD.

Quality of life in patients with atopic dermatitis: Impact of tacrolimus ointment

BACKGROUND

Atopic dermatitis (AD), a significant problem in Japan, has a major impact on health-related quality of life (QOL). The development of steroid phobia in patients with AD may restrict the therapeutic options available to these patients. Tacrolimus ointment is a safe and effective nonsteroid treatment for AD. It may be an appropriate alternative for patients with AD and steroid phobia. The aim of this study was to determine the impact of AD on QOL and to investigate the effect of tacrolimus ointment on QOL in patients with steroid phobia.

METHODS

Firstly, QOL scores were investigated in patients with AD and steroid phobia using the World Health Organization Quality of Life instrument, WHOQOL-26, and were compared with QOL scores from a previous study in volunteers from Tokyo, Japan. Secondly, patients with steroid phobia received tacrolimus ointment treatment for 12 weeks. Quality of life scores were assessed using WHOQOL-26 at baseline and study end.

RESULTS

The overall mean QOL score of 106 patients with AD was significantly lower than that of 708 volunteers (3.1 +/- 0.5 vs. 3.3 +/- 0.5, P < 0.001). The overall QOL score improved from 2.9 +/- 0.4 at baseline to 3.3 +/- 0.4 following 12 weeks' tacrolimus ointment treatment in 35 patients with AD and steroid phobia (P < 0.001).

CONCLUSIONS

Atopic dermatitis significantly lowers QOL. Tacrolimus ointment is associated with a significant improvement in QOL in patients with steroid phobia, indicating that it is an effective alternative to topical corticosteroids in these patients.

A clinician's paradigm in the treatment of atopic dermatitis

Successful management of atopic dermatitis requires a multipronged approach that includes skin barrier function care, use of topical or systemic agents, and identification and elimination of precipitating or exacerbating factors. Because the origin of atopic dermatitis is multifactorial and trigger factors differ among patients, treatment plans must be specific to the individual patient. This article offers an example of a permutational, or flexible, treatment paradigm. The approach utilizes 4 topical regimens--high-potency topical corticosteroids, lowest effective potency topical corticosteroids, topical calcineurin inhibitors (TCIs), or topical corticosteroid/TCI combinations--as initial therapy in a variety of induction protocols, as determined by the severity of a patient's condition and history. The paradigm permits treatment to progress from a chosen induction therapy to maintenance therapy. During the patient's induction therapy, as soon as an acceptable level of clearance is achieved, therapy should be adjusted to a maintenance regimen, such as monotherapy with either a TCI or a lowest effective potency topical corticosteroid (the latter used intermittently) or an alternation of the two agents. If there is no clearance or positive response with the initial induction protocol, the clinician should move to one of the alternative regimens.

Topical calcineurin inhibitors in the treatment of atopic dermatitis: a meta-analysis of current evidence

PURPOSE

To summarize success rates of the topical calcineurin inhibitors tacrolimus and pimecrolimus in treating atopic dermatitis.

METHODS

Randomized controlled trials (RCTs) comparing either drug to themselves (i.e. dose-ranging studies), each other, the vehicle (or placebo), or corticosteroids were obtained from Medline, EMBASE, and Cochrane databases. Two reviewers identified studies and extracted data, a third reviewer adjudicated disagreements. Outcomes included success, as defined by 90%, 75%, or 50% reductions from baseline in Eczema Area and Severity Index (EASI) scores or equivalent at 1, 3, 6, and 12 months, and also the difference between drug and vehicle (placebo). Rates were combined using a random effects meta-analytic model.

RESULTS

Of 180 articles identified, 165 were rejected (142 not RCTs/inappropriate outcome, 23 inappropriate/unextractable data). We included 15 articles reporting on 16 trials (nine tacrolimus and seven pimecrolimus trials) involving a total of 5301 patients, of whom 2107 received tacrolimus, 1225 received pimecrolimus and 1969 patients were controls. Tacrolimus reduced EASI scores by 65.6% at 1 month and 73.0% at 3 months; pimecrolimus reduced scores by 61.5% at 1 month, 60.3% at 6 months, and 61.9% at 12 months. When the difference in EASI score reductions were compared between active drug and placebo, tacrolimus success was 51.5% above placebo at 1 month and pimecrolimus was 45.9% higher at 1 month, 24.9% at 6 months, and 16.1% at 12 months.

CONCLUSIONS

Success rates for tacrolimus and pimecrolimus were statistically similar. However, tacrolimus rates were consistently higher numerically than those for pimecrolimus, and tacrolimus was used in patients with more severe disease. A head-to-head RCT is required to determine if true differences exist between these drugs.

Comparing tacrolimus ointment and oral cyclosporine in adult patients affected by atopic dermatitis: a randomized study

BACKGROUND

Atopic dermatitis (AD) is a chronic allergic inflammatory disease, which manifests itself with eczematous skin lesions.

OBJECTIVE

We compared the clinical efficacy of tacrolimus ointment (0.1%) given twice a day and oral cyclosporine (3 mg/kg) given once daily. Rescue medication for itching included cetirizine 10-20 mg (equal to one or two tables).

METHODS

Thirty patients, aged 13-45 years (mean+/-SD 27.1+/-10.9), with a history of moderate-to-severe AD were randomized to treatments, 15 patients for each treatments. Assessment of efficacy was based on SCORAD, on scores of daily itching, erythema, interference with sleep, due to the skin condition and days without use of cetirizine tablets. SCORAD, measured on a scale (0-103), was evaluated before treatment (0) and at 7, 14, 21, 28, 35 and 42 days after treatment. Similarly, the means of daily symptoms, on a scale (0-3), were evaluated before the treatment (0) and at 7, 14, 21, 28, 35 and 42 days after treatment; finally, on day without use of cetirizine tablets. The safety of the study treatments was assessed through haematologic, biochemical and urinary testing and on systolic and diastolic blood pressures and heart rate measurements.

RESULTS

SCORAD decreased in the two treatment groups 14 days after the beginning of the period study. However, the patients in tacrolimus ointment group reported significantly lower SCORAD than those treated with oral cyclosporine. Overall SCORAD, as assessed by the area under the curve (AUC) day(0-42) (score/day), was significantly lower in the tacrolimus ointment group when compared with oral cyclosporine (P<0.001). Similarly, AUC day(0-42) (score/day) for itching, erythema and number of nights without interference with the sleep due to skin condition were significantly lower in the group of patients treated with tacrolimus compared with those treated with cyclosporine (P=0.003, 0.005 and 0.01, respectively). As regards the use of rescue medication, expressed by median of number of days without use of anti-H(1), it was significantly lower in the group treated with tacrolimus (82.5) than in the cyclosporine group (76.5) (P=0.03). There were no appreciable changes in haematological and biochemical indices, in both treatments groups.

CONCLUSION

The results of this comparative study demonstrate that tacrolimus ointment twice daily and cyclosporine administered orally once daily are effective on SCORAD, daily symptoms and anti-H(1) rescue. When we compared tacrolimus and cyclosporine there was a faster onset of action in the group treated with tacrolimus. The two drugs presented the same safety. However, these data support the preferential use of topical tacrolimus 0.1% in AD, because cyclosporine has potential side-effects.

Increased Topical Tacrolimus Absorption in Generalized Leukemic Erythroderma

OBJECTIVE

To report a case of elevated blood tacrolimus concentration after application of topical tacrolimus ointment in an erythrodermic patient.

CASE SUMMARY

A 44-year-old man developed generalized erythroderma and itching due to infection with human T-cell lymphotropic virus. Despite application of strong glucocorticosteroid ointments, the symptoms and area of erythroderma were not alleviated. Daily topical application of tacrolimus 0.1% ointment was added and therapeutic drug monitoring was started. The dose and applied area of tacrolimus were gradually increased from 2.5 to 12.5 g/d and from 10% to 90% of body surface area, respectively. Because the trough concentration of tacrolimus in whole blood increased from 7.5 ng/mL on treatment day 9 to 15.4 ng/mL on day 13, the dose was reduced to 10 g/d. However, the concentration further elevated to 16.5 ng/mL. Therefore, the applied area was reduced to 20% of body surface area, and the tacrolimus concentration decreased gradually thereafter. Although the transient increase of blood tacrolimus concentration was observed on day 23, treatment with 20% applied area and 5 g/d were maintained.

DISCUSSION

Topically applied tacrolimus was substantially absorbed with the expansion of its applied area and dose. Increased tacrolimus concentrations may have a tendency to depend on the increase of the percent of body surface area per dose. Our findings showing the elevation of blood tacrolimus concentration after application of the ointment to a large area of the body suggest that the applied area should be as narrow as possible in a barrier-disrupted condition such as erythroderma. However, the safety of tacrolimus ointment has not been established in patients with generalized erythroderma.

CONCLUSIONS

Tacrolimus concentrations in whole blood should be carefully monitored to prevent nephrotoxicity. Based on the results of that monitoring, the application area and dose of tacrolimus ointment should be closely adjusted, especially in generalized erythrodermic cases.

Tacrolimus ointment 0.1% in the treatment of nickel-induced allergic contact dermatitis

BACKGROUND

Tacrolimus is a macrolactam that prevents the transcription of messenger RNA for various inflammatory cytokines in both helper T cells (types 1 and 2) (T(H)1 and T(H)2). It is currently approved for the treatment of moderate to severe atopic dermatitis, a Th2-mediated disease, in children and adults.

OBJECTIVE

We sought to evaluate the safety and efficacy of tacrolimus ointment 0.1% in the treatment of nickel-induced allergic contact dermatitis, a T(H)1-mediated disease.

METHODS

This was a double-blind, randomized, vehicle-controlled, bilateral paired comparison study to assess the safety and efficacy of topical tacrolimus (Protopic, Fujisawa Healthcare Inc, Deerfield, Ill) ointment 0.1% in the treatment of allergic contact dermatitis induced by nickel sulfate. Volunteers were individuals with known hypersensitivity to nickel. Reactivity to nickel was graded both as the investigator's global assessment and total signs and symptoms, which consisted of the cumulative grade from 0 to 4 for each of the following parameters: erythema, induration, vesiculation, and pruritus (range of scores: 0-16). Reactivity was assessed in the per-protocol group at 1 and 2 weeks after beginning treatment with study drug and control. Adverse events were assessed in the intent-to-treat population.

RESULTS

Of the 19 volunteers who completed the study (per protocol), 18 had an improvement in total signs and symptoms with tacrolimus versus 10 patients with the vehicle. Of patients, 80% had an improvement in the investigator's global assessment score on the tacrolimus-treated site versus 30% of patients on the placebo-treated site. Overall, tacrolimus was more effective than placebo in ameliorating the nickel reaction. Although the tacrolimus treated site was clear or almost clear in a greater number of individuals at week 1, this difference did not become significant until the second week of the study. Other than application site burning in 25% of volunteers, no significant adverse events were noted in the intent-to-treat population.

CONCLUSION

Topical tacrolimus (Protopic, Fujisawa Healthcare Inc) ointment 0.1% may be an option for the treatment of allergic contact dermatitis induced by nickel.

An open pilot study using tacrolimus ointment in the treatment of seborrheic dermatitis

Seborrheic dermatitis is generally treated with topical steroids, antifungals, or both. This pilot study was undertaken to examine the possibility of tacrolimus as a useful therapy for seborrheic dermatitis. In a single-center, open-label study, 18 consecutive patients with seborrheic dermatitis were treated with 0.1% tacrolimus for a total of 28 days or until complete clearance occurred, if sooner. Of the patients, 11 (61%) showed 100% clearance of their seborrheic dermatitis; the remaining 7 patients showed 70% to 99% clearance. The most common side effects were mild local burning and irritation.

Topical pimecrolimus: a review of its clinical potential in the management of atopic dermatitis

Pimecrolimus (SDZ ASM 981), an ascomycin derivative, is a nonsteroid, has anti-inflammatory activity, and has demonstrated efficacy in reducing symptoms of atopic dermatitis in adult and paediatric patients when applied topically. Compared with vehicle, topical pimecrolimus 1.0% cream was significantly more effective at reducing symptoms of atopic dermatitis, as measured by the Eczema Area and Severity Index (EASI), in infants aged 3 to 23 months, children aged 2 to 17 years and adults. The median reductions from baseline in the total EASI score in adults after treatment with pimecrolimus 1.0% or corresponding vehicle twice daily for 3 weeks were 47 and 0%, respectively. In infants and children, treatment with pimecrolimus 1.0% twice daily for 6 weeks resulted in significant decreases in mean EASI scores compared with vehicle. The severity of pruritus was significantly reduced in patients of all age groups after topical treatment with pimecrolimus 1.0% cream. Compared with vehicle, the incidence of eczematous flares was also reduced by intermittent long-term use of topical pimecrolimus 1.0% in adults, children and infants. Sixty percent of children treated with pimecrolimus for 1 year completed the first 6 months of treatment without experiencing a flare, compared with 35% of patients who received vehicle. Furthermore, the use of topical corticosteroids for the treatment of uncontrolled flares in adults, children and infants was lower in the pimecrolimus groups than in the vehicle groups. Topical pimecrolimus 1.0% cream is well tolerated in atopic dermatitis patients of all age groups. There were no clinically relevant systemic adverse events reported from any of the studies in patients with atopic dermatitis. The most frequently reported adverse events pertained to application site reactions, such as burning and a feeling of warmth. In conclusion, topical pimecrolimus 1.0% cream has shown efficacy in the treatment of mild to moderate atopic dermatitis in infants, children and adults. Although tolerability data concerning infants and children have not yet been published in full, the drug appears to be well tolerated in all age groups, and there have been no reports of clinically relevant systemic adverse events. Furthermore, pimecrolimus 1.0% cream has shown no potential for skin atrophy, a problem commonly associated with treatment with topical corticosteroids. Pimecrolimus 1.0% cream provides a promising and well tolerated treatment option in the management of infants, children and adults with mild to moderate atopic dermatitis.

Topical cyclosporin in the treatment of dermatologic diseases

Cyclosporine A (CsA) has been in clinical use for some decades, primarily for the prevention and treatment of organ transplant rejection and graft-versus-host disease. In more recent years, Cyclosporine has been recognized as beneficial in the treatment of dermatologic diseases, such as: psoriasis, lichen planus, Behcet disease, atopic dermatitis, pyoderma gangrenosum and epidermolysis bullosa acquisita. Above all, Cyclosporine is an important therapeutic modality for several dermatologic diseases that are refractory to other agents.