Tacrolimus ointment 0.1% in pityriasis alba: an open-label, randomized, placebo-controlled study

Post-Inflammatory Hypopigmentation: Review of the Etiology, Clinical Manifestations, and Treatment Options

Post-inflammatory hypopigmentation is a common acquired pigmentary disorder that is more prominent in skin of color, leading to great cosmetic and psychosocial implications. Often, a diagnosis with a pigmentary disorder can negatively impact an individual's health-related quality of life and may result in stigma. Although most cases of post-inflammatory hypopigmentation resolve spontaneously over time, a systematic diagnostic approach can help with identifying the underlying etiology and informing treatment strategies. It can be due to cutaneous inflammation, sequelae of inflammatory or infectious dermatoses, or dermatologic procedures. Therefore, a thorough understanding of the epidemiology, patient history, physical exam findings, and clinical features of post-inflammatory hypopigmentation phenomenon can explain the primary cause to providers and allow for patient education. It is also important to understand the various therapeutic approaches available and the efficacy of these options, which will inform providers to choose the appropriate therapy for patients. Although algorithms exist for classifying acquired disorders of hypopigmentation, there are no established algorithms for the diagnosis and treatment of post-inflammatory hypopigmentation, which warrants further exploration and discourse.

Pityriasis alba: toward an effective treatment

BACKGROUND

Pityriasis alba is a common skin condition that may be challenging to treat, especially in patients with darker skin type where the hypopigmentation may be more noticeable and represents a major cosmetic concern.

OBJECTIVES

This study aims to evaluate the efficacy of three cost-effective treatments of PA in comparison with placebo.

PATIENTS/METHODS

This prospective study was conducted on 80 patients complaining from PA and divided into 4 equal groups according the received topical treatment on the target lesions twice daily for 8 weeks (Calcipotriol 0.005% cream, Tacrolimus 0.03% ointment, topical corticosteroid; Clobetasone butyrate 0.05% cream and Petrolatum as Placebo). Clinical evaluation, Physician Global Assessment, Patient's satisfaction levels as well as point counting planimetry were done for evaluation of the response.

RESULTS

Significant improvement of scaling and erythema within 3 weeks after initiation of therapy and hypopigmentation by the 8th week, except for those received placebo. Tarolimus 0.03% ointment showed simple superiority over both Calcipotriol 0.005% cream and topical corticosteroid as regards repigmenation, although, the later received the highest level of patient satisfaction.

CONCLUSION

The three treatments were superior to placebo with relative superiority to Tacrolimus 0.03% due to limited side effects.

Dermatologic Problems Commonly Seen by the Allergist/Immunologist

Allergists/immunologists see a variety of skin disorders, some of which have a known immunologic basis whereas others do not. We review the prevalence, etiology, clinical presentation, and effective and low-cost care of common dermatologic conditions seen in outpatient practices. Conditions discussed include pityriasis alba, seborrheic dermatitis, rosacea, acne, tinea infections, intertrigo, lichen planus, tinea versicolor, lichen simplex chronicus, scabies, pityriasis rosea, keratosis pilaris, and seborrheic keratosis. An understanding of frequently encountered cutaneous diseases and their therapies will help provide immediate access to treatment and improve the experience for both the affected patient and the clinician.

The color of skin: white diseases of the skin, nails, and mucosa

White diseases are a heterogenous group characterized by hypopigmentation or depigmentation. Skin and eye color are determined by the number and size of melanosomes present. Melanin is produced by melanosomes in the melanocytes present within the epidermis of the skin, uvea, and retinal pigmented epithelium (RPE). Conditions altering the number of melanocytes or concentration of melanin result in a lack of pigmentation, appearing as "white diseases" ranging from the well-known albinism and vitiligo to more esoteric white hand syndrome and Degos disease.

Acquired disorders with hypopigmentation: A clinical approach to diagnosis and treatment

Acquired hypopigmented skin changes are commonly encountered by dermatologists. Although hypopigmentation is often asymptomatic and benign, occasional serious and disabling conditions present with cutaneous hypopigmentation. A thorough history and physical examination, centered on disease distribution and morphologic findings, can aid in delineating the causes of acquired hypopigmented disorders. The second article in this 2-part continuing medical education series focuses on conditions with a hypopigmented phenotype. Early diagnosis and appropriate management of these disorders can improve a patient's quality of life, halt disease progression, and prevent irreversible disability.

Pityriasis Alba--Common Disease, Enigmatic Entity: Up-to-Date Review of the Literature

Pityriasis alba (PA) is a skin disorder that affects children and adolescents. Although it is common worldwide, its incidence is markedly higher in darker skin phototypes. Its characteristic features include an extended, multistage course and spontaneous remissions and recurrences. Preceded by erythematous changes, patches of hypopigmented skin of up to a few centimeters in diameter appear on the upper body. Pruritus may accompany it. Even though its etiology is unknown, possible reported triggering factors include sunlight, beauty treatments, and microorganisms, among others. Calcineurin inhibitors play the most crucial role in PA pharmacotherapy. PA often coexists with atopic dermatitis and is considered one of its milder forms.

Diagnosis of Atopic Dermatitis: Mimics, Overlaps, and Complications

Atopic dermatitis (AD) is one of the most common skin diseases affecting infants and children. A smaller subset of adults has persistent or new-onset AD. AD is characterized by pruritus, erythema, induration, and scale, but these features are also typical of several other conditions that can mimic, coexist with, or complicate AD. These include inflammatory skin conditions, infections, infestations, malignancies, genetic disorders, immunodeficiency disorders, nutritional disorders, graft-versus-host disease, and drug eruptions. Familiarity of the spectrum of these diseases and their distinguishing features is critical for correct and timely diagnosis and optimal treatment.

Tissue immunostaining for factor XIIIa in dermal dendrocytes of pityriasis alba skin lesions

BACKGROUND

Pityriasis alba affects 1% of the world population and about 9.9% of the children in Brazil. However, its etiology remains uncertain.

OBJECTIVE

The objective of the present study was to evaluate the immunoexpression of factor XIIIa in dermal dendrocytes of skin lesions of pityriasis alba.

METHOD

Twenty patients with pityriasis alba and 20 patients with atopic dermatitis underwent biopsy. The dermal dendrocytes marked by factor XIIIa were counted by means of immunohistochemical analysis.

RESULTS

The mean amount of dermal dendrocytes found in the patients with pityriasis alba was 2, whereas in the patients with atopic dermatitis it was 4, with a statistically significant difference between them. A cutoff point of 3 cells/square inch was established to differentiate pityriasis alba from atopic dermatitis, with 80% sensibility and 90% specificity.

CONCLUSION

We believe that pityriasis alba and atopic dermatitis should be considered different clinical forms within the spectrum of atopic disease, in which sun radiation plays an important role by modulating the progression of the disease.

Follicular disorders of the face

Follicular disorders are possibly a commonly seen, though rarely reported, group of disorders, which are localized around follicles and appendages and clinically present as small papules. Classically, clinicopathological follicular plugging is seen in the "true" follicular disorders, which are appropriately referred to as follicular keratosis. Another subtype is folliculitis (infectious or noninfectious) and the follicular mimickers that clinically resemble "true" follicular disorders without the follicular keratoses. Acne vulgaris has an amalgamation of all the above lesion types. Our review is aimed at describing all the follicular disorders and gives an algorithm for diagnosing the common follicular disorders.

Double-blind, placebo-controlled, randomized study comparing 0.0003% calcitriol with 0.1% tacrolimus ointments for the treatment of endemic pityriasis alba

Background. Pityriasis alba (PA) is a frequent cause of consultation in tropical areas due to its chronic course, frequent relapses, and notorious hypopigmented lesions in pediatric dark skin populations. Currently, no treatment is widely accepted. Objective. To assess the efficacy of 0.0003% calcitriol and 0.1% tacrolimus ointments compared with placebo in the treatment of endemic PA. Methods. Twenty-eight children aged 3–17 years with 56 symmetrical lesions and phototype IV-V, were randomly assigned to receive the treatments on target lesions on the face. Improvement was evaluated at baseline and 8 weeks later clinically and by digital quantification of the affected area, colorimetry, and transepidermal water loss (TEWL). Results. Tacrolimus and calcitriol ointments induced a mean improvement of 68%, compared to 44% of placebo. We found an elevated TEWL in PA lesions. In the treated plaques, the reduction of the affected area was associated with improvement of pigmentation and TEWL. Conclusions. Calcitriol and tacrolimus induced similar repigmentation in endemic PA lesions. Melanogenic, anti-inflammatory, and barrier defect restoration properties of these drugs may explain these findings.

Innovative use of topical calcineurin inhibitors

Topical tacrolimus and pimecrolimus are indicated for treatment of atopic dermatitis, but they have been studied in many off-label uses. Double-blind and open studies have shown favorable results with topical tacrolimus and pimecrolimus in oral lichen planus. In 1 study of oral lichen planus, blood tacrolimus was detected in 54% of patients, but there were no signs of systemic toxicity. Double-blind and open studies of vitiligo have shown favorable results with tacrolimus in combination with excimer laser, especially for lesions over bony prominences and on extremities. Similarly, double-blind studies of vitiligo have shown favorable results when pimecrolimus is combined with narrow-band UVB, especially for facial lesions. Double-blind and open studies of psoriasis have shown favorable results for tacrolimus and pimecrolimus, especially for inverse psoriasis. Topical calcineurin inhibitors have been effective in many other cutaneous disorders, and further studies would help clarify their roles.

Assigning new roles to topical tacrolimus

Tacrolimus is an ascomycin macrolactam derivative with immunomodulatory and anti-inflammatory activity that belongs to the class of calcineurin inhibitors. Tacrolimus in its topical formulation has been established as a safe and effective alternative to topical corticosteroids because of its mild side effects and its minimal systemic absorption. Topical tacrolimus has been approved for the treatment of atopic dermatitis in two concentrations, 0.03 and 0.1%. In a thorough research of literature the authors review all of the available data regarding the off-label uses of the medication in other dermatoses. It seems that compared to pimecrolimus, tacrolimus has proved to be a more effective treatment. There is no causal relationship that has been established between tacrolimus and carcinogenesis. Furthermore, the authors believe that, without any evidence, the theoretical concerns are not enough to produce warnings. Tacrolimus ointment 0.1% may be recommended as a first-line choice for seborrheic dermatitis of the face and trunk, facial and intertriginous psoriasis and probably for allergic contact dermatitis and Zoon's balanitis. It has been ineffective in numerous dermatoses such as alopecia areata, necrobiosis lipoidica, internal pruritus and in thick hyperkeratotic plaques of psoriasis when administered as the commercially available formulation without occlusion. There is yet unexploited therapeutic potential regarding the use of topical tacrolimus in dermatology. Isolated cases of successful administration of the medication in various cutaneous conditions require further large-scale studies to clarify the actual effectiveness.