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Ramos GDA, Leite TDB, Lobo CB, Santos PSDS, Moreira MCR, Antunes HS. Treatment of oral chronic graft-versus-host disease: a retrospective cohort study. EINSTEIN-SAO PAULO 2021; 19:eAO6177. [PMID: 34730704 PMCID: PMC8528385 DOI: 10.31744/einstein_journal/2021ao6177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 05/10/2021] [Indexed: 11/15/2022] Open
Abstract
Objective The aim of this study was to evaluate patients with complete response of oral chronic graft-versus-host disease to immunosuppressive treatment. Methods A total of 29 patients submitted to allogeneic hematopoietic stem cell transplantation, with oral chronic graft-versus-host disease, were enrolled in this retrospective study, from September 2012 to February 2018. Patients were treated with combined topical dexamethasone solution and topical tacrolimus ointment, combined topical dexamethasone and topical tacrolimus, systemic immunosuppressive medication, and topical dexamethasone only. Results The mean time of complete response of lichenoid lesions, erythema, and ulcers using dexamethasone and systemic immunosuppressive medication was of 105, 42 and 42 days, respectively (p=0.013).When we associated dexamethasone, tacrolimus and systemic immunosuppressive medication, the mean time of complete response of lichenoid lesions, erythema and ulcers was of 91,84 and 77 days (p=0.011). When dexamethasone was used alone, the mean time of complete response of lichenoid lesions, erythema and ulcers was 182, 140, 21 days, respectively (p=0.042). Conclusion Our study shows that lichenoid lesions require more time to heal. Notably, lichenoid lesions tend to respond better to dexamethasone combined with tacrolimus and systemic immunosuppressive medication, whereas erythema and ulcers respond better to dexamethasone combined with systemic immunosuppressive medication and dexamethasone only, respectively.
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Affiliation(s)
- Gabriela de Assis Ramos
- Divisão de Pesquisa Clínica, Instituto Nacional de Câncer - INCA, Rio de Janeiro, RJ, Brazil
| | | | - Camila Brandão Lobo
- Divisão de Pesquisa Clínica, Instituto Nacional de Câncer - INCA, Rio de Janeiro, RJ, Brazil
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Elad S, Aljitawi O, Zadik Y. Oral Graft-Versus-Host Disease: A Pictorial Review and a Guide for Dental Practitioners. Int Dent J 2021; 71:9-20. [PMID: 33616057 PMCID: PMC9275209 DOI: 10.1111/idj.12584] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Graft-versus-host disease (GVHD) is a complication of haematopoietic stem cell transplantation (HSCT). GVHD may also develop following solid transplants or blood transfusions if white blood cells are transferred. GVHD affects multiple organs, including the oral tissues. OBJECTIVE This pictorial review provides a background of GVHD to dental practitioners, describes the most common oral manifestations of GVHD and highlights the main treatment modifications needed to deliver dental care to patients with GVHD. METHODS A narrative review enhanced with clinical photographs. RESULTS Acute GVHD may manifest in the oral mucosa; however, it often develops immediately following HSCT when routine dental treatment is postponed. Chronic GVHD may manifest in the oral mucosa, the salivary glands and the musculoskeletal compartment. It may indirectly affect the teeth and the oral flora, putting the patient at risk for infections. Importantly, GVHD poses an increased risk for oral cancer. CONCLUSION GVHD has a wide range of oral manifestations, some of which may affect dental treatment.
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Affiliation(s)
- Sharon Elad
- Division of Oral Medicine, Eastman Institute for Oral Health, University of Rochester Medical Center, Rochester, NY, USA.
| | - Omar Aljitawi
- Department of Hematology and Oncology, Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY, USA
| | - Yehuda Zadik
- Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
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An Open-Label Phase II Randomized Trial of Topical Dexamethasone and Tacrolimus Solutions for the Treatment of Oral Chronic Graft-versus-Host Disease. Biol Blood Marrow Transplant 2016; 22:2084-2091. [PMID: 27590106 DOI: 10.1016/j.bbmt.2016.08.020] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Accepted: 08/17/2016] [Indexed: 02/06/2023]
Abstract
The objective of this study was to evaluate the safety and efficacy of single-agent dexamethasone or tacrolimus topical solution as first-line treatment for symptomatic oral chronic graft-versus-host disease (cGVHD). This was a prospective, single-center, open-label, randomized phase II trial of patients with symptomatic oral cGVHD without prior topical therapy. Subjects were randomly assigned 1:1 to either topical dexamethasone (.5 mg/mL) or tacrolimus (.5 mg/mL) solution and instructed to rinse with 5 mL for 5 minutes, 4 times a day, for 4 weeks. Oral cGVHD assessments (National Institutes of Health [NIH] criteria) were completed at baseline and end of treatment (NIH criteria, global response, and tolerability). The primary endpoint was the response rate defined as ≥3-point reduction in patient-reported sensitivity score (range, 0 to 10). A parallel 2-stage design was employed so that a less efficacious arm could be terminated early. The accrual goal was 60 evaluable patients; 30 in each arm), accruing 14 in the first stage and 16 in the second stage. If both arms were regarded as efficacious, a "pick-the-winner" method would be employed to choose a better treatment for future investigation. Forty-six subjects were randomized to receive either dexamethasone (n = 28) or tacrolimus (n = 18). Six subjects were excluded from the analysis because of changes in systemic immunosuppression (dexamethasone = 1, tacrolimus = 3) or lack of end-of-treatment visit (1 per arm). After the first stage evaluation, the tacrolimus arm was terminated because of lack of activity (3 of 14 responses; response rate, 21%). Twenty-six subjects in the dexamethasone arm completed both study visits and were included in the response analysis, with a 58% (15 of 26) response rate, compared with 21% (3 of 14) in the tacrolimus arm (P = .05). The response rates according to the NIH score in the dexamethasone and tacrolimus arms were 50% (13 of 26) and 2% (2 of 14), respectively (P = .04). From the onset of therapy, 31% versus 21% patients reported feeling "much better" and 38% versus 36% reported feeling "slightly better," giving an overall global response rate ("much better" or "slightly better") of 81% (21 of 26) versus 71% (10 of 14), in the dexamethasone and tacrolimus arms, respectively. Dexamethasone rinses were well tolerated and taste was reported as "very pleasant" or "tolerable" in most subjects (96%). Intensive topical therapy with dexamethasone solution is effective for managing patients with new-onset symptomatic oral cGVHD and should be considered for first-line therapy. Topical tacrolimus solution appears less effective, at least for first-line therapy.
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[Chronic or recurrent ulceration of the tongue]. Ann Dermatol Venereol 2016; 143:297-308; quiz 295-6, 309-10. [PMID: 27038855 DOI: 10.1016/j.annder.2016.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2015] [Revised: 01/31/2016] [Accepted: 02/04/2016] [Indexed: 11/23/2022]
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Albuquerque R, Khan Z, Poveda A, Higham J, Richards A, Monteiro L, Jané-Salas E, Lopez-Lopez J, Warnakulasuriya S. Management of oral Graft versus Host Disease with topical agents: A systematic review. Med Oral Patol Oral Cir Bucal 2016; 21:e72-81. [PMID: 26615510 PMCID: PMC4765756 DOI: 10.4317/medoral.20968] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Accepted: 08/28/2015] [Indexed: 12/17/2022] Open
Abstract
Background Oral Graft-versus-Host Disease (oGvHD) is a common complication of haematopoietic stem cell transplantation. Choosing the right topical application to be used intra orally can be a challenge. Consequently, the aim of this work is to review the effectiveness and safety of topical agents currently used in the management of the inflammatory mucosal lesions encountered in oGVHD. Material and Methods We carried out electronic searches of publications up to May 2015 of the databases Pubmed, National Library of Medicine’s Medline, Embase and the Cochrane Central Register of Controlled Clinical trials to identify potentially relevant studies (keywords: “oral”, “graft”, “versus”, “host”, “disease” and “treatment”). The main inclusion criterion was the reported use of a topical agent which was not intentionally swallowed when used for the treatment of oGVHD. A 3-point grading system, described by the Swedish Council on Technology Assessment in Health Care and the Centre for Reviews and Dissemination, University of York, was used to rate the methodological quality of the papers. Results From the 902 entries identified in the search, 7 studies qualifying for inclusion were analysed. Overall, there is limited evidence with regards to the effectiveness of topical steroids for oGVHD. However, the studies showed some effect of Budesonide alone and when combined with dexamethasone. Topical tacrolimus also appears to have some effect and clobetasol propionate mouthwash had a significantly better clinical response than dexamethasone mouthwash in treating oGVHD. Conclusions As the number of clinical trials conducted is limited, there is little evidence to support the use of topical therapies to treat the inflammatory mucosal lesions found in oGVHD. High quality randomised control trials are needed in order to measure the effectiveness of any topical application for the treatment of the inflammatory mucosal lesions found in oGVHD. Key words:Oral, graft versus host disease, topical, therapy.
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Affiliation(s)
- Rui Albuquerque
- Oral Medicine Department, Birmingham Dental Hospital/School of Dentistry, University of Birmingham, Birmingham B4 6NN, UK,
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Clinical approach in the management of oral chronic graft-versus-host disease (cGVHD) in a series of specialized medical centers. Support Care Cancer 2014; 23:1615-22. [DOI: 10.1007/s00520-014-2503-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2014] [Accepted: 10/27/2014] [Indexed: 01/11/2023]
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Noce CW, Gomes A, Shcaira V, Corrêa MEP, Moreira MCR, Silva Júnior A, Gonçalves LS, Garnica M, Maiolino A, Torres SR. Randomized Double-Blind Clinical Trial Comparing Clobetasol and Dexamethasone for the Topical Treatment of Symptomatic Oral Chronic Graft-Versus-Host Disease. Biol Blood Marrow Transplant 2014; 20:1163-8. [DOI: 10.1016/j.bbmt.2014.04.009] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2013] [Accepted: 04/07/2014] [Indexed: 01/12/2023]
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Topical tacrolimus and periodontal therapy in the management of a case of oral chronic GVHD characterized by specific gingival localization. Case Rep Dent 2014; 2014:127219. [PMID: 24639902 PMCID: PMC3930030 DOI: 10.1155/2014/127219] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2013] [Accepted: 12/03/2013] [Indexed: 11/19/2022] Open
Abstract
Background. Chronic graft versus host disease (cGVHD) is a complication following bone marrow transplantation. The oral lesions are difficult to control with a systemic pharmacological therapy. Case Description. A 63-year-old female patient, who underwent an allogeniec transplantation for acute myeloid leukemia, developed a chronic oral and cutaneous GVHD. The patient was treated with topical tacrolimus 0.1%, twice daily for two months, and underwent a protocol of oral hygiene characterized by 3 appointments of scaling, root planning, and daily oral hygiene instructions. The patient showed marked resolution of gingival lesions and a significant improvement of related pain and gingival inflammatory indexes. Clinical Implications. This case report suggests that treatment with topical tacrolimus and professional oral hygiene may be helpful in the management of chronic oral GVHD with severe gingival involvement.
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Brown RS, Edwards D, Walsh-Chocolaad T, Childs RW. Topical tacrolimus with custom trays in the treatment of severe oral chronic graft-versus-host disease refractory to a potent topical steroid therapy: a case report. Oral Surg Oral Med Oral Pathol Oral Radiol 2012; 115:e26-30. [PMID: 23102802 DOI: 10.1016/j.oooo.2012.07.487] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2012] [Revised: 07/08/2012] [Accepted: 07/20/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND The authors present a case demonstrating the success of topical tacrolimus (TAC) therapy with custom trays in the treatment of oral chronic graft-versus-host disease (cGVHD). The 41-year-old male patient initially responded to topical steroid therapy (clobetasol propionate 0.05% ointment) applied both topically and with flexible carrier trays, but later became refractory to this potent topical agent. Topical TAC therapy with flexible carrier trays and systemic prednisone therapy was initiated. RESULTS The patient responded favorably with the change to topical TAC therapy with custom trays (and oral prednisone). His oral cGVHD lesions resolved within a period of 4 weeks. The improvement has remained stable at 14 months of follow-up. CLINICAL IMPLICATIONS This is the first case reported with regard to the successful resolution of steroid recalcitrant cGVHD successfully treated with topical TAC with custom trays.
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Affiliation(s)
- Ronald S Brown
- Department of Oral Diagnostic Services, Howard University College of Dentistry, Washington, DC 20059, USA.
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Abstract
Chronic graft-versus-host disease (cGVHD) is a major complication of allogeneic hematopoietic cell transplantation that is associated with a diminished quality of life. The oral cavity is frequently affected, with a wide variety of signs and symptoms that can result in significant short- and long-term complications ranging from mucosal sensitivity and limited oral intake to secondary malignancy and early death. This article provides a comprehensive approach to the diagnosis and clinical management of patients with oral cGVHD, with particular attention to differential diagnosis, control of symptoms, and prevention of and screening for secondary complications. The clinical considerations and recommendations presented are intended to be practical and relevant for all clinicians involved in the care of patients with oral cGVHD, with the ultimate goal of improving care and outcomes.
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Dignan FL, Scarisbrick JJ, Cornish J, Clark A, Amrolia P, Jackson G, Mahendra P, Taylor PC, Shah P, Lightman S, Fortune F, Kibbler C, Andreyev J, Albanese A, Hadzic N, Potter MN, Shaw BE. Organ-specific management and supportive care in chronic graft-versus-host disease. Br J Haematol 2012; 158:62-78. [DOI: 10.1111/j.1365-2141.2012.09131.x] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Affiliation(s)
| | | | | | - Andrew Clark
- Bone Marrow Transplant Unit; Beatson Oncology Centre; Gartnavel Hospital; Glasgow
| | - Persis Amrolia
- Department of Bone Marrow Transplantation; Great Ormond Street Hospital; London
| | - Graham Jackson
- Department of Haematology; Freeman Road Hospital; Newcastle
| | - Prem Mahendra
- Department of Haematology; University Hospital Birmingham; Birmingham
| | - Peter C. Taylor
- Department of Haematology; Rotherham General Hospital; Rotherham
| | - Pallav Shah
- Department of Respiratory Medicine; Royal Brompton Hospital; London
| | - Sue Lightman
- University College London/Institute of Opthalmology; Moorfields Eye Hospital; London
| | - Farida Fortune
- Department of Oral Medicine; Barts and the London NHS Trust; London
| | | | - Jervoise Andreyev
- Department of Medicine; The Royal Marsden NHS Foundation Trust; London
| | | | - Nedim Hadzic
- Paediatric Liver Service & Institute of Liver Studies; King's College Hospital; London
| | - Michael N. Potter
- Section of Haemato-oncology; The Royal Marsden NHS Foundation Trust; London
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Elad S, Epstein JB, Yarom N, Drucker S, Tzach R, von Bültzingslöwen I. Topical immunomodulators for management of oral mucosal conditions, a systematic review; part I: calcineurin inhibitors. Expert Opin Emerg Drugs 2011; 15:713-26. [PMID: 21091397 DOI: 10.1517/14728214.2010.528389] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
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.
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Affiliation(s)
- Sharon Elad
- Hebrew University-Hadassah School of Dental Medicine, Department of Oral Medicine, POB 12272, Jerusalem 91120, Israel.
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Meier JKH, Wolff D, Pavletic S, Greinix H, Gosau M, Bertz H, Lee SJ, Lawitschka A, Elad S. Oral chronic graft-versus-host disease: report from the International Consensus Conference on clinical practice in cGVHD. Clin Oral Investig 2010; 15:127-39. [PMID: 20859645 DOI: 10.1007/s00784-010-0450-6] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2010] [Accepted: 07/26/2010] [Indexed: 01/12/2023]
Abstract
Chronic graft-versus-host disease (cGVHD) is a multi-organ disease that occurs post-hematopoietic stem cell transplantation, with the mouth being one of the most frequently affected organs. In 2009, the German-Austrian-Swiss working party on bone marrow and blood stem cell transplantation held a consensus conference to define clinical management of cGVHD. The consensus conference aimed to summarize the literature on diagnosis and topical treatment options for oral cGVHD and to provide recommendations for clinical practice, including routine dental and oral care as well as monitoring for secondary malignancies and bisphophonate-induced osteonecrosis of the jaw.
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Affiliation(s)
- Johannes K-H Meier
- Department of Cranio-Maxillo-Facial Surgery, University of Regensburg, Regensburg, Germany
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Wolff D, Gerbitz A, Ayuk F, Kiani A, Hildebrandt GC, Vogelsang GB, Elad S, Lawitschka A, Socie G, Pavletic SZ, Holler E, Greinix H. Consensus conference on clinical practice in chronic graft-versus-host disease (GVHD): first-line and topical treatment of chronic GVHD. Biol Blood Marrow Transplant 2010; 16:1611-28. [PMID: 20601036 DOI: 10.1016/j.bbmt.2010.06.015] [Citation(s) in RCA: 143] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2010] [Accepted: 06/21/2010] [Indexed: 10/19/2022]
Abstract
Chronic graft-versus-host disease (cGVHD) after allogeneic hematopoietic stem cell transplantation is still associated with significant morbidity and mortality. First-line treatment of cGVHD is based on steroids of 1 mg/kg/day of prednisone. The role of calcineurin inhibitors remains controversial, especially in patients with low risk for mortality (normal platelets counts), whereas patients with low platelets at diagnosis and/or high risk for steroid toxicity may be treated upfront with the combination of prednisone and a calcineurin inhibitor. Additional systemic immunosuppressive agents, like thalidomide, mycophenolic acid, and azathioprine, failed to improve treatment results in the primary treatment of cGVHD and are in part associated with higher morbidity, and in the case of azathioprine, with higher mortality. Despite advances in diagnosis of cGVHD as well as supportive care, half of the patients fail to achieve a long-lasting response to first-line treatment, and infectious morbidity continues to be significant. Therefore, immunomodulatory interventions with low infectious morbidity and mortality such as photopheresis need urgent evaluation in clinical trials. Beside systemic immunosuppression, the use of topical immunosuppressive interventions may improve local response rates and may be used as the only treatment in mild localized organ manifestations of cGVHD.
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Affiliation(s)
- Daniel Wolff
- Department of Hematology and Clinical Oncology, University of Regensburg, F.J. Strauss Allee 11, Regensburg, Germany.
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Zangrilli A, Campione E, Diluvio L, Paternò EJ, Orlandi A, Simone MD, Chimenti S. Treatment of disfiguring chronic graft versus host disease in a child with topical pimecrolimus. Pediatr Int 2010; 52:e161-3. [PMID: 20723118 DOI: 10.1111/j.1442-200x.2010.03078.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Arianna Zangrilli
- Departments of Dermatology, Mediterranean Institute of Hematology, University of Rome Tor Vergata, Rome, Italy.
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Bauters T, Bordon V, Van de Velde V, Van Lancker S, Robays H, Benoit Y, Laureys G. Highly effective treatment with tacrolimus ointment in an adolescent with oral graft-versus-host disease. ACTA ACUST UNITED AC 2010; 32:350-2. [PMID: 20364437 DOI: 10.1007/s11096-010-9386-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2010] [Accepted: 03/22/2010] [Indexed: 10/19/2022]
Abstract
CASE We report a case of acute oral graft-versus-host disease in an adolescent, which was successfully treated with tacrolimus 0.1% ointment. CONCLUSION Although tacrolimus ointment is not licensed for the indication of oral GvHD, this case report provides preliminary evidence for a potential effectiveness of using tacrolimus in case of failure when GvHD is resistant.
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Affiliation(s)
- T Bauters
- Department of Pharmacy, Ghent University Hospital, -1 K12, De Pintelaan 185, 9000, Ghent, Belgium.
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Combined topical dexamethasone/tacrolimus therapy for management of oral chronic GVHD. Bone Marrow Transplant 2009; 45:1062-7. [DOI: 10.1038/bmt.2009.301] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Alexandroff A, Burd R. Footprints of the EADV: a meeting report from the 17th Congress of the European Academy of Dermatology and Venereology. Br J Dermatol 2009; 160:938-45. [DOI: 10.1111/j.1365-2133.2009.09107.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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