The role of topical calcineurin inhibitors for skin diseases other than atopic dermatitis

Drugs for the Treatment of Chronic Hand Eczema: Successes and Key Challenges

Chronic hand eczema (CHE) is a common and burdensome inflammatory skin condition seen in up to 10% of the population, more often in high-risk occupational workers. Topical therapeutics comprise the standard of care, but up to 65% of cases do not resolve after treatment, and moderate-to-severe cases are often resistant to topical therapeutics and require systemic options instead. To date, there are no systemic therapeutics approved to treat CHE in the United States, but several drugs are under investigation as potential treatments for CHE. The primary focus of this review is on the novel therapeutics, topical and systemic, that are under investigation in recently completed or currently ongoing trials. This review also briefly outlines the existing treatments utilized for CHE, often with limited success or extensive adverse effects. CHE represents a major challenge for physicians and patients alike, and efforts to improve the minimally invasive diagnostic tools and treatment paradigms are ongoing. In the near future, CHE patients may benefit from new topical and systemic therapeutics that specifically target abnormally expressed immune markers.

Tacrolimus 0.1% versus ciclopiroxolamine 1% for maintenance therapy in patients with severe facial seborrheic dermatitis: A multicenter, double-blind, randomized controlled study

BACKGROUND

No long-term maintenance therapy has been tested in patients with seborrheic dermatitis (SD).

OBJECTIVE

We sought to compare the efficacy and tolerance of tacrolimus 0.1% ointment versus ciclopiroxolamine 1% cream as maintenance therapy for severe SD.

METHODS

This double-blind randomized controlled study was conducted from 2014 to 2017 in 5 Dermatology Departments and 15 dermatology practices in France. Consecutive patients with severe and chronic facial SD were included. Patients were initially treated with desonide 0.05% cream twice daily for 7 days. Patients cleared after this open phase were randomized to receive tacrolimus 0.1% or ciclopiroxolamine 1% cream 2 times a week 24 weeks. The primary endpoint was disease-free-duration, defined as the time from randomization to first relapse.

RESULTS

One hundred fourteen patients were randomized (tacrolimus, n = 57; ciclopiroxolamine, n = 57). Twelve patients relapsed in the tacrolimus group after a median delay of 91.5 days (range 15-195 days) versus 23 patients in the ciclopiroxolamine group (median delay, 27 days [range 13-201 days]). Comparison of disease-free duration curves showed that patients in the tacrolimus group had a longer duration of complete remission than those in the ciclopiroxolamine group (P = .018), corresponding to a hazard ratio of relapse of 0.44 (95% confidence interval 0.22-0.89; P = .022).

LIMITATIONS

The theoretical sample size was not reached.

CONCLUSION

Tacrolimus 0.1% is more effective than ciclopiroxolamine 1% as maintenance therapy for patients with facial SD.

Comparison of topical clobetasol propionate 0.05% and topical tacrolimus 0.1% in the treatment of cutaneous lichen planus

Introduction

The effectiveness of topical tacrolimus in the treatment of oral and genital lichen planus has been verified in many randomized studies; however, there are only few case reports in treatment of cutaneous lichen planus (CLP).

Aim

We sought to compare the safety and efficacy of topical clobetasol propionate and tacrolimus ointment in the treatment of CLP.

Material and methods

Retrospective analysis of patient files was performed. We enrolled patients who were diagnosed with CLP and treated with topical tacrolimus 0.1% or topical clobetasol propionate 0.05%. Visual Analogue Scale (VAS) scores of pigmentation and pruritus, clinical response, laboratory data and adverse effects were obtained from medical records.

Results

A total of 27 patients were included in the clobetasol group and 23 patients in the tacrolimus group. Both groups showed an improvement in VAS scores regarding pruritus and pigmentation but a statistically significant difference was observed in the clobetasol group (p< 0.05). At week 12, a complete response was observed in 63% (n = 17) of the clobetasol and 26% (n = 6) of the tacrolimus group.

Conclusions

In our study, both treatments were found effective in the treatment of CLP but clobetasol propionate was more effective. However tacrolimus may be preferred before topical corticosteroids for lesions on the face, neck, and intertriginous regions of the body, which are sensitive to the cutaneous adverse effects of topical corticosteroids. Our study may be one of the first studies to compare the effects of topical clobetasol and tacrolimus ointment in the management of CLP.

Treatment of Psoriasis: Novel Approaches to Topical Delivery

Topical treatment is the cornerstone for the management of mild to moderate psoriasis. Despite efforts in drug development, patient's satisfaction with the available topical treatments is limited. A strategy to improve safety, efficacy and comfort of topical treatment provides the development of new drug delivery and drug carrier systems. This review provides an overview of recent advances in this field with a focus on psoriasis. Laser-assisted drug delivery, foam formulations, nanoparticles, ethosomes, and niomes are considered. Hopefully, these new developments will improve topical drug therapy and patient satisfaction.

Itch: From mechanism to (novel) therapeutic approaches

Itch is a common sensory experience that is prevalent in patients with inflammatory skin diseases, as well as in those with systemic and neuropathic conditions. In patients with these conditions, itch is often severe and significantly affects quality of life. Itch is encoded by 2 major neuronal pathways: histaminergic (in acute itch) and nonhistaminergic (in chronic itch). In the majority of cases, crosstalk existing between keratinocytes, the immune system, and nonhistaminergic sensory nerves is responsible for the pathophysiology of chronic itch. This review provides an overview of the current understanding of the molecular, neural, and immune mechanisms of itch: beginning in the skin, proceeding to the spinal cord, and eventually ascending to the brain, where itch is processed. A growing understanding of the mechanisms of chronic itch is expanding, as is our pipeline of more targeted topical and systemic therapies. Our therapeutic armamentarium for treating chronic itch has expanded in the last 5 years, with developments of topical and systemic treatments targeting the neural and immune systems.

TRPML1: The Ca(2+)retaker of the lysosome

Efficient functioning of lysosome is necessary to ensure the correct performance of a variety of intracellular processes such as degradation of cargoes coming from the endocytic and autophagic pathways, recycling of organelles, and signaling mechanisms involved in cellular adaptation to nutrient availability. Mutations in lysosomal genes lead to more than 50 lysosomal storage disorders (LSDs). Among them, mutations in the gene encoding TRPML1 (MCOLN1) cause Mucolipidosis type IV (MLIV), a recessive LSD characterized by neurodegeneration, psychomotor retardation, ophthalmologic defects and achlorhydria. At the cellular level, MLIV patient fibroblasts show enlargement and engulfment of the late endo-lysosomal compartment, autophagy impairment, and accumulation of lipids and glycosaminoglycans. TRPML1 is the most extensively studied member of a small family of genes that also includes TRPML2 and TRPML3, and it has been found to participate in vesicular trafficking, lipid and ion homeostasis, and autophagy. In this review we will provide an update on the latest and more novel findings related to the functions of TRPMLs, with particular focus on the emerging role of TRPML1 and lysosomal calcium signaling in autophagy. Moreover, we will also discuss new potential therapeutic approaches for MLIV and LSDs based on the modulation of TRPML1-mediated signaling.

Acute Pustular Dermatosis, Following Topical Treatment With Pimecrolimus, in a Child Affected With Atopic and Contact Hand Dermatitis

Atopic dermatitis is considered an important risk factor for chronic hand dermatitis, which can be seen in children too. Pimecrolimus cream 1% is approved to treat atopic dermatitis in children aged 2 years or older. In adults, this drug has been used for some clinical indications other than atopic dermatitis, such as chronic hand dermatitis. Here, we describe an adverse drug reaction in a 2-year-old child affected with atopic dermatitis, who was treated with topical pimecrolimus in order to ameliorate her concomitant hand dermatitis. The use of topical pimecrolimus led to a previously undescribed hand pustular dermatosis, being consistent with a form of pustular leukocytoclastic vasculitis, which required the permanent discontinuation of topical pimecrolimus.

Treatment of a Crohn's disease-related cutaneous facial lesion with topical tacrolimus

We report a case of an orofacial lesion in Crohn's disease successfully treated with tacrolimus ointment. A 22-year-old woman with Crohn's disease presented with a discharging lesion on the right side of her face. Intraorally, there was a resultant loss of the sulcal depth. She reported a 1-year history of variable right-sided facial swelling for which she had undergone extraoral incision and drainage, resulting in localized paresthesia and nonhealing of the incision site. Following exclusion tests, a treatment of twice-daily extraoral application of tacrolimus 0.1% ointment was commenced. Upon review, the lesion had reduced in size, with minimal discharge. Further improvement over 12 months of tacrolimus use resulted in a satisfactory cosmetic result as well as resolution of the intraoral features and reestablishment of the full sulcal depth. This case illustrates the successful use of topical tacrolimus to treat a cutaneous manifestation of Crohn's disease.

Recent advances in the understanding and management of rosacea

Rosacea is a chronic relapsing inflammatory facial dermatosis. There are several known triggers but the pathogenesis remains unknown. Recent achievements in understanding this disease point to the importance of skin-environmental interactions. This includes physical and chemical factors, but also microbial factors. The impairment of the skin barrier function and the activation of the innate immune defences are major and connected pathways contributing to an ongoing inflammatory response in the affected skin. This becomes modulated by endogenous factors like neurovascular, drugs, and psychological factors. These factors offer new therapeutic targets for rosacea treatment. There is a broader range of anti-inflammatory compounds available with a favourable safety record. Only recently have persistent erythema and flushing been addressed by new drug formulations.

Topical anti-inflammatory agents for seborrhoeic dermatitis of the face or scalp

BACKGROUND

Seborrhoeic dermatitis is a chronic inflammatory skin disorder affecting primarily the skin of the scalp, face, chest, and intertriginous areas, causing scaling and redness of the skin. Current treatment options include antifungal, anti-inflammatory, and keratolytic agents, as well as phototherapy.

OBJECTIVES

To assess the effects of topical pharmacological interventions with established anti-inflammatory action for seborrhoeic dermatitis occurring in adolescents and adults.

SEARCH METHODS

We searched the following databases up to September 2013: the Cochrane Skin Group Specialised Register, CENTRAL in The Cochrane Library (2013, Issue 9), MEDLINE (from 1946), Embase (from 1974), LILACS (from 1982), and the GREAT database. We searched five trials databases and checked the reference lists of included studies for further references to relevant randomised controlled trials (RCTs).

SELECTION CRITERIA

We included RCTs in adults or adolescents (> 16 years) with diagnosed seborrhoeic dermatitis of the scalp or face, comparing topical anti-inflammatory treatments (steroids, calcineurin inhibitors, and lithium salts) with other treatments.

DATA COLLECTION AND ANALYSIS

Pairs of authors independently assessed eligibility for inclusion, extracted data, and evaluated the risk of bias. We performed meta-analyses if feasible.

MAIN RESULTS

We included 36 RCTs (2706 participants), of which 31 examined topical steroids; seven, calcineurin inhibitors; and three, lithium salts. The comparative interventions included placebo, azoles, calcipotriol, a non-steroidal anti-inflammatory compound, and zinc, as well as different anti-inflammatory treatments compared against each other. Our outcomes of interest were total clearance of symptoms, erythema, scaling or pruritus scores, and adverse effects. The risk of bias in studies was most frequently classified as unclear, due to unclear reporting of methods.Steroid treatment resulted in total clearance more often than placebo in short-term trials (four weeks or less) (relative risk (RR) 3.76, 95% confidence interval (CI) 1.22 to 11.56, three RCTs, 313 participants) and in one long-term trial (lasting 12 weeks). Steroids were also more effective in reducing erythema, scaling, and pruritus. Adverse effects were similar in both groups.There may be no difference between steroids and calcineurin inhibitors in total clearance in the short-term (RR 1.08, 95% 0.88 to 1.32, two RCTs, 60 participants, low-quality evidence). Steroids and calcineurin inhibitors were found comparable in all other assessed efficacy outcomes as well (five RCTs, 237 participants). Adverse events were less common in the steroid group compared with the calcineurin group in the short-term (RR 0.22, 95% CI 0.05 to 0.89, two RCTs, 60 participants).There were comparable rates of total clearance in the steroid and azole groups (RR 1.11, 95% CI 0.94 to 1.32, eight RCTs, 464 participants, moderate-quality evidence) as well as of adverse effects in the short-term, but less erythema or scaling with steroids.We found mild (class I and II) and strong (class III and IV) steroids comparable in the assessed outcomes, including adverse events. The only exception was total clearance in long-term use, which occurred more often with a mild steroid (RR 0.79, 95% CI 0.63 to 0.98, one RCT, 117 participants, low-quality evidence).In one study, calcineurin inhibitor was more effective than placebo in reducing erythema and scaling, but there were similar rates in total clearance or adverse events for short-term treatment. In another study, calcineurin inhibitor was comparable with azole when erythema, scaling, or adverse effects were measured for longer-term treatment.Lithium was more effective than placebo with regard to total clearance (RR 8.59, 95% CI 2.08 to 35.52, one RCT, 129 participants) with a comparable safety profile. Compared with azole, lithium resulted in total clearance more often (RR 1.79, 95% CI 1.10 to 2.90 in short-term treatment, one RCT, 288 participants, low-quality evidence).

AUTHORS' CONCLUSIONS

Topical steroids are an effective treatment for seborrhoeic dermatitis of the face and scalp in adolescents and adults, with no differences between mild and strong steroids in the short-term. There is some evidence of the benefit of topical calcineurin inhibitor or lithium salt treatment. Treatment with azoles seems as effective as steroids concerning short-term total clearance, but in other outcomes, strong steroids were more effective. Calcineurin inhibitor and azole treatment appeared comparable. Lithium salts were more effective than azoles in producing total clearance.Steroids are similarly effective to calcineurin inhibitors but with less adverse effects.Most of the included studies were small and short, lasting four weeks or less. Future trials should be appropriately blinded; include more than 200 to 300 participants; and compare steroids to calcineurin inhibitors or lithium salts, and calcineurin inhibitors to azoles or lithium salts. The follow-up time should be at least one year, and quality of life should be addressed. There is also a need for the development of well-validated outcome measures.

Topical calcineurin inhibitors in dermatology. Part I: Properties, method and effectiveness of drug use

Topical calcineurin inhibitors (TCI) are a relatively new class of drugs used in dermatology. There are two drug forms available – tacrolimus 0.03% or 0.1% ointment and 1.0% pimecrolimus cream. The drugs act by inhibiting synthesis of proinflammatory cytokines. The only approved indication for using TCI is treatment of atopic dermatitis. The TCI may be used as an alternative therapy to corticosteroids. Tacrolimus is used to treat moderate-to-severe atopic dermatitis, pimecrolimus – mild-to-moderate atopic dermatitis. Topical calcineurin inhibitors do not cause skin atrophy and the drug absorption through the skin is minimal. The TCI have been well-studied, their efficacy was evaluated in a number of vast, long-term studies. The anti-inflammatory potency of tacrolimus ointment is similar to a corticosteroid with moderate activity, while the latter is clearly more active than pimecrolimus cream. Topical calcineurin inhibitors significantly relieve pruritus in atopic eczema.

Current treatment strategies in pediatric alopecia areata

Alopecia areata (AA) is a non-scarring autoimmune disease of the hair follicle that can present at any age. Pediatric cases are commonly seen in a dermatology clinic, and management can potentially be challenging, with a small proportion of cases experiencing a chronic relapsing course marked by distressing hair loss that can bring about significant psychosocial morbidity. We review the established treatments for pediatric alopecia areata, alongside second and third line therapies that have shown to be efficacious. We also offer a treatment algorithm as a guide to the treatment of pediatric AA.

Allergic skin disease

The two most common allergic skin diseases in the world are often the least familiar to practicing surgeons: atopic dermatitis and contact dermatitis. When unrecognized, these disorders can cause great discomfort and decreased quality of life. This is only made worse by a surgical procedure which can exacerbate the disease process. Through proper recognition, management, and peri-surgical prophylaxis flares of these diseases can be avoided, leading to decreased morbidity and improved patient satisfaction. This article summarizes the pathophysiology and management of both atopic and contact dermatitis, with attention to implications for the surgeon.

Sarcoidosis and molecular mimicry--important etiopathogenetic aspects: current state and future directions

Sarcoidosis is a disease of uncertainty in terms of its cause, presentation, and clinical course. The disease has a worldwide distribution and affects all ages, races, and both sex. Sarcoidosis of the skin may have an extremely heterogeneous clinical presentation, so that the definitions of 'great imitator' and 'clinical chameleon' have long been used. The factors that influence clinical picture and severity of the disease are probably linked to the etiopathogenesis of sarcoidosis, which continues to be shrouded in mystery. The current state of the art on the pathogenesis of sarcoidosis is that it is an immunological response in a genetically susceptible individual to an as-yet undefined antigenic stimulus. How exposure occurs in genetically predisposed patients is not completely clear, but the most likely explanation is that these agents or antigens are either inhaled into the lungs or enter through contact with the skin, as these are the common target organs that are constantly in contact with the environment. An autoimmune etiology of sarcoidosis could possibly occur through a process of molecular mimicry of infectious or other environmental antigens to host antigens. This could lead to a cross-mediated immune response and induction of autoimmune disease. This molecular mimicry may probably be responsible for the heterogeneous clinical presentations of the disease. Several investigations and studies have provided valuable evidence on the etiopathogenesis of sarcoidosis, which may lead to the future development of targeted and innovative treatment strategies. Nevertheless, we are still a long way from unravelling the underlying cause of this mysterious disease.

Rosacea and rhinophyma in the elderly

Rosacea is a chronic inflammatory disease with a predominance of facial manifestations. The prevalence is increasing with age, peaking in the group aged older than 65 years. In 1997, one in eight Americans was aged 65 years and older. By 2030, more than 70 million individuals will be in this age group. This contribution reviews the current understanding of pathogenesis, aggravating factors, classification, comorbidities, and treatment options. Rosacea is a manageable disease that negatively affects quality of life. Rosacea increases the risk of depression and shows a significant proportion of extracutaneous manifestations, in particular ocular rosacea.

Ablative erbium:YAG laser treatment of idiopathic chronic inflammatory non-cicatricial balanoposthitis (Zoon's disease)--a series of 20 patients with long-term outcome

BACKGROUND

Chronic inflammatory non-cicatricial balanitis/balanoposthitis (Zoon 1952) is not uncommon among aged uncircumcised males. The course is chronic and will lead to severe epidermal atrophy. This disease is poorly responsive to topical treatment. The golden standard for treatment is circumcision.

OBJECTIVE

This study was performed to evaluate the efficacy and safety of ablative erbium:YAG laser treatment.

METHODS

An uncontrolled trial was performed with 20 Caucasian male patients (mean age 64.8 years) who presented with chronic inflammatory non-cicatricial balanitis or balanoposthitis. The patients received multiple topical treatments. The disease duration ranged from 1 to more than 7 years. Diagnosis was confirmed by histology. Topical anaesthesia was performed before erbium:YAG laser ablation (focus 1.6-5 mm; frequency 8 Hz; impulse energy mostly 800 mJ; fluence between 11.3 and 20 J cm(-2)). The pulses were partly overlapping. The pain sensation was recorded by visual analogue scale (VAS). Complete clearance was defined as complete absence of erythematous, smooth-faced, 'wet'-looking patches or erosions. Patients were requested to attend a regular follow-up once a year. The outcome was further assessed by patient's global assessment (PGA).

RESULTS

In all patients a complete re-epithelialization could be achieved within 2-3 weeks. During follow-up between 3 months and 30 months (mean 12.1 +/- 7.2 months), a complete and stable clearing was achieved in 20 patients (100%). There were no severe adverse effects. With topical anaesthetic cream the VAS was very low (mean 1.5 +/- 4.1 mm for 18 patients and 22 treatments). All but three patients were 'completely satisfied' with the procedure and the outcome; three were 'satisfied'.

CONCLUSIONS

Ablative erbium:YAG laser therapy is a safe, effective and minimally invasive treatment option in chronic inflammatory non-cicatricial balanitis/balanoposthitis.

Consensus conference on clinical practice in chronic graft-versus-host disease (GVHD): first-line and topical treatment of chronic GVHD

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.

Topical calcineurin inhibitors in systemic lupus erythematosus

Cutaneous lupus erythematosus (CLE) encompasses a variety of lesions that may be refractory to systemic or topical agents. Discoid lupus erythematosus (DLE) and subacute cutaneous lupus erythematosus (SCLE) are the most common lesions in clinical practice. The topical calcineurin inhibitors, tacrolimus and pimecrolimus, have been used to treat resistant cutaneous lupus since 2002 and inhibit the proliferation and activation of T-cells and suppress immune-mediated cutaneous inflammation. This article reviews the mechanism of action, efficacy, adverse effects, and the recent concern about their possible carcinogenic effect. Although the total number of patients is small and there is only one relevant randomized controlled study, the data are encouraging. Many patients, previously resistant to systemic agents or topical steroids, improved after four weeks of treatment. DLE and SCLE lesions were less responsive, reflecting the chronicity of the lesions, although more than 50% of patients still showed improvement. Topical calcineurin inhibitors may be a safe and effective alternative to topical steroids for CLE although the only approved indication is for atopic dermatitis.

The role of calcineurin inhibitors in the management of lichen sclerosus

Lichen sclerosus is a chronic inflammatory disorder with a propensity to affect the mucocutaneous anogenital area. Topical corticosteroids remain the treatment of choice for this condition and constitute an effective therapeutic modality. However, in patients with corticosteroid-resistant disease, when long-term remission is not sustainable, or in those intolerant to these agents, topical calcineurin inhibitors may be considered. Studies have demonstrated their efficacy and tolerability; however, concerns remain with regard to their malignant potential with long-term use. As lichen sclerosus is a potentially precancerous dermatosis, topical calcineurin inhibitors should be used with caution in this disorder.

Tacrolimus ointment in the treatment of occupationally induced chronic hand dermatitis

BACKGROUND

Occupational hand dermatitis (OHD) is a common and often chronic condition. Usage of topical corticosteroids is limited in long-term therapy because of potential side-effects. New treatment options are highly appreciated.

OBJECTIVE

To study efficacy and safety of tacrolimus in patients suffering from OHD.

PATIENTS AND METHODS

In a prospective, open, multicentre study, 29 patients with OHD of predominantly mild-to-moderate severity were treated with tacrolimus ointment (Protopic 0.1%) during a 4-week active treatment period with twice daily application followed by a 2-month optional treatment period. Efficacy was evaluated by the use of a standardized hand eczema score and by clinical severity rating, conducted on all study visits (screening, baseline and weeks 2, 4, 6, and 12). Adverse events were recorded for safety evaluation.

RESULTS

The hand eczema score declined significantly after 2 weeks of treatment compared with baseline and further declined until the end of the study. Finally, 12 (44%) patients were clear of hand eczema. Worsening of the dermatitis occurred in 2 patients (7%). Clinical grading indicated improvement too. Overall tolerability was good.

CONCLUSION

Topical tacrolimus might be an efficacious treatment option for chronic OHD. Blinded and randomized controlled studies are necessary to confirm the results of this pilot study.