Capecitabine-Induced Genital Hand-Foot Syndrome Treated With Topical Tacrolimus

We describe a rare case of capecitabine-induced palmar-plantar erythrodysesthesia (PPE), or hand-foot syndrome (HFS), involving the genitals, which resolved with tacrolimus therapy, in a patient with cT3dN3 stage IIIc moderately differentiated proximal rectal adenocarcinoma who was undergoing neoadjuvant chemotherapy. Given its severe impact on the quality of life, HFS often requires independent local anti-inflammatory treatment and subsequent dose delay and/or modification of the patient's chemotherapy. We believe that our findings in this report can aid clinicians in the early recognition and management of capecitabine-associated HFS resulting in balanitis, as prompt treatment may reduce morbidity and avoid prolonged interruption of chemotherapy in these patients.

Tacrolimus Ointment in Periorbital Atopic Dermatitis

Periorbital atopic dermatitis (AD) is a common sign in ophthalmological practice and usually has a persistent and relapsing course. Treatment with topical corticosteroids has various side effects associated with their usage. Tacrolimus topical ointment has unique immunomodulatory properties that decrease skin inflammation and pruritus in AD. In this case series, we present a prospective case series of five patients (three males and two females) who received topical application of tacrolimus ointment 0.1-0.03% in the periorbital area twice daily for one to four weeks. The pre- and post-treatment images of all patients were recorded to compare the effects of the treatment. The cases were selected from patients attending the outpatient clinics of East Jeddah Hospital, Saudi Arabia. All patients were suffering from AD. Patients underwent a clinical assessment by tactile inspection (location, size, color, and surface condition) in the first week, secondweek, third month, and first year. We may conclude from this study that tacrolimus showed promising outcomes and is safe and effective for the treatment of flares or resistant periorbital AD in both adults and children.

Reasons for Patient Call-backs while being Treated with Topical 5-fluorouracil: A Retrospective Chart Review

Objective

To assess the frequency and character of adverse events (AE) associated with 5-FU and compare rate of these events to topical tacrolimus, another irritating topical treatment, as a control.

Methods

Patients prescribed 5-FU for Actinic keratosis (AK) between 1/2015 to 10/2021 were contacted via phone to assess frequency of AE and why they did or did not contact their dermatologist via retrospective chart review. A similar retrospective chart review was done for patients prescribed topical tacrolimus between 1/2015 to 10/2021.

Results

Participants frequently reported AE with 5-FU treatment (58%), which most commonly included redness or inflammation (38%) and burning, stinging, or pain (27%). There were 33 call backs for 5-FU (37 distinct questions) and the most common reasons included issues obtaining the medication (n=12) and inquiries about severe LSR (n=11). There were two call backs for topical tacrolimus related to issues obtaining the medication.

Limitations

Topical tacrolimus as a control helps address the lack of objective assessment of AE severity and potential recall bias limitations of the study methodology.

Conlcusion

Participants in our cohort frequently reported AE, and those who reported AE often contacted their dermatologist. The irritation induced by 5-FU is of greater severity compared to topical tacrolimus, as evidenced by much greater call-back rate. Addressing the risks and benefits of 5-FU, severity of LSR, and use of alternative treatments may improve AK treatment outcomes.

Systematic review of therapies for refractory ulcerative proctitis

Patients with ulcerative proctitis have favorable long-term outcomes but are typically excluded from ulcerative colitis clinical trials. Refractory proctitis presents a management conundrum for gastroenterologists, and there remains a lack of clarity as to the best therapeutic strategy. This study aimed to undertake a systematic review of studies assessing the clinical efficacy and safety of therapies for refractory proctitis. PubMed, Embase, Cochrane Library, and MEDLINE databases were searched without restriction from inception to October 27, 2022. Both interventional and noninterventional studies examining efficacy of therapeutic modalities for the induction and/or maintenance of remission in refractory proctitis were included. Included studies were grouped by therapeutic modalities as follows: (i) immunomodulators, (ii) monoclonal antibodies, (iii) topical calcineurin inhibitors, (iv) other topical therapies, and (v) appendicectomy. The search strategy identified 3301 studies, of which 13 met eligibility criteria for inclusion. Clinical remission rates for systemic therapies ranged from 20-26% for azathioprine to 50-69% for tumor necrosis factor-α inhibitor therapies. The use of systemic therapies for proctitis raised safety concerns, with 22-37% of patients discontinuing therapies due to adverse effects across four retrospective cohort studies. Prospective clinical trials of topically applied tacrolimus demonstrated clinical remission rates of 42-46%, with a favorable safety profile. Substantial heterogeneity in study design precluded meta-analysis. Refractory ulcerative proctitis remains a neglected entity, with a dearth of prospective clinical trials to guide therapeutic decision-making. Current evidence supports a role for topically administered tacrolimus.

Different methods of enhancing the efficacy of topical tacrolimus in extra-facial vitiligo: A comparative study

BACKGROUND

Vitiligo is an acquired pigmentation disorder due to loss of melanocytes. Topical tacrolimus is effective in vitiligo treatment with minimal effect on extra-facial lesions.

OBJECTIVE

To assess different methods of enhancing the absorption of topical tacrolimus in extra-facial vitiligo sites using microneedling and occlusion.

METHODS

This study included 20 adult patients of both sexes with non-segmental vitiligo. Four extra-facial vitiligo lesions in each patient were randomly labeled A, B, C, and D and treated as follows: area A: tacrolimus ointment (0.03%) application twice/day, area B: microneedling once/week and tacrolimus ointment application directly after microneedling and twice/day the rest of the week, area C: microneedling once/week alone, and area D: tacrolimus ointment application twice/day under occlusion by polyethylene foil. The evaluation was done clinically by calculating the re-pigmentation percent after 6 months of treatment.

RESULTS

Responders in area B were 45%, and 35% in area C, and 25% in both areas A and D. No statistically significant difference was detected regarding the re-pigmentation percent between the four areas (p > 0.05). No correlations were detected between re-pigmentation percent and patients' data.

CONCLUSION

Combination of microneedling and topical tacrolimus has an edge over monotherapy in vitiligo, and further studies are needed to verify such results.

Topical Tacrolimus 0.1% for treatment of cutaneous microcystic lymphatic malformations

Microcystic lymphatic malformations as described in the international literature form a subgroup of low-flow congenital vascular malformations (VM) resulting from irregular embryological development. Microcystic lesions normally manifest as an accumulation of lymph- and blood-filled vesicles that, when externalized, cause skin maceration with consequent pain and potential infection resulting in the impairment of the patient's quality of life. There is no consensus on a standardized algorithm nor clear guidelines for successful treatment of this type of lymphatic malformation, and treatment options employed often result in ambivalent and transient outcomes with a high rate of recurrence. The topical formulation of tacrolimus is a well-known FDAapproved anti-T cell agent that was recently identified as a potent activator of ALK1, which is involved in several processes and functions including angiogenesis. We investigated if topical administration of tacrolimus may be an effective therapy for directly targeting cutaneous microcystic lymphatic malformations as a complement to systemic treatment. The study enrolled four patients with cutaneous microcystic lymphatic malformations: three male (ages: 13,15,18) and one female (age: 30). Two of the patients presented lesions on their backs, one patient on the left hand and one on the left lower limb. All four patients received treatment with topical tacrolimus 0.1% twice a day for 10 weeks on a previously selected area for application. Weekly clinical follow-ups were conducted along with close physician-patient contact. All patients displayed a satisfactory response after treatment. Lymphorrhea and bleeding were stopped in all cases and the esthetic aspect of lesions improved in two patients. To date, all patients presented no clinically significant changes to the size or extension of the lesion. Topical tacrolimus treatment is a promising and reasonable option for microcystic lymphatic malformations. Our results encourage further exploration in larger populations with the consideration that it is a safe and effective alternative or complementary therapy to systemic treatment.

Occlusive treatment enhances efficacy of tacrolimus 0.1% in a pediatric patient with severe alopecia areata: Case report and literature review

Tacrolimus is an immunomodulatory drug, available for topical and systemic treatment of several dermopathies that are characterized by immune dysregulation. In the case of alopecia areata, standard application has proven insufficient to yield satisfactory results. Herein, we present a 6-year-old patient with Down syndrome who was treated with topical tacrolimus 0.1% ointment under occlusion overnight with remarkable clinical improvement within 4 months.

Effectiveness and safety of topical tacrolimus in treatment of vitiligo

Vitiligo is one of the most primitive well-known dermatoid disorders with different suggested therapies. Therefore, this study investigated the efficiency and safety of topical tacrolimus in treatment of patients with vitiligo. This study was a clinical randomized designed study pre- post-test method, has been conducted on thirty cases with vitiligo who have referred to polyclinic and dermatology clinic. Participant's evaluated and demographic information recorded in designed checklist. In the next stage, the disease activity scored by vitiligo index disease activity system. Photography and depigmentation percent has recorded before treatment and further in 4^th, 8^th, 12^th, 16^th, 20^th, and 24^th weeks. Finally, gathered data compared through SPSS-20 software. The final sample comprised 30 persons including: 12 men (40%) and 18 women (60%). The average of patient's age in this study was 26/13 ± 18/20 (2-76-year-old). Eleven persons was ≤15 years old and rest was older than 15. Sixty-six lesions have funded in patients that maximum has accrued on face and neck (37/87%) and trunk (21/21%). In addition, minimum of lesions is related to genitalia (9/09%). In the in 4^th, 8^th, 12^th, 16^th weeks, improvement in face and neck had increased significantly, into the past weeks. In the 20^th and 24^th weeks, the improvement has increased although it was not significant enhancement. Also about trunk, in the 4^th week the improvement does not have significant increasing in compare to the past week. In the eighth, 12^th, 16^th, 20^th, and 24^th weeks the improvement has been increased significantly in compare to the past weeks. Although in the case of limbs and genitalia, the improvement was lower. There was no significant difference between male and females and age. Although the improvement was, slow in older persons. Study results, has presented applying topical tacrolimus in vitiligo, particularly in face and neck, could be effective and does not seen any specified adverse effects during consumption of tacrolimus, it could be effective in decreasing effects in use of corticosteroid.

Pyoderma gangrenosum following breast reduction: treatment with topical tacrolimus and steroids

Pyoderma gangrenosum (PG) is a rare, noninfectious, inflammatory dermatosis usually associated with autoimmune disorders. Wounds may mimic a necrotizing infection, and the diagnosis is usually made after antibiotic therapy fails. Debridement may cause even larger wounds because of pathergy, so PG treatment consists of corticosteroids and local wound care. Pyoderma gangrenosum can be a devastating complication of breast and aesthetic surgery. We describe a case of PG following unilateral breast reduction that resulted in systemic inflammatory response; after treatment with prednisone and topical tacrolimus, the PG was resolved. The application of topical tacrolimus may reduce the need for prolonged corticosteroids.

LEVEL OF EVIDENCE

5.

Topical tacrolimus as treatment of atopic dermatitis

Atopic dermatitis (AD) is a common, chronic, relapsing, severely pruritic, eczematous skin disease. The mainstays of treatment for AD are topical tacrolimus and topical steroids. Tacrolimus, a calcineurin inhibitor, not only complements existing treatment options but also overcomes some of the drawbacks of topical steroid therapy when given topically and thus meets the long-term needs of patients in preventing disease progression. Topical tacrolimus has been widely recognized in terms of its short- and long-term efficacies and safety, and it is also accepted as a first-line treatment for inflammation in AD. The recent proactive use of topical tacrolimus may emphasize a long-term benefit of this calcineurin inhibitor for AD treatment. To reduce possible long-term adverse effects, it is important to monitor its topical doses in daily clinics.