ARTICLE
Sir,
We read with interest the report by Yosahimasu and colleagues of the
use of 0.1% tacrolimus ointment in patients with various forms of lupus
erythematosus [1]. In contrast to their experience in patients with chronic
discoid lupus erythematosus (CDLE), we have recently had success in treating
two patients with severe recalcitrant CDLE with a compound preparation
of 0.3% tacrolimus in 0.05% clobetasol propionate ointment. The details
of these cases will shortly be published in the British Journal of Dermatology
but are described here in brief. A 54-year-old woman with systemic lupus
erythematosus and recalcitrant CDLE (Fig. 1) who
had failed to respond to antimalarials, thalidomide and very potent topical
corticosteroids was treated with 0.3% tacrolimus in 0.05% clobetasol propionate.
A dramatic improvement was noted within 10 days and has been maintained
over a period of six months (Fig. 2). A similar
response to this novel therapy has also been achieved in a 52-year-old
woman whose CDLE was not controlled by a combination of very potent topical
corticosteroids, hydroxychloroquine, mepacrine and prednisolone.
Because 0.3% tacrolimus in 0.05% clobetasol propionate has been used
successfully in our department to manage pyoderma gangrenosum [2], we
chose to use this preparation in two patients who had failed to respond
to other measures including potent topical corticosteroids. None of three
patients with CDLE treated by Yoshimasu's group with 0.1% tacrolimus ointment
showed any improvement; one patient with erythematous lupus and all three
with systemic lupus did improve. The authors suggest that low absorption
or unresponsiveness of target cells may be responsible. We would like
to suggest that the former explanation may be correct and that the tissue
concentrations achieved with the 0.1% ointment may have been sufficient
for patients with less infiltrated forms of cutaneous lupus but inadequate
in those with chronic discoid plaques. It is also possible that the combination
of tacrolimus with corticosteroids had an additive or even synergistic
effect. More formal studies are now required to confirm the place of topical
tacrolimus in the management of cutaneous lupus but these initial experiences
suggest that it may prove to have significant advantages over current
therapy options.
References
1. Yoshimasu T, Ohtani T, Oshima A, et al. Topical FK506
(tracrolimus) therapy for facial erythematous lesions of cutaneous lupus
erythematosus and dermatomyositis. Eur J Dermatol 2002; 12: 50-2.
2. Lyon CC, Smith AJ, Beck MH, et al. Parastomal pyoderma
gangrenosus: clinical features and management. J Am Acad Dermatol
2000; 42: 992-1002.
 
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