LETTER
Tacrolimus To Treat Pyoderma Gangrenosum Resistant to Cyclosporine
Renata D'Inca, MD;
Stefano Fagiuoli, MD; and
Giacomo Carlo Sturniolo, MD
1 May 1998 | Volume 128 Issue 9 | Pages 783-784
TO THE EDITOR:
Steroids and, recently, cyclosporine, are effective in the treatment of most pyodermic lesions [1]. Tacrolimus, a new immunosuppressive drug, inhibits T-cell activation by blocking receptor-mediated signal transduction pathways [2, 3].
A 30-year-old man developed ileocolonic Crohn disease complicated by perianal fistula in 1984. After two ileal resections, he received maintenance therapy with sulfasalazine (4 g/d) until May 1996, when steroid therapy was started for a clinical relapse. On 25 July 1996, the patient noted diarrhea with purulent discharge from his perianal fistula and developed painful swelling and a synovial effusion of the right knee. Soon after, a 5-cm painful pustula appeared on the pretibial area. The cutaneous lesion ulcerated; produced a purulent, necrotic discharge, and had deep purple, undermined edges. Cultures of the lesion were negative.
Therapy with intravenous cyclosporine (4 mg/kg of body weight per day) was started. This was changed to oral therapy at 1 week, and the blood level of the agent was maintained between 150 and 350 ng/mL. The pyodermic lesion partly re-epithelialized in 10 days, and the patient's clinical condition steadily improved and remained stable for the following month.
On 15 October 1996, the patient was readmitted with fever (body temperature, 38 °C); severe pain in the left leg; and a 15-cm area of necrotic, purulent discharge at the site of the previous lesion, which was surrounded by multiple small, purple, satellite pustulae. Despite a combination of cyclosporine and systemic antibiotics, the ulcerative lesion deepened and spread over the whole circumference of the leg. On 26 October 1996, oral therapy with tacrolimus (0.1 mg/kg per day) was started. Within a few days, wide areas of granulation tissue became evident, and re-epithelialization was complete in 1 month. Tacrolimus therapy was discontinued in March 1997, and the patient remains in remission with azathioprine maintenance therapy alone after 10 months.
Tacrolimus can effectively and safely treat highly destructive cyclosporine-resistant pyoderma gangrenosum.
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Author and Article Information
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University of Padua; 35127 Padua, Italy
1. Hughes JR, Smith E, Higgins EM, Berry H, du Vivier AW. Pyoderma gangrenosum in a patient with rheumatoid arthritis responding to treatment with cyclosporin A. Br J Rheum. 1994; 33:680-1.
2. Abu Elmagd K, Jegasothy BV, Ackerman CD, Thomson AW, Rilo H, Nikolaidis N, et al. Efficacy of FK 506 in the treatment of recalcitrant pyoderma gangrenosum. Transplant Proc. 1991; 23:3328-9.[Medline]
3. Cooley HM, Castelino D, McNair P, Russell DM, Chohan V, Kay TW, et al. Resolution of pyoderma gangrenosum using tacrolimus (FK-506). Aust N Z J Med. 1996; 26:238-9.
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