ARTICLE
Auteur(s) : Filiz Canpolat1,
Bengü Çevirgen Cemil1, Semih Tatlican1, Fatma
Eskioglu1, Murat Oktay2, Murat
Alper2
1Department of Dermatology
2Ministry of Health Diskapi Yildirim Beyazit
Education and Research Hospital, Department of Pathology,
Ankara, Turkey
The mechanism of action of pimecrolimus is blockage of T-cell
activation, blocking signal transduction pathways in T cells, and
inhibition of the synthesis of inflammatory cytokines which play a
key role in the pathogenesis of psoriasis. The highly lipophilic
nature of this compound reduces the risk of systemic absorption
through normal and inflammed skin [1]. Childhood psoriasis requires
a treatment approach other than topical corticosteroids which carry
the risk of skin atrophy and percutaneous absorptions. We therefore
investigated the efficacy and safety of topical pimecrolimus in an
infant.
Case report
A 6-month-old-girl presented with a 3 month history of confluent
thick scaly plaques on the trunk, extremities and scalp, and
erythema in the diaper area. She was treated with topical steroids
which were ineffective. Cutaneous examination revealed widespread
erythematous thick scaly plaques and the diaper area was involved
with sharply demarcated, bright red, non-scaly plaques. Thick,
silvery, scaling plaques diffusely involved the scalp (figures 1A, B). There was
no nail involvement. The Auspitz sign was positive. The diagnosis
of psoriasis was confirmed pathologically. She was otherwise
healthy and there was no family history of psoriasis. First we used
3% salicylic acid gel without occlusion twice daily for 5 days to
thin the affected areas and increase penetration of the
pimecrolimus cream. After one month of topical application of
pimecrolimus 1% cream, the psoriatic lesions completely resolved
with post-inflamatory hypopigmentation (figures 1C, D). No
significant side effects were observed. Then pimecrolimus was
stopped. The patient has shown no recurrence of disease activity 17
months after discontinuation of therapy.
Discussion
Because long-term application of corticosteroids is associated with
well-known adverse effects, such as skin atrophy and percutaneous
absorptions, especially in areas such as inguinal folds and
genitals, new therapeutic alternatives for these regions have been
investigated. Thus pimecrolimus was started for use in the therapy
of inverse psoriasis. 1% pimecrolimus has been investigated for the
treatment of intertriginous psoriasis in double-blind, vehicle
controlled studies and shown to be safe and effective [2]. Besides
this, pimecrolimus has recently been shown to be safe and effective
for the treatment of atopic dermatitis and facial psoriasis [1, 3].
In addition, to our knowledge, only one case report has described
complete clearing of psoriatic lesions in a child [4].
Pimecrolimus inhibits T-cell proliferation and production and
the release of pro-inflammatory cytokines including interleukin-2
(IL-2), IL-4, interferon-γ (INF-γ) and tumor necrosis factor-α
(TNF-α) which play a crucial role in the pathogenesis of psoriasis
[1]. Pimecrolimus has been shown to be effective in the treatment
of plaque psoriasis in adults when applied under occlusion [4].
Gisondi et al. concluded that pimecrolimus may well work in
psoriasis, particularly when lesions are not keratotic and are
localized on the face or skin folds [1]. In our case, salicylic
acid was preferred to occlusion, to increase penetration. In
contrast to corticosteroids, pimecrolimus does not affect
endothelial cells and fibroblasts, and therefore does not induce
skin atropy [5]. The propensity of pimecrolimus to pass through the
skin is about 90 times lower than corticosteroids [6].
On the basis of our case observation, pimecrolimus 1% cream
appears an effective and safe treatment option for infants with
plaque psoriasis involving the anogenital region. Its main
advantages compared with conventional topical corticosteroid
therapy are that it is more selective in its mode of action, does
not induce skin atrophy and is not associated with significant
systemic absorption. Future studies are warranted to further
evaluate the effects of pimecrolimus in the long term use of
childhood psoriasis.
Acknowledgements
Financial support: none. Conflict of interest: none.
References
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2 Kreuter A, Sommer A, Hyun J, et al. 1%
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Treatment of Intertriginous Psoriasis. Arch Dermatol 2006; 142:
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5 Queille-Roussel C, Paul C, Duteil L,
et al. The new topical ascomycin derivative SDZ ASM 981 does
not induce skin atropy when applied to normal skin for 4 weeks: a
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507-13.
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Percutaneous absorption of drugs used in atopic eczema:
pimecrolimus permeates less through skin than CS and tacrolimus.
Int J Pharmacol 2004; 269: 29-35.
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