Topical pimecrolimus in the treatment of seborrheic dermatitis
1. Department of Dermatology, Baylor College of Medicine Houston, TX 2. Carolinas Dermatology Group Columbia, SC. email@example.com
Isaac Brownell MD PhD,1 Long T Quan MD PhD,2 and Sylvia Hsu MD1
Dermatology Online Journal 9(3): 13
Seborrheic dermatitis is a chronic inflammatory disease that mainly affects seborrheic areas of skin. An inflammatory response to the yeast Pityrosporum ovale has been thought to be important in the etiology of the condition. Therefore, topical antifungals and corticosteroids have been the mainstay of treatment. The recent development of topical macrolactam immunomodulators has offered a useful, safe alternative to corticosteroids in the treatment of various inflammatory skin disorders. We report successful treatment of seborrheic dermatitis with pimecrolimus.
|Figure 1||Figure 2|
|Scattered scaly patches on forehead, nasal bridge, and scalp line (Fig. 1). One month followup showing complete clearance (Fig. 2).|
An 18-year-old woman with no significant past medical history presented with a 1-year history of asymptomatic lesions on her face. On physical examination, there were scattered, scaly patches on her forehead, nasal bridge, and scalp line (Fig. 1). She had been treated with ketoconazole cream, ketoconazole 2 % shampoo, and hydrocortisone 1 % cream without improvement. A skin biopsy confirmed the diagnosis of seborrheic dermatitis. The patient was prescribed pimecrolimus cream twice daily. On followup at 1 month the eruption had completely cleared (Fig. 2).
Seborrheic dermatitis is a chronic inflammatory disease arising in areas with high concentrations of sebaceous glands. The etiology of seborrheic dermatitis in unclear, but many factors including genetics, environment, hormonal status, and immunocompetence have been implicated. An inflammatory reaction to the commensal lipophilic yeast Pityrosporum ovale has been proposed to play a central role in the evolution of this disorder. Consistent with this observation, antimycotic preparations can be effective in the treatment of seborrheic dermatitis.
Management of seborrheic dermatitis starts with frequent cleansing of affected areas to remove oils. Topical antifungals and topical corticosteroids are first-line pharmacological treatments. In severe disease, keratolytics such as salicylic acid or coal tar are used to reduce adherent scale. When faced with severe refractory disease, isotretinoin (Accutane®) can be used as a sebosuppressive agent. Although these therapies are effective in most cases, there are potential side effects to consider. The use of topical corticosteroids is associated with skin atrophy, hirsutism, and telangectasia formation. For this reason, steroids are used with reluctance on the face, axillae, and groin—all common sites for seborrheic dermatitis. Likewise, isotretinoin is a teratogen that can cause hyperlipidemia and hepatitis.
The recent development of topical macrolactam immunomodulators has offered an alternative to corticosteroids in the treatment of inflammatory skin diseases such as atopic dermatitis, psoriasis, pyoderma gangrenosum, and allergic contact dermatitis.[4, 5, 6, 7]
Pimecrolimus (Elidel®), an ascomycin macrolactam derivative, binds macrophilin-12 (FKBP-12) and acts by inhibiting calcineurin, the same target as that of the systemic immunosuppressant cyclosporine. Without the phosphatase activity of calcineurin, nuclear factor of activated T-cells (NF-AT) cannot translocate to the nucleus and activate transcription of proinflammatory cytokines, including IL-2, IL-3, IL-4, IL-5, IL-10, GMCSF, and TNF-α. Thus, inhibition of NF-AT by pimecrolimus blocks the formation of cytokines required for helper T-cell activation. Similarly, pimecrolimus is thought to prevent mast-cell degranulation and inhibit Langerhans cell function. Here we report that seborrheic dermatitis is responsive to the anti-inflammatory effects of pimecrolimus-mediated immunomodulation. This finding is consistent with the observation that seborrheic dermatitis lesions show cellular infiltrates with increased production of inflammatory cytokines.
Pimecrolimus is well tolerated, with burning or a feeling of warmth at the application site being the most frequently reported adverse event (up to 26 % of patients). Unlike topical steroids, pimecrolimus does not inhibit epidermal growth or collagen synthesis and shows no risk of epidermal atrophy or striae distensae. Topical pimecrolimus is minimally absorbed into the blood and essentially avoids systemic side effects.
References1. Crutchfield CE 3rd. Pimecrolimus: a new treatment for seborrheic dermatitis. Cutis 2002;70(4):207-8.
2. Johnson BA, Nunley JR. Treatment of seborrheic dermatitis. Am Fam Physician 2000; 61(9):2703-10, 2713-4.
3. Faergemann J, Bergbrant IM, Dohse M, Scott A, Westgate G. Seborrhoeic dermatitis and Pityrosporum (Malassezia) folliculitis: characterization of inflammatory cells and mediators in the skin by immunohistochemistry. Br J Dermatol 2001; 144(3):549-56.
4. Bornhovd E, Burgdorf WH, Wollenberg A. Macrolactam immunomodulators for topical treatment of inflammatory skin diseases. J Am Acad Dermatol 2001; 45(5):736-43.
5. Nghiem P, Pearson G, Langley RG. Tacrolimus and pimecrolimus: from clever prokaryotes to inhibiting calcineurin and treating atopic dermatitis. J Am Acad Dermatol 2002; 46(2): 228-41.
6. Wellington K, Jarvis B. Topical pimecrolimus: a review of its clinical potential in the management of atopic dermatitis. Drugs 2002:62(5):817-40.
7. Ling MR. Topical tacrolimus and pimecrolimus: future directions. Semin Cutan Med Surg 2001; 20(4):268-74.
© 2003 Dermatology Online Journal