Dermatology Online Journal

Pimecrolimus 1 percent cream in the treatment of psoriasis in a child
Parvin Mansouri, and Susan Farshi
Dermatology Online Journal 12 (2): 7

Department of Dermatology, Tehran University of Medical Sciences, Imam Hospital, Keshavarz Blvd, Gharib St, Tehran, Iran. sfarshi@razi.tums.ac.ir

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Abstract

Psoriasis is a chronic inflammatory skin disorder of multifactorial etiology. Because of the potential side effects of repeated topical application of potent corticosteroids, equally-effective, safer therapeutic options are required, especially in the treatment of children. We report on the efficacy of twice daily application of pimecrolimus 1 percent cream in a girl who suffered from psoriasis involving the eyelids and anogenital region. After 20 days of application of pimecrolimus cream the plaques completely resolved. No significant side effects have been observed. Topical pimecrolimus appears to be an effective and safe treatment for children with psoriasis. Our case observations provide further evidence for the beneficial effects of topical pimecrolimus in the treatment of psoriasis. Vehicle-controlled studies on a larger number of patients are now needed to investigate long-term efficacy and safety of topical pimecrolimus in the treatments of a variety of types of psoriasis in children.

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Psoriasis vulgaris is a T-cell mediated inflammatory skin disease afflicting up to 2.5 percent of the world population [1, 2]. The disease is characterized by hyperproliferation of keratinocytes and inflammatory changes that lead to the clinical features of bright-red scaly plaques [3]. Symptoms may be mild or involve the entire body surface leading to exfoliative dermatitis. T cells, in particular, play a key role in the pathogenesis of this disease. Advances in psoriasis treatments are based on this key role of T cells in disease pathogenesis [2, 3]. One hypothesis is that keratinocyte hyperproliferation is triggered by soluble mediators released by T cells. Removal of the activated pathogenic T-cell population would be expected to ameliorate the disease process [3, 4]. Pimecrolimus cream 1 percent (Elidel®, Novartis Pharmaceuticals) is a medication in the new class of immunomodulating macrolactams. It has significant anti-inflammatory activity and low systemic immunosuppressive potential. The mechanism of action of pimecrolimus is blockage of T-cell activation [5, 6]. We therefore investigated the efficacy and safety of topical pimecrolimus in a girl who had eyelid and anogenital psoriasis.

Clinical synopsis

A 10-year-old girl presented with a 2-year history of sharply demarcated, thick, scaly plaques in her periorbital (Figs. 1A, 1B) and anogenital (Figs. 2A, 2B) regions. She had a history of erythematous scaly plaques on several areas of the body for many years. The diagnosis of psoriasis was confirmed by pathology from a truncal biopsy. Histologic features included focal parakeratosis that contained fragmented nuclei and spongiform pustules, regular acanthosis, and elongated club-shaped rete ridges of the epidermis. Papillary dermal changes included edema, ectatic capillary vessels, and perivascular infiltration of lymphocytes, histiocytes, and a few neutrophils, with random eosinophils (Fig. 3). The remainder of her physical examination was unremarkable. She was otherwise healthy and there was no family history of psoriasis.

Figure 1A	Figure 1B
Eyelid involvement of the affected child with psoriasis

Figure 1C	Figure 1D
Eyelids after 3-weeks twice-daily application of pimecrolimus 1 percent cream

Figure 2A	Figure 2B
Anogenital involvement of the affected child with psoriasis

Figure 2C	Figure 2D
Anogenical area after 3-weeks twice-daily application of pimecrolimus 1 percent cream

Figure 3A	Figure 3B
Skin biopsy from a small plaque in the lower abdominal wall of the affected child.

Treatment with betamethasone 0.1 percent ointment and calcipotriol 0.005 percent ointment (Dovonex® ointment, Leo, Denmark) did not provide long term effectiveness. Pimecrolimus 1 percent cream was applied in a thin layer to the affected areas without occlusion twice daily. After 20 days of topical application of pimecrolimus 1 percent cream, erythema, induration, and scaling were evaluated. As seen in the figures 1C, 1D, 2C, and 2D, the psoriatic lesions completely resolved. She continued her treatment of pimecrolimus 1 percent cream for 2 months. The patient showed no recurrence of disease activity 2 months after discontinuation of therapy.

Conclusion

Pimecrolimus belongs to the ascomycin class of macrolactam immunosuppressives and acts by the inhibition of T-cell activation via the calcineurin pathway and inhibition of the release of cytokines and proinflammatory mediators from mast cells [5]. Pimecrolimus cream 1 percent has been proven efficacious in long term management of atopic dermatitis in infants, children, and adults [7]. Atrophy of the skin limits the long term use of highly potent topical steroids in clinical practice so there is a need for alternative effective and safe treatments of psoriasis in children [8]. In addition, topical steroid use on the eyelids has the potential to induce glaucoma and cataracts with long-term use. In contrast to high potency topical corticosteroids, pimecrolimus did not induce skin atrophy in a double blind study [8]. Therefore, pimecrolimus may be an important treatment option for children.

A recent clinical trial demonstrated that pimecrolimus was significantly more effective than vehicle, but less effective than calcipotiol and clobetasol ointment in the treatment of psoriasis [9]. Pimecrolimus, has been shown to be effective in the treatment of plaque-type psoriasis when applied topically under occlusion, comparable to treatment with clobetasol propionate [10, 11]. Several case reports indicate that topical tacrolimus without occlusion is effective in the treatment of psoriasis on the face and intertriginous areas [10]. In a study of topical application of pimecrolimus for inverse psoriasis, the drug was found to be effective [12]. The oral administration of pimecrolimus was effective and well tolerated in a multicenter study [13].

On the basis of our case observation, pimecrolimus 1 percent cream appears to be a safe and effective treatment for children with plaque type psoriasis involving periorbital and anogenital regions. Because this was an open clinical trial rather than a controlled study, we cannot exclude the possibility that the benefit observed was the result of the vehicle. The excellent clinical response in our patient suggests that controlled studies to evaluate efficacy of topical pimecrolimus for the treatment of psoriasis are indicated.

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