Generalized pustular psoriasis successfully treated with topical tacrolimus

Abstract

abscesses, and severe necrotizing pneumonia. 1 Gillet et al. pointed out that PVL-positive strains of S. aureus cause rapid progressive severe necrotic pneumonia in otherwise healthy children and young adults. 2 We report an immunocompromised patient with tendon destruction associated with PVLpositive S. aureus infection.A 62-year-old woman with Sézary syndrome, a leukaemic variant of cutaneous T-cell lymphoma, had received oral prednisolone 10 mg daily for 2 years. She also suffered from diabetes and recurrent bacterial skin infections. She developed a painful abscess on the dorsum of her right hand associated with a low-grade fever (Fig. 1). Laboratory investigations showed a white blood cell count of 22AE4 · 10 9 L )1 with 51% neutrophils, 4% lymphocytes, 2AE5% monocytes and 41% atypical lymphocytes. C-reactive protein was 2AE1 mg dL )1 . No radiological signs of osteomyelitis were noted. Bacterial cultures from the abscess yielded methicillin-resistant S. aureus. Polymerase chain reaction amplification detected the PVL gene from the strain, and the nucleotide sequence of PVL was confirmed by direct sequencing. Enterotoxins and toxic shock syndrome toxin-1 were not detected in the supernantants. Blood cultures were negative. She was treated with surgical drainage and a combination of fosfomycin, albekacin sulphate and ampicillin sodium ⁄sulbactam sodium. Although the abscess slowly improved, an extension disturbance of the finger appeared due to destruction of the tendons of the extensor digitorum muscle a few days later, and this did not improve.Although hand infections in diabetic patients result in more deep-space infections, osteomyelitis, tenosynovitis, deformity and permanent disability than in nondiabetic patients, 3 subcutaneous abscesses rarely causes tendon damage. Our case suggests that PVL may cause tendon destruction when PVL-producing S. aureus infects immunocompromised hosts.

Japanese guidelines for the management and treatment of generalized pustular psoriasis: The new pathogenesis and treatment of GPP

“…Comments: The efficacy of topical tacrolimus in pustular psoriasis has been shown only in two case reports and not in clinical studies. In addition, unlike topical steroids or topical active form vitamin D 3 , topical tacrolimus has been used less frequently, and therefore accumulation of further studies is required to discuss the efficacy.…”

Tacrolimus for the management of psoriasis: clinical utility and place in therapy

“…A number of case reports and small case series have suggested that topical tacrolimus treatment is effective for generalized pustular psoriasis, 29 , 30 palmoplantar pustular psoriasis, 31 and oral psoriasis. 32 , 33 Topical tacrolimus and excimer laser treatment was effective for a patient with inverse psoriasis; it was postulated that the laser therapy decreased the thickness of the epidermis and thus facilitated penetration of the topical preparation, which lead to a reduction in the number of cutaneous nerve fibers and diminished pruritus.…”

Pustular psoriasis: pathophysiology and current treatment perspectives

“…The recommended second-line therapies include adalimumab, etanercept, psoralen plus ultraviolet-A (PUVA) phototherapy, topical corticosteroids, topical calcipotriene, and topical tacrolimus, or combination therapy for recalcitrant disease (which includes a first-line oral systemic agent plus a biologic agent such as adalimumab or etanercept). 18 , 40 – 45 The initial use of infliximab to treat severe acute disease, followed by treatment with etanercept has also been reported to be successful. 18 The use of systemic steroids is generally avoided when treating pustular psoriasis, given the risk of worsening disease following withdrawal of the medication.…”