Severe Tacrolimus-Induced Granulomatous Rosacea Recalcitrant to Oral Tetracyclines

June 2015 | Volume 14 | Issue 6 | Case Reports | 628 | Copyright © June 2015


Lissy Hu BA,a Christina Alexander BA,b Nicole F. Velez MD,c F. Clarissa Yang MD,c
Alvaro Laga Canales MD MMSc,c,d Stephanie Liu MD,c and Ruth Ann Vleugels MD MPHc,

aHarvard Medical School, Boston, MA
bDivision of Dermatology, University of Arizona, Tucson, AZ
cDepartment of Dermatology, Brigham and Women’s Hospital, Boston, MA
dDepartment of Pathology, Brigham and Women’s Hospital, Boston, MA

D. folliculorum is one precipitant) plays a central role in the pathogenesis.10 Pimecrolimus cream, another topical calcineurin inhibitor, has also been reported to induce rosaceiform eruptions.11-14 However the eruptions associated with pimecrolimus cream, which is mostly water-based, are less severe than those reported with tacrolimus ointment due to the occlusive properties of the latter.11
To the best of our knowledge, severe GR induced by tacrolimus and recalcitrant to tetracyclines has not previously been reported. In prior case reports, patients improved within a few months after topical tacrolimus was withdrawn and oral doxycycline or minocycline was initiated. The severity of this patient’s eruption may correspond to the duration of tacrolimus use, which spanned multiple years, given that topical tacrolimus can disrupt epidermal permeability and antimicrobial function by impairing skin-barrier recovery, as shown in recent studies.15 These barrier-recovery deficiencies, acquired over long-term use of tacrolimus, may have predisposed our patient to a more severe eruption and protracted recovery. Accordingly, our patient required aggressive treatment with multiple topical therapies in conjunction to oral tetracyclines.
Topical tacrolimus is generally a well-tolerated medication that is used successfully for a variety of conditions. Although tacrolimus-induced granulomatous rosacea is rarely reported, recognition of the entity is important, and successful treatments strategies may include combining systemic and topical therapies with chemical peels.

DISCLOSURES

The authors have no conflicts of interest to declare.

REFERENCES

  1. Fonacier L, Spergel J, Charlesworth EN, et al. Report of the Topical Calcineurin Inhibitor Task Force of the American College of Allergy, Asthma and Immunology and the American Academy of Allergy, Asthma and Immunology. J Allergy Clin Immunol. Jun 2005;115(6):1249-1253.
  2. Wollina U. The role of topical calcineurin inhibitors for skin diseases other than atopic dermatitis. Am J Clin Dermatol. 2007;8(3):157-173.
  3. Reitamo S, Rustin M, Ruzicka T, et al. Efficacy and safety of tacrolimus ointment compared with that of hydrocortisone butyrate ointment in adult patients with atopic dermatitis. J Allergy Clin Immunol. Mar 2002;109(3):547-555.
  4. Fujiwara S, Okubo Y, Irisawa R, Tsuboi R. Rosaceiform dermatitis associated with topical tacrolimus treatment. J Am Acad Dermatol. Jun 2010;62(6):1050-1052.
  5. Teraki Y, Hitomi K, Sato Y, Izaki S. Tacrolimus-induced rosacea-like dermatitis: a clinical analysis of 16 cases associated with tacrolimus ointment application. Dermatology. 2012;224(4):309-314.
  6. Antille C, Saurat JH, Lübbe J. Induction of rosaceiform dermatitis during treatment of facial inflammatory dermatoses with tacrolimus ointment. Arch Dermatol. Apr 2004;140(4):457-460.
  7. Bernard LA, Cunningham BB, Al-Suwaidan S, Friedlander SF, Eichenfield LF. A rosacea-like granulomatous eruption in a patient using tacrolimus ointment for atopic dermatitis. Arch Dermatol. Feb 2003;139(2):229-231.
  8. Roihu T, Kariniemi AL. Demodex mites in acne rosacea. J Cutan Pathol. Nov 1998;25(10):550-552.
  9. Amichai B, Grunwald MH, Avinoach I, Halevy S. Granulomatous rosacea associated with Demodex folliculorum. Int J Dermatol. Oct 1992;31(10):718-719.
  10. Steinhoff M, Buddenkotte J, Aubert J, et al. Clinical, cellular, and molecular aspects in the pathophysiology of rosacea. J Investig Dermatol Symp Proc. Dec 2011;15(1):2-11.
  11. Lübbe J, Stucky L, Saurat JH. Rosaceiform dermatitis with follicular Demodex after treatment of facial atopic dermatitis with 1% pimecrolimus cream. Dermatology. 2003;207(2):204-205.
  12. Gorman CR, White SW. Rosaceiform dermatitis as a complication of treatment of facial seborrheic dermatitis with 1% pimecrolimus cream. Arch Dermatol. Sep 2005;141(9):1168.
  13. El Sayed F, Ammoury A, Dhaybi R, Bazex J. Rosaceiform eruption to pimecrolimus. J Am Acad Dermatol. Mar 2006;54(3):548-550.
  14. Yoon TY, Kim HJ, Kim MK. Pimecrolimus-induced rosacea-like demodicidosis. Int J Dermatol. Oct 2007;46(10):1103-1105.
  15. Jung YJ, Jung M, Kim M, Hong SP, Choi EH. IL-1α stimulation restores epidermal permeability and antimicrobial barriers compromised by topical tacrolimus. J Invest Dermatol. Mar 2011;131(3):698-705.

AUTHOR CORRESPONDENCE

Ruth Ann Vleugels MD MPH…….................................... rvleugels@partners.org
Previous presentations of this manuscript: Presented in poster form at the International Investigative Dermatology meeting 2013
Close Menu