The use of topical calcineurin inhibitors for pyoderma gangrenosum in inflammatory bowel disease: A case series

Abstract

Introduction: Pyoderma gangrenosum (PG) is rare cutaneous condition characterized by ulcerative lesions with neutrophilic infiltrates, which can be seen in patients with systemic diseases, including inflammatory bowel disease (IBD). Tacrolimus and pimecrolimus are calcineurin inhibitors (CNIs) that can be applied topically for the management of PG; however, to date there have only been small-scale cohort studies and small case series evaluating their efficacy. We present six cases of topical CNI use in patients with IBD and report their safety and efficacy in the management of PG. Methods: We reviewed six patients with IBD who were managed with either topical tacrolimus (0.03%-0.1%) or pimecrolimus (1%) for PG across three tertiary centres. Results: Our cases are summarized in Table 1. The cohort was predominantly female (83%), with a mean age of 32.8 years, with severe stricturing (50%) or fistulizing Crohn's disease (50%), including one patient who expressed both phenotypes. Overall, 67% of our cohort were anti-tumor necrosis factor (anti-TNF)-experienced and 83% had previous diseaserelated surgical resections. The mean time to first clinical response was 3.2 weeks (range, 1-8 weeks). The mean duration of treatment was 12.2 weeks, excluding one patient who is still in the seventh week of treatment. Complete resolution of the lesion was achieved in 83% of patients; however, there was recurrence in two patients at 2 weeks and 12 months, respectively. Response was recaptured in these two patients with CNI therapy at 1 week and 4 weeks, respectively. There were no documented side effects to either CNI. Conclusion: In our case series, topical therapy with tacrolimus or pimecrolimus appears to be a safe and effective option in the management of PG among both anti-TNF-experienced and -naive patients with IBD. Treatment response was noted to be rapid and seen as early as Week 1. There are currently no recommendations on the optimal treatment formulation and duration of CNI therapy. Larger-scale studies are needed to confirm these findings and guide the use of topical CNI in clinical practice.