a r c h s o c e s p o f t a l m o l .

2 0 1 6;9 1(1 0):505–507

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ESPAÑOLA DE OFTALMOLOGÍA

www.elsevier.es/oftalmologia

Short communication

Topical tacrolimus 0.03% for the treatment of ocular

psoriasis夽

P. Rodríguez-Ausín a,∗ , D. Antolín-Garcia a , M. Ruano del Salado b , C. Hita-Antón a

a Departamento de Oftalmología, Hospital Universitario de Torrejón, Torrejón de Ardoz, Madrid, Spain
b Departamento de Dermatología, Hospital Universitario de Torrejón, Torrejón de Ardoz, Madrid, Spain

a r t i c l e i n f o a b s t r a c t

Article history: Objective/methods: Cases are presented of 4 patients suffering from severe symptoms due to
Received 7 August 2015 ocular psoriasis and who were treated with off-label 0.03% tacrolimus once a day.
Accepted 19 March 2016 Results/conclusions: All four patients had a mixed blepharitis and keratitis. Pseudopterygium
Available online 6 July 2016 and corneal opacities were present in three of them. All of them experienced an improve-
ment of their itching and ocular surface. They all referred to a marked improvement of their
Keywords: quality of life in a follow-up period ranging from six months to two years. Therefore, topical
Tacrolimus tacrolimus could be considered an option in the treatment of ocular psoriasis.
Ocular psoriasis © 2016 Sociedad Española de Oftalmologı́a. Published by Elsevier España, S.L.U. All rights
Psoriasis reserved.
Blepharitis
Pseudopterygium

Tacrolimus tópico al 0,03% en el tratamiento de la psoriasis ocular

r e s u m e n

Palabras clave: Objetivo/método: Presentamos una serie de 4 pacientes afectos de psoriasis ocular con sin-
Tacrolimus tomatología severa, a los que se indicó tratamiento off label con tacrolimus tópico al 0,03%
Psoriasis ocular una vez al día.
Psoriasis Resultados/conclusión: La blefaritis mixta y queratitis es común a los 4, y en 3 casos hay seu-
Blefaritis dopterigión y opacidades corneales. Se apreció mejoría subjetiva del prurito en 2 semanas,
Seudopterigión y al mes mejoría de la superficie. Todos manifiestan mejoría significativa de su calidad de
vida tras un rango de seguimiento de 6 meses a 2 años. El tacrolimus tópico puede ser
considerado una opción en el tratamiento de la psoriasis ocular.
© 2016 Sociedad Española de Oftalmologı́a. Publicado por Elsevier España, S.L.U. Todos
los derechos reservados.

夽
Please cite this article as: Rodríguez-Ausín P, Antolín-Garcia D, Ruano del Salado M, Hita-Antón C. Tacrolimus tópico al 0,03% en el
tratamiento de la psoriasis ocular. Arch Soc Esp Oftalmol. 2016;91:505–507.
∗
Corresponding author.
E-mail address: pazrausin@telefonica.net (P. Rodríguez-Ausín).
2173-5794/© 2016 Sociedad Española de Oftalmologı́a. Published by Elsevier España, S.L.U. All rights reserved.
506 a r c h s o c e s p o f t a l m o l . 2 0 1 6;9 1(1 0):505–507
Introduction
Psoriasis is a relatively frequent inflammatory skin disease,
affecting up to 2% of the population and diminishing quality
of life in 80% de patients.1 Ocular psoriasis rates are not pre-
cisely determined but range between 10 and 67% according to
different authors.2 A series of 4 patients with ocular psoria-
sis is presented, who experienced quality of life improvement
after beginning treatment with 0.03% topical tacrolimus.
Clinic case reports
Patients
Four patients, 2 males and 2 females, with a mean age of
72 ± 2.82 years, with psoriasis since youth and experiencing
pruritus and chronic ocular discomfort. All four exhibited
mixed blepharitis (Fig. 1) and inferior keratitis punctata, while
3 had circumferential pseudopterygium (Fig. 2) and corneal
opacities. In one of the patients (Fig. 3), the right eye (RE)
exhibited severe thinning and topographic signs of sec-
ondary ectasia. Palpebral hygiene measures for blepharitis
Fig. 1 – Mixed blepharitis, the most frequent finding
in psoriasis.
Fig. 2 – Circumferential pseudo-pterygium with small
vessels and whitish line parallel to the limbus.
Fig. 3 – Chronic corneal involvement with a nasal
pseudo-pterygium over stromal thinning and leukomae.
and oral doxycycline were insufficient, with a patient experi-
encing relapse after suspending said treatment. Topical 0.5%
cyclosporine in oily carrier (middle chain triglycerids) was
applied although intolerance arose in all cases. After obtaining
the authorization of the pharmacy committee of the hospital
and requesting the patient to sign an informed consent, off
label utilization of 0.03% topical tacrolimus was prescribed in a
preparation with vaseline, supplied by the hospital pharmacy.
The prescription established 2 daily applications for the first
15 days, followed by an indefinite single nocturnal main-
tenance application. Subjective improvement appeared in 2
weeks, and after one month pruritus and keratitis diminished,
while lacrimal film stabilized. In one case, keratitis disap-
peared at month 3. Gradual reduction of applications up to
one weekly application at 6 months follow-up was consid-
ered. Follow-up ranged between 3 months and 3 years, without
adverse effects. All patients referred substantial changes in
their quality of life and none required systemic treatment for
psoriasis.
Discussion
Psoriasis is a chronic disease, the elementary lesion of which
is a scale-covered erithematous papula with highly variable
clinic and evolution. Ocular symptoms as frequently underes-
timated in psoriasis patients, with doctors or patients failing
to appreciate the possible connection with the base disease.
Extracutaneous expressions are infrequent although, due to
the epithelial nature of psoriasis, ocular involvement must be
considered in addition to the possible existence of psoriasis
plaque on the skin of the eyelids.1
In a review on ocular psoriasis, Rehal et al.2 described
mixed blepharitis as the most prevalent ocular finding, with
burning and itching as the most frequent symptoms. Psori-
asis tends to respect the face and therefore the appearance
of facial lesions is considered a severity marker. Psoria-
sis plaque rarely appears on the eyelids and is treated on
the basis of corticoids and equivalent medications such as
 a r c h s o c e s p o f t a l m o l . 2 0 1 6;9 1(1 0):505–507
tacrolimus. Nonspecific chronic conjunctivitis and/or yellow-
reddish plaque can appear on the palpebral conjunctiva and
in addition 18% of patients suffer dry eye due to lacrimal
gland involvement as in other selfimmune systemic diseases.2
Corneal disease is very rare, normally secondary to dry eye
and trichiasis. The most common finding is keratitis punctata,
although the clinic range comprises opacities, sterile infil-
trates, neovascularization, cicatrization and severe peripheral
ulcerative keratitis.3
Additional ocular involvement of psoriasis includes ante-
rior uveitis and Birdshot chorioretinopathy. The side effects of
psoriasis treatments cannot be dismissed, such as isotretinoin
and methotrexate, with possible involvement of the ocular
posterior pole by the former (neuropathy, maculopathy) and
keratitis and dry eye by the latter. Doxycycline should not be
utilized simultaneously with isotretinoin as it increases its
neurological toxicity.
The 4 patients of the series have chronic blepharitis, 3 with
a significant corneal involvement that indicates chronicity
such as circumferential pseudopterygium. The main symp-
tom is ocular and palpebral pruritus, which improves slightly
with palpebral hygiene, heat and massage and more with oral
doxycycline and corticoids. Relapse upon suspension of this
treatment indicates an efficient anti-inflammatory therapy
with less side effects than corticoids.
Tacrolimus, Protopic® (Astellas Pharma, Pozuelo de Alar-
cón, Madrid, Spain), is a calcineurin inhibitor generally used
at 0.03% for atopic dermatitis. The presence of excipients (pro-
pylene carbonate) in the skin cream gives rise to doubts about
ocular surface toxicity although literature references report
goods tolerance in anterior segment diseases refractory to
507
corticoid treatment.4–6 To date, local or systemic side effects
attributable to the use of tacrolimus on the ocular surface have
not published. By way of conclusion, 0.03% topical tacrolimus
could be an efficient and well tolerated therapeutic option for
ocular psoriasis when it has a negative repercussion on the
quality of life of patients.
Conflict of interests
No conflict of interests was declared by the authors.
references
1. Sousa LB, Bass LJ. Psoriasis. In: Mannis MJ, Macsai MS, Huntley
AC, editors. Eye and skin disease. Philadelphia:
Lippincot-Raven Publishers; 1996. p. 319–26.
2. Rehal B, Modjtahedi BS, Morse LS, Schwab IR, Maibach HI.
Ocular psoriasis. J Am Acad Dermatol. 2011;65:1202–12.
3. Huynh N, Cervantes-Castaneda RA, Bhat P, Gallagher MJ, Foster
CS. Biologic response modifier therapy for psoriatic ocular
inflammatory disease. Ocul Immunol Inflamm. 2008;16:
89–93.
4. Miyazaki D, Tominaga T, Kakimaru-Hasegawa A, Nagata Y,
Hasegawa J, Inoue Y. Therapeutic effects of tacrolimus
ointment for refractory ocular surface inflammatory diseases.
Ophthalmology. 2008;115:988–92.
5. Kymionis GD, Klados NE, Kontadakis GA, Mikropoulos DG.
Treatment of superior limbic keratoconjunctivitis with topical
tacrolimus 0.03% ointment. Cornea. 2013;32:1499–5015.
6. Wang C, Lin A. Efficacy of topical calcineurin inhibitors
in psoriasis. J Cutan Med Surg. 2014;18:8–14.