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Home , Tacrolimus, Tetracycline

Combination Therapy of and Resulting in Rapid Resolution of -Induced Periocular

Anju Pabby, MD; Kathy P. An, MD; Richard A. Laws, MD

Standard treatment of steroid-induced rosacea The patient reported improvement several days includes discontinuation of and use of after starting therapy. At the 3-week follow-up an oral tetracycline. A temporary decrease to a visit, we noted marked improvement in the patient’s lower-potency steroid prior to discontinuation except for faint infraorbital erythema remains optional. The limitations of standard (Figure 2). The patient was advised to continue the therapy include a prolonged course of treat- tacrolimus ointment on an as-needed basis. ment with exacerbations prior to permanent improvement. Our challenge was to identify a Comment treatment regimen to resolve steroid-induced Topical steroids are paramount in treating many der- periocular rosacea quickly and with minimal matologic diseases; however, their prolonged use has rebound effect. multiple side effects, most notably . Another Cutis. 2003;72:141-142. side effect that may result from improper use is steroid-induced rosacea. Several theories exist as to the pathogenesis of Case Report steroid-induced rosacea. Topical steroids may inhibit A 55-year-old man with an unremarkable medical collagen synthesis, eventually causing dermal atro- history was referred to us by his physician for a phy. The decrease in supporting connective tissue persistent facial rash. The patient had a long-term allows for passive dilation of the blood vessels and history of seborrheic dermatitis that had been easier visualization of dermal capillaries, clinically treated for approximately the previous 12 months resulting in prominent telangiectasias and back- with fluticasone cream twice a day. ground erythema.1 Additionally, inflammatory Results of the patient’s physical examination papules and pustules may be caused by a reaction to revealed background erythema and telangiectasias increased colonization of pilosebaceous bacterial or with 1- to 3-mm discrete erythematous papules fungal flora, though specific organisms have not (Figure 1). The history and physical examination of been isolated yet.2 the facial rash was most consistent with steroid- The rebound phenomenon of steroid-induced induced periocular rosacea. periocular dermatitis also is unclear. The vasocon- The use of the fluticasone cream was discontin- strictive action of may lead to ued, and the patient was started on tacrolimus 0.1% the buildup of potent vasodilators such as nitric ointment twice a day for 3 weeks and oral tetracy- oxide. After the is discontinued, cline 500 mg twice a day. vessels dilate beyond their original diameter because of the accumulation of such vasodilators.3 Additionally, the immunosuppressive effect of

Accepted for publication March 27, 2003. corticosteroids may facilitate the overgrowth of Drs. Pabby and Laws are from the Department of that may then act as super- and Surgery, Roger Williams Medical Center, Providence, antigens. Withdrawal of may Rhode Island. Dr. An is from the Department of Internal Medicine, lead to an immunologic response and a heightened Rhode Island Hospital, Providence. inflammatory reaction.4 Reprints: Richard A. Laws, MD, Boston University School of Medicine, Department of Dermatology and Skin Surgery, Roger Tacrolimus is a topical immunomodulator that Williams Medical Center, Elmhurst Bldg, 50 Maude St, Providence, mediates its effects through inhibition of cal- RI 08908 (e-mail: [email protected]). cineurin. Tacrolimus inhibits release of inflammatory

VOLUME 72, AUGUST 2003 141 Steroid-Induced Periocular Rosacea

Figure 1. A patient with periocular dermatitis resulting Figure 2. Minimal erythema at the infraorbital region of from approximately 12 months of use. the face following a 3-week course of tacrolimus and Note the erythematous papules on a background of oral tetracycline. erythema and few telangiectasias.

cytokines, most notably , and thus rosacea with combination therapy of topical inhibits subsequent T-cell activation.5 Although tacrolimus and oral tetracycline. tacrolimus and corticosteroids are comparable topi- cal immunomodulators, they differ considerably in REFERENCES their side effect profile. Unlike topical corticoste- 1. Sibenge S, Gawkrodger DJ. Rosacea: a study of clinical pat- roids, tacrolimus is minimally absorbed into the terns, blood flow, and the role of Demodex folliculorum. J Am systemic circulation, does not accumulate in tissue, Acad Dermatol. 1992;26:590-593. and does not cause decreased collagen synthesis and 2. Egan CA, Rallis TM, Meadows KP, et al. Rosacea induced resultant atrophy. In addition, tacrolimus does not by beclomethasone dipropionate nasal spray. Int J Dermatol. cause vasoconstriction and the subsequent rebound 1999;38:133-134. phenomenon seen with topical corticosteroid ther- 3. Rapaport MJ, Rapaport V. Eyelid dermatitis to red face apy. The most common side effects of tacrolimus are syndrome to cure: clinical experience in 100 cases. J Am transient pruritus and burning on application.6 Acad Dermatol. 1999;41:435-442. Tacrolimus recently has been approved by the 4. Leung DYM. : new insights and opportu- US Food and Drug Administration for use in atopic nities for therapeutic intervention. J Allergy Clin Immunol. dermatitis. A previous study of 3 patients with 2000;105:860-876. steroid-induced rosacea found that patients treated 5. Ruzicka T, Assmann T, Homey B. Tacrolimus: the drug for the with tacrolimus ointment twice daily for 7 to turn of the millennium? Arch Dermatol. 1999;135:574-580. 10 days experienced a mild rebound flare when the 6. Berkersy I, Fitzsimmons W, Tanase A, et al. Nonclinical and tacrolimus was discontinued. These patients subse- early clinical development of tacrolimus ointment for the quently had to be treated with oral , treatment of atopic dermatitis. J Am Acad Dermatol. topical 1%, and sodium 2001;44(1 suppl):S17-S27. 10% and 5% lotions for complete resolu- 7. Goldman D. Tacrolimus ointment for the treatment of tion.7 Our patient showed a rapid response and steroid-induced rosacea: a preliminary report. J Am Acad experienced no exacerbations of his periocular Dermatol. 2001;44:995-998.

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