Pimecrolimus: A New Treatment for Seborrheic Dermatitis Charles E. Crutchfield III, MMB, MD Seborrheic dermatitis is a chronic recurrent involved in the inflammatory response. Specifically, inflammatory skin condition that mainly affects pimecrolimus inhibits calcineurin, a calcium- areas containing sebaceous glands. I present a dependent phosphatase enzyme. As a result, macrolac- case of a novel effective topical nonsteroidal tam immunomodulators also are known as calcineurin treatment (pimecrolimus 1.0% cream) for facial inhibitors. Calcineurin is essential in activating a seborrheic dermatitis. Pimecrolimus is a member nuclear transcription factor of activated T cells—a of a new class of nonsteroidal agents— factor that enhances production of many of the macrolactam immunomodulators. cytokines involved in the inflammatory response. Pimecrolimus seems to not produce the side effects eborrheic dermatitis is a chronic recurrent common with chronic use of topical steroids.7,8 inflammatory skin condition that affects the S nasolabial folds, ears, eyebrows, scalp (dan- Case Report druff), chest, umbilicus, and other areas containing A 33-year-old man presented with pink-to-red sebaceous glands.1 This condition also may have patches and plaques on the central area of the face hormonal influences—hence the appearance of (including the nasolabial folds) and overlying greasy seborrheic dermatitis on both the scalp in infants scales (Figure 1A). Ear, scalp, and chest involve- younger than 6 months (cradle cap) and on sebum- ment was minimal. The rash, which had been 1-3 1 rich areas in postadolescents. Seborrheic dermati- present intermittently for 1 /2 years, was progressing tis also has been associated with Pityrosporum in severity and frequency and was failing to respond yeasts, AIDS, and neurologic disease.4-6 The course to over-the-counter hydrocortisone 1% cream. The of the condition is usually intermittent, chronic, patient had no history of neurologic disease. Four and progressive. There is no known cause or cure months before presentation, he had had a general for seborrheic dermatitis, which affects 3% to 5% of physical examination, including a test for human the adult population.1 Standard treatment for facial immunodeficiency virus, and had been found to be seborrheic dermatitis relies heavily on topical in good health. glucocorticoids. Unfortunately, chronic use of A diagnosis of seborrheic dermatitis was made. topical steroids is associated with many side effects, The patient was instructed to apply approximately including atrophy, telangiectasia, glaucoma, 0.5 g of topical pimecrolimus 1.0% cream to adrenal suppression, and diminishing effectiveness.7 affected areas twice daily until he returned to the Pimecrolimus is a member of a new class of non- clinic for follow-up 14 days later. By follow-up, the steroidal agents—macrolactam immunomodulators. seborrheic dermatitis had cleared completely An ascomycin derivative, pimecrolimus has a (Figure 1B). The patient reported that clearing had molecular weight of 809 d. This agent was initially been complete on approximately day 8 but that he designated ASM 981 during development. Pime- had continued the regimen as instructed. At follow- crolimus, like the related macrolide agent up, he was instructed to start a preventive regimen tacrolimus, exerts its anti-inflammatory effects by (once-daily applications, weekends only) and to inhibiting production of many of the cytokines treat any breakthrough recurrences with 3 to 10 days of twice-daily applications. From private practice in Eagan, Minnesota, and the University Comment of Minnesota. Reprints: Charles E. Crutchfield III, MMB, MD, 1185 Town Center Dr, Seborrheic dermatitis is a frustrating, recurrent, Suite 101, Eagan, MN 55123 chronic inflammatory skin condition of unknown (e-mail: [email protected]). cause and cure. Mainstays of treatment have been VOLUME 70, OCTOBER 2002 207 Seborrheic Dermatitis Figure not available online Figure not available online A B Facial seborrheic dermatitis before (A) and after (B) 14 days of twice-daily application of topical pimecrolimus 1.0% cream. topical corticosteroid preparations, antifungal 4. Wikler JR, Nieboer C, Willemze R. Quantitative skin creams, and antidandruff/antifungal shampoos.1,9,10 cultures of Pityrosporum yeasts in patients seropositive for Unfortunately, these treatments can become inef- the human immunodeficiency virus with and without fective, and certain risks are associated with long- seborrheic dermatitis: seborrheic dermatitis in patients term use of steroids on the face. Reported here is a with acquired immunodeficiency syndrome. J Am Acad case of facial seborrheic dermatitis successfully Dermatol. 1992;27:37-39. treated with pimecrolimus 1.0% cream. What is 5. Mathes BM, Douglass MC. Seborrheic dermatitis in unclear is whether the molecular size of pime- patients with acquired immunodeficiency syndrome. J Am crolimus makes this agent less than maximally effec- Acad Dermatol. 1985;13:947-951. tive (by virtue of forming a barrier to penetration) in 6. Binder RL, Jonelis FJ. Seborrheic dermatitis in neuroleptic- treating inflammatory skin disorders with epithelial induced parkinsonism. Arch Dermatol. 1983;119:473-475. disruption—as occurs with tacrolimus. Neverthe- 7. Bornhovd E, Burgdorf WH, Wollenberg A. Macrolactam less, because of the significant effectiveness and immunomodulators for topical treatment of inflam- minimal side-effect profile of pimecrolimus in treat- matory skin diseases. J Am Acad Dermatol. ing atopic dermatitis and seborrheic dermatitis, this 2001;45:736-743. agent may be used to treat a variety of inflammatory 8. Nghiem P, Pearson G, Langly RG. Tacrolimus and skin conditions. Pimecrolimus represents a promis- pimecrolimus: from clever prokaryotes to inhibiting cal- ing alternative to topical glucocorticoids, especially cineurin and treating atopic dermatitis. J Am Acad when it is desirable to minimize or avoid their use. Dermatol. 2002;46:228-241. 9. Green CA, Farr PM, Shuster S. Treatment of seborrhoeic REFERENCES dermatitis with ketoconazole, II: response of seborrhoeic 1. Ackerman AB, Kerl H, Sanchez J, et al, eds. A Clinical dermatitis of the face, scalp and trunk to topical ketocona- Atlas of 101 Common Skin Diseases With Histopathologic zole. Br J Dermatol. 1987;116:217-221. Correlation. New York, NY: Ardor Scribendi Ltd; 2000. 10. Peter RU, Richarz-Barthauer U. Successful treatment and 2. Webster G. Seborrheic dermatitis. Int J Dermatol. prophylaxis of scalp seborrhoeic dermatitis and dandruff 1991;30:843-844. with 2% ketoconazole shampoo: results of a multicentre, 3. Mimouni K, Mukamel M, Zaharia A, et al. Prognosis of double-blind, placebo-controlled trial. Br J Dermatol. infantile seborrheic dermatitis. J Pediatr. 1995;127:744-746. 1995;132:441-445. 208 CUTIS®.