Oral Tacrolimus for the Treatment of Refractory Atopic Keratoconjunctivitis and Dermatitis
Nimesh Patel MD, Anat Galor MD
Department of Ophthalmology, Bascom Palmer Eye Institute, Miami, Florida.
To describe a case of severe refractory atopic keratoconjunctivitis (AKC) with dermatitis that showed a marked response to treatment with oral tacrolimus. This offers a new treatment option as well as highlights the underlying T-cell mediated pathophysiology of this chronic and blinding disease.
The patient was a 47 year old male with history of dermatitis and conjunctivitis. He had been seen by multiple subspecialists and trialed on many treatments in the past 5 years including topical and oral steroids. On initial presentation, the exam showed severe dermatitis of the face and body. The eyelids had notable hyperpigmentation and lichenification (Figure 1). The conjunctiva showed marked injection and the cornea showed diffusely irritated epithelium. The patient was placed on artificial tears, topical fluorometholone, as well as oral tacrolimus 5mg daily.
Results: The patient had a dramatic response with marked improvement of both dermatitis and conjunctivitis within 1 month and did not have any relapses over the course of 1 year (Figure 2).
Discussion / Conclusion: AKC is a chronic disease that can lead to blindness through corneal scarring and opacification. Topical and oral steroids are often a temporizing measure with a tacyphylaxis effect. The pathophysiology of AKC is a T-cell mediated inflammation. Tacrolimus inhibits calcineurin and T- cell signaling to block the release of IL-2 thus inhibiting the inflammatory cascade. Topical and oral tacrolimus have been used to treat severe atopic dermatitis in dermatology with good effect and safety profile. This case demonstrates the use in Ophthalmology as a novel targeted treatment for refractory AKC.
Figure 1. Initial presentation with severe atopic dermatitis (a) and conjunctivitis (b)
Figure 1. 1 year follow up with improvement of dermatitis (a) and conjuntivitis (b)
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