The effect of topical tacrolimus on severe recalcitrant chronic discoid lupus erythematosus

Sir, Although chronic discoid lupus erythematosus (CDLE) can often be controlled with antimalarials and potent topical corticosteroids, some patients prove resistant to treatment.1 We report the response of two women with severe recalcitrant CDLE to topical tacrolimus therapy. Patient 1. A 52‐year‐old‐woman who had had disfiguring scalp and facial CDLE for 9 years had failed to respond to combinations of very potent topical corticosteroids, oral prednisolone and antimalarials. Thalidomide had been tried with some minor improvement, but had had to be stopped due to the development of abnormal nerve conduction. Despite oral hydroxychloroquine 200 mg daily, mepacrine 100 mg daily, prednisolone 12·5 mg daily, sun protection and topical 0·05% clobetasol propionate cream twice daily, she continued to have extensive active disease over her nose, cheeks, forehead and scalp (Fig. 1a). In May 2001 she was supplied with a formulation of 0·3% tacrolimus in 0·05% clobetasol propionate ointment, which has been used successfully in our department for the management of pyoderma gangrenosum.2 She applied this twice daily for 6 weeks to a test area on her right cheek. She continued to apply clobetasol propionate cream to the other affected areas. On review, these latter areas remained unchanged but the response of the test plaque was dramatic, with almost complete resolution of inflammation (Fig. 1b). The tacrolimus/clobetasol propionate preparation was extended to other areas, with similar dramatic resolution (Fig. 1c). Reducing the frequency of application to three times weekly resulted in a recurrence of inflammation which then responded to resumption of the twice daily regimen. In the 6 months since tacrolimus was introduced she has been able to stop hydroxychloroquine and to reduce the prednisolone from 12·5 to 5 mg daily without ill effect.