Published online June 1, 2006
PEDIATRICS Vol. 117 No. 6 June 2006, pp. 2325-2326 (doi:10.1542/peds.2005-2900)

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Can Tacrolimus Ointment (Protopic) Exacerbate an Intercurrent Fungal Infection?

David E. Bronstein, MD
James D. Cherry, MD
Departments of Pediatrics
David Geffen School of Medicine
University of California
Los Angeles, CA 90095-1752

To the Editor.—

Previous studies, including the recent randomized, vehicle-controlled study by Schachner et al,¹ have emphasized the safety of tacrolimus ointment (Protopic) in the treatment of pediatric patients with atopic dermatitis.^1–5 The experience of an adolescent in our clinic, however, has suggested that the systemic absorption of tacrolimus ointment, although minimal, may potentially exacerbate a concurrent infectious process.

Our patient is a 14-year-old immunocompetent white male who presented to his pediatrician in June 2004 with a left posterior neck mass that was 2.5 cm in diameter. Unaltered by a 2-week course of penicillin, the mass was identified by fine-needle aspiration biopsy as a reactive lymph node and was partially excised in August; Coccidioides immitis grew from the culture. Within days of the surgical procedure, he experienced swelling of his neck once again in the same location, and his serum Coccidioides complement-fixation (CF) antibody titer was 1:128. Fluconazole was started orally at a dose of 400 mg daily, and within 1 month his neck mass decreased in size, with a concomitant drop in his CF titer to 1:64.

In November 2004 he began topical therapy with 0.025% triamcinolone cream for a new-onset mild psoriatic eruption on his right forearm and axilla. He continued on daily fluconazole, and his neck mass diminished over the next few months such that it was barely detectable on examination in January 2005, when his CF titer was 1:32. His psoriatic lesions persisted, and in February he was prescribed 0.03% Protopic ointment, which he used sparingly twice daily only on his right arm. Within 1 month of starting the Protopic ointment, his left-sided neck mass grew to its original size, and his Coccidioides CF titer remained at 1:32. The Protopic was promptly discontinued, and the topical steroid was resumed. Within weeks the mass once again decreased in size, and his CF titer dropped to 1:16. Thus, the temporal correlation between the application of Protopic and the recurrence of our patient's neck mass suggests that even minimal systemic absorption of tacrolimus may be sufficient to worsen an intercurrent fungal infection.

REFERENCES

1. Schachner LA, Lamerson C, Sheehan MP, et al. Tacrolimus ointment 0.03% is safe and effective for the treatment of mild to moderate atopic dermatitis in pediatric patients: results from a randomized, double-blind, vehicle-controlled study. Pediatrics. 2005;116(3) . Available at: www.pediatrics.org/cgi/content/full/116/3/e334
2. Hanifin JM, Paller AS, Eichenfield L, et al. Efficacy and safety of tacrolimus ointment treatment for up to 4 years in patients with atopic dermatitis. J Am Acad Dermatol. 2005;53(2 suppl 2) :S186 –S194
3. Harper J, Smith C, Rubins A, et al. A multicenter study of the pharmacokinetics of tacrolimus ointment after first and repeated application to children with atopic dermatitis. J Invest Dermatol. 2005;124 :695 –699[CrossRef][Medline]
4. Kang S, Lucky AW, Pariser D, Lawrence I, Hanifin JM. Long-term safety and efficacy of tacrolimus ointment for the treatment of atopic dermatitis in children. J Am Acad Dermatol. 2001;44(1 suppl) :S58 –S64
5. Alaiti S, Kang S, Fielder VC, et al. Tacrolimus (FK506) ointment for atopic dermatitis: a phase I study in adults and children. J Am Acad Dermatol. 1998;38 :69 –76[CrossRef][Web of Science][Medline]

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PEDIATRICS (ISSN 1098-4275). ©2006 by the American Academy of Pediatrics

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Can Tacrolimus Ointment (Protopic) Exacerbate an Intercurrent Fungal Infection?: In Reply

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This Article Extract Full Text (PDF) Submit a response Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services E-mail this article to a friend Related articles in Pediatrics Similar articles in this journal Similar articles in Web of Science Similar articles in PubMed Alert me to new issues of the journal Add to My File Cabinet Download to citation manager Request Permissions Citing Articles Citing Articles via CrossRef Citing Articles via Google Scholar Google Scholar Articles by Bronstein, D. E. Articles by Cherry, J. D. Search for Related Content PubMed PubMed Citation Articles by Bronstein, D. E. Articles by Cherry, J. D. Related Collections Allergy & Dermatology Related AAP Red Book topics: Fungal Diseases Social Bookmarking                         What's this?