Topical tacrolimus alcohol induced flush presenting as food allergy

Abstract

Rationale Topical treatment with tacrolimus may be complicated by ingestion related flushing after consuming small amounts of alcohol that can be mistaken for food allergy. Methods The case history of a representative patient with an alcohol induced reaction to local tacrolimus treated dermatitis is reviewed. Results A patient with a history of allergic rhinitis, atopic dermatitis, oral allergy syndrome and fish anaphylaxis was evaluated for ingestion related facial eruptions which began shortly after instituting topical tacrolimus to his peri-oral and peri-orbital eczema. Food allergy was first thought to be the problem with beer the most frequent trigger. Over time, it became clear that alcohols, including neutral spirits like vodka, were also implicated. An in office challenge was done with less than 1 ounce of white wine. Within 2-3 minutes of ingestion, there appeared an intense, non-pruritic erythema restricted to the areas of applied tacrolimus (peri-oral and peri-orbital distribution). In discussions with Fujisawa (maker of Protopic® brand of topical tacrolimus) they acknowledged receiving other anecdotal reports of topical tacrolimus related alcohol induced flushing. On this basis tacrolimus use was discontinued and within 2 weeks, the alcohol flush reaction disappeared but the eczema returned. Since the initial case presentation, this practice has seen two more patients with similar stories and response to tacrolimus cessation. Conclusions A careful history including alcohol use should be obtained in patients who use topical tacrolimus presenting with new skin complaints, as these may be evidence of an avoidable drug interaction and not worsening of atopic disease or an additional food allergy.