To the Editor: Lichen myxedematosus (LM) is a chronic idiopatic papular mucinosis which is divided into a generalized and sclerodermoid form (best known as scleromyxedema) with monoclonal gammopathy and systemic, disabling manifestations and a localized form with only cutaneous involvement. The latter includes 4 types: (1) discrete type, (2) acral persistent papular mucinosis, (3) cutaneous mucinosis of infancy, and (4) nodular LM.1Rongioletti F. Rebora A. Mucinoses.in: Bolognia J.L. Jorizzo J.L. Rapini R.P. Horn T.D. Mascaro J.M. Mancini A.J. Dermatology. Mosby, New York2003: 647-658Google Scholar There is no specific therapy for localized LM, but topical steroids are usually the first line of treatment with variable success.2Rongioletti F. Rebora A. Updated classification of papular mucinosis, lichen myxedematosus, and scleromyxedema.J Am Acad Dermatol. 2001; 44: 273-281Abstract Full Text Full Text PDF PubMed Scopus (349) Google Scholar We report the first two cases of the discrete type of LM who have been treated successfully with tacrolimus 0.1% ointment. A 67-year-old white woman (patient 1) and a 50-year-old woman (patient 2) presented with a 6-month and a 3-month history of a skin eruption, respectively. On examination, patient 1 exhibited numerous small, firm, waxy, asymptomatic papules, symmetrically localized on her décolleté (Fig 1, A), while patient 2 presented with small, firm, flesh-colored papules, sometimes gathering into plaques, on the shins and on the neck (Fig 2, A). In the latter, an 8-week course of topical steroids gave no appreciable results. Blood chemistry, including HIV, electrophoresis, immunoelectrophoresis, and thyroid function were normal or negative. Histologically, the upper- and mid-dermis shows a focal mucinous deposit under normal epidermis. Both patients were treated with tacrolimus 0.1% ointment twice daily and a gradually complete resolution of the papular lesions was observed within 3 months in patient 1 (Fig 1, B) and within 1 month in patient 2 (Fig 2, B). No new lesions recurred after a follow-up of 3 months with a twice-weekly application of tacrolimus in patient 1. On the contrary, 1 month after stopping the application of tacrolimus ointment, some new papules recurred in patient 2.Fig 2Patient 2. A, Small, firm, flesh-colored papules, sometimes gathering into plaques, on the shins. B, Complete healing 1 month after topical tacrolimus.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Our patients are a typical example of the discrete type of localized LM. As it is limited to the skin and has little or no morbidity, a “wait and see” approach is usually recommended.1Rongioletti F. Rebora A. Mucinoses.in: Bolognia J.L. Jorizzo J.L. Rapini R.P. Horn T.D. Mascaro J.M. Mancini A.J. Dermatology. Mosby, New York2003: 647-658Google Scholar, 2Rongioletti F. Rebora A. Updated classification of papular mucinosis, lichen myxedematosus, and scleromyxedema.J Am Acad Dermatol. 2001; 44: 273-281Abstract Full Text Full Text PDF PubMed Scopus (349) Google Scholar Although it rarely occurs, some cases spontaneously resolve.2Rongioletti F. Rebora A. Updated classification of papular mucinosis, lichen myxedematosus, and scleromyxedema.J Am Acad Dermatol. 2001; 44: 273-281Abstract Full Text Full Text PDF PubMed Scopus (349) Google Scholar However, the treatment may be sometimes helpful when the lesions are pruritic and located on cosmetic areas, such as the décolleté or the neck as it occurred in our cases. Topical and intralesional steroids have been tried in at least half of the cases, with variable results.3Sulis D.J. Harford R. O'Neill J.T. Discrete papular form of lichen myxedematosus: a case report and review of the literature.Cutis. 2005; 75: 105-112PubMed Google Scholar Oral isotretinoin was effective in a HIV case,4Rongioletti F. Ghigliotti G. De Marchi R. Rebora A. Cutaneous mucinoses and HIV infection.Br J Dermatol. 1998; 139: 1077-1080Crossref PubMed Scopus (51) Google Scholar while oral thyroxine failed in another patient.3Sulis D.J. Harford R. O'Neill J.T. Discrete papular form of lichen myxedematosus: a case report and review of the literature.Cutis. 2005; 75: 105-112PubMed Google Scholar Sulis et al3Sulis D.J. Harford R. O'Neill J.T. Discrete papular form of lichen myxedematosus: a case report and review of the literature.Cutis. 2005; 75: 105-112PubMed Google Scholar recently treated a patient with discrete LM using pimecrolimus cream. They observed a relief in pruritus but the skin lesions remained. On the contrary, we treated our patients with tacrolimus ointment 0.1%, and the papular eruption cleared in 1 and 3 months, respectively, with no side effects. Tacrolimus is a topical immunomodulator that blocks the calcineurine signal pathway, inhibits tumor necrosis factor–alfa secretion in human keratinocytes,5Lan C.C. Yu H.S. Wu C.S. Kuo H.Y. Chai C.Y. Chen G.S. FK506 inhibits tumor necrosis factor-alpha secretion in human keratinocytes via regulation of nuclear factor-kappaB.Br J Dermatol. 2005; 153: 725-732Crossref PubMed Scopus (45) Google Scholar and inhibits transforming growth factor-beta–induced collagen synthesis.6Nagano J. Iyonaga K. Kawamura K. Yamashita A. Ichyasu H. Hokamoto T. et al.Use of tacrolimus, a potent antifibrotic agent, in bleomycin-induced lung fibrosis.Eur Respir J. 2006; 27: 460-469Crossref PubMed Scopus (44) Google Scholar This suppressant activity may be why it has been effective in localized LM as transforming growth factor-beta and tumor necrosis factor–alfa are known to stimulate glycosaminoglycan synthesis from skin fibroblasts.2Rongioletti F. Rebora A. Updated classification of papular mucinosis, lichen myxedematosus, and scleromyxedema.J Am Acad Dermatol. 2001; 44: 273-281Abstract Full Text Full Text PDF PubMed Scopus (349) Google Scholar