Topical Corticosteroid Therapy Research Articles

Evaluation of topical corticosteroids in children with phimosis through morphological and immunohistochemical analyses of the foreskin.

Introduction:Histopathological analysis of the foreskin has become more common in the last two decades.Objectives:This study aims to analyze the morphology of the foreskin and determine the effects of topical corticosteroid therapy on this tissue.Materials and Methods:We retrospectively evaluated forty foreskin samples from children aged from 2 years to 15 years with phimosis undergoing circumcision at our institution over a 2-year period. In the foreskin samples, we analyzed the elastic fibers (Verhoeff), epidermal thickness (hematoxylin and eosin), and Annexin 1 and Langerhans cells (LCs) (immunohistochemistry).Results:In the present study, 18 (45%) patients made use of topical corticosteroids, and 22 (55%) did not, while 4 (10%) had a history of balanoposthitis as previous complication. Forty patients were divided according to the parameter analyzed: with or without previous complication and with or without previous topical corticotherapy. Annexin 1 expression was significantly higher in group with a history of complications when compared with group without complications (P = 0.024) and lower in the group of those who used corticosteroids when compared with those who did not used corticosteroids (P = 0.364). In the analysis of all samples, the density of mature LCs was significantly higher when compared with immature LCs (P < 0.0001). The density of immature LCs was significantly higher in patients without previous complications when compared with group with complications (P = 0.028).Conclusions:These findings contribute to a better understanding of the histopathological aspects of previous complications and of treatment with corticosteroids in children with phimosis.

Topical Steroid Withdrawal: A Case Series of 10 Children.

Concerns about topical steroid withdrawal are causing some patients to cease long-term topical corticosteroid therapy, however, little is known about the ensuing clinical outcomes. This qualitative case series studied 10 children whose parents stopped their chronic topical corticosteroid use and subsequently developed features typically reported in adults experiencing topical steroid withdrawal. Patients were seen in an Australian general practice between April 2014 and October 2018, with follow-up periods ranging from 18 months to 4 years. Symptoms were difficult initially for the children and their families, however, all ultimately improved. At the final review, 4 of the children had clear skin and another 4 had symptoms consistent with their original, pre-treatment atopic dermatitis. More research is required into long-term topical corticosteroid use and its discontinuation, including topical steroid withdrawal, particularly in the pediatric population.

Chronic Ulcerative Disorder (ex-CUS) with SES-ANA

Chronic Ulcerative Disorder (ex-CUS) with SES-ANA

Allergic fungal rhinosinusitis: a clinical study in Srikakulam

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; Allergic fungal rhinosinusitis is one of the differential diagnoses for chronic bacterial rhinosinusitis. Recognition and understanding of this unique disease will lead to efficient diagnosis and treatment of this curable process. India being a tropical country, provides an apt environment for fungal growth, the clinical diagnosis of Allergic fungal rhinosinusitis should not be missed and should be thoroughly investigated and managed to prevent recurrence. The objective of the study was to verify the management protocol for allergic fungal rhinosinusitis, after surgical clearance with functional endoscopic sinus surgery and postoperative histopathological examination and to see the efficacy of steroid and antifungal treatment&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; A one year prospective study was considered with 28 patients from July 2016 to July 2017. Clinically suspected cases of rhinosinusitis depending upon their clinical presentation were subjected to nasal endoscopy, radiological examination and functional endoscopic sinus surgery. Postoperative histopathological examination was performed. Patients were followed up after giving steroid and antifungal treatment. &lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; 28 cases were non-invasive. &lt;em&gt;Aspergillus&lt;/em&gt; was found to be the most common isolate. The criteria responsible for good prognosis of allergic fungal rhinosinusitis management were mainly found to be functional endoscopic sinus surgery followed by topical corticosteroid therapy.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; Allergic fungal rhinosinusitis is a disease entity on the rise. Prompt diagnosis and intervention prevents recurrence and complications.&lt;/p&gt;

Dismissing the fallacies of childhood eczema management: case scenarios and an overview of best practices.

BackgroundEczema or atopic dermatitis (AD) is a common relapsing childhood dermatologic illness. Treatment of AD is primarily topical with emollients and corticosteroid/calcineurin inhibitor, which is efficacious for the majority of patients. However, AD is often complicated and difficult to manage in many Asian cities. Effective therapy is impeded by fallacies in the following aspects: (1) mistrust and unrealistic expectations about Western medicine, (2) skin care and allergy treatment, (3) ambiguity about optimal bathing and moisturizing, (4) hesitation and phobias about the usage of adequate topical corticosteroid and immunomodulatory therapies, (5) food and aeroallergen avoidance and dietary supplementation, and (6) complementary and alternative therapies.Methods and ResultsEleven anonymized case scenarios are described to illustrate issues associated with these fallacies. A literature review is performed and possible solutions to handle or dismiss these fallacies are discussed.ConclusionsThe first step in patient care is to accurately assess the patient and the family to evaluate possible concerns, anxiety, and phobias that could impede therapeutic efficacy. Education about the disease should be individualized. Conflicting recommendations on the usage of topical steroid have a detrimental effect on management outcomes, which must be avoided.

Impact of topical corticosteroid pretreatment on susceptibility of the injured murine cornea to Pseudomonas aeruginosa colonization and infection

Research with animal models of Pseudomonas aeruginosa keratitis has shown that use of a topical corticosteroid alone against an established infection can significantly increase the number of colonizing bacteria or worsen clinical disease. Moreover, retrospective analysis has suggested that corticosteroid use in humans is associated with an increased risk of keratitis in eyes with pre-existing disease. Thus, while corticosteroids are often used to reduce ocular inflammation in the absence of infection, the risk of opportunistic infection remains a concern. However, the effect of corticosteroids on the intrinsic barrier function of uninfected corneas is unknown. Here, we tested if short-term topical corticosteroid treatment of an uninfected murine cornea would increase susceptibility to P. aeruginosa colonization or infection after epithelial injury. Topical prednisolone acetate (1%) was administered to one eye of C57BL/6 mice three times a day for 3 days; control eyes were treated with sterile PBS. Prior to inoculation with a cytotoxic P. aeruginosa corneal isolate strain 6206, corneas were subject to superficial-injury by tissue paper blotting, or scratch-injured followed by 12 h of healing. Previously we have shown that blotting renders mouse corneas susceptible to P. aeruginosa adhesion, but not infection, while 12 h healing reduces susceptibility to infection after scratching. Corneas were evaluated at 48 h for bacterial colonization and microbial keratitis (MK). To monitor impact on wound healing, corneal integrity was examined by fluorescein staining immediately after scarification and after 12 h healing. For both the tissue paper blotting and scratch-injury models, there was no significant difference in P. aeruginosa colonization at 48 h between corticosteroid-pretreated eyes and controls. With the blotting model, one case of MK was observed in a control (PBS-pretreated) cornea; none in corticosteroid-pretreated corneas. With the 12 h healing model, MK occurred in 6 of 17 corticosteroid-pretreated eyes versus 2 of 17 controls, a difference not statistically significant. Corticosteroid-pretreated eyes showed greater fluorescein staining 12 h after scarification injury, but this did not coincide with increased colonization or MK. Together, these data show that short-term topical corticosteroid therapy on an uninfected murine cornea does not necessarily enhance its susceptibility to P. aeruginosa colonization or infection after injury, even when it induces fluorescein staining.

Pregnancy complications, treatment characteristics and birth outcomes in women with atopic dermatitis in Denmark.

The risk of prenatal, obstetric and birth complications in mothers with atopic dermatitis (AD), along with treatment use during pregnancy, is unknown. To examine the associations between prenatal, obstetric and birth complications in mothers with AD and describe the dermatologic care received during pregnancy. Mother-child pairs, in which the mother had a history of AD, were identified through the Danish Medical Birth Registry and matched 1:10 with non-AD pairs. Data on dermatologic treatment and prenatal, obstetric and birth complications were obtained through linkage via nationwide registers. Multiple logistic regression was performed. We identified 10668 births from 1997 through 2014 to women with AD. Women with a hospital/ambulatory contact for AD during pregnancy had increased topical corticosteroid and ultraviolet therapy use during pregnancy compared to prior. However, overall, women with AD received decreased dermatologic therapy during pregnancy compared to prior. In adjusted analysis, maternal AD was inversely associated with gestational diabetes [OR 0.79, 95% CI (0.68-0.92)], but positively associated with premature rupture of membranes [1.15 (1.05-1.27)] and staphylococcal neonatal septicemia [2.45 (1.33-4.49)]-albeit the latter was rare. These associations did not meet statistical significance in sub-analysis where body mass index data were available. No associations were found with preeclampsia, prematurity or non-staphylococcal neonatal septicaemia. Women with AD during pregnancy mainly used topical corticosteroids and ultraviolet therapy to control their disease. While premature rupture of membranes and staphylococcal neonatal septicaemia were over-represented in maternal AD, no associations were found with any other significant prenatal, obstetric or birth outcome.

Steroid Withdrawal Effects Following Long-term Topical Corticosteroid Use.

Concerns about topical steroid withdrawal (TSW) are leading some patients to cease long-term topical corticosteroid (TCS) therapy. Diagnostic criteria for this condition do not exist. The aim of this study was to examine the demographics and outcomes in adult patients who believe they are experiencing TSW following discontinuation of chronic TCS overuse. This was a retrospective cohort study of patients in an Australian general practice presenting with this clinical scenario between January 2015 and February 2018. Women represented 56% of the 55 patients seen, and ages ranged from 20 to 66 years (mean, 32.9 years; median, 30.0 years). Seventy-six percent had an original diagnosis of atopic dermatitis. Sixty percent had used potent TCSs on the face, and 42% had a history of oral corticosteroid use for skin symptoms. Burning pain was reported in 65%; all had widespread areas of red skin; and so-called "elephant wrinkles," "red sleeve," and the headlight sign were seen in 56%, 40%, and 29%, respectively. Patients with a history of long-term TCS overuse may experience symptoms and signs described in TSW on stopping TCSs. Diagnostic criteria, reflecting the histories and examination findings of the patients studied, are suggested in this article with the aim to advance discussion and research into TSW.

Topical Corticosteroids and Non-steroidal Anti-inflammatory Drugs in the Therapy of Non-infectious Uveitis

Topical corticosteroids are effective anti-inflammatory drugs in the treatment of anterior uveitis. The intraocular efficacy of topical corticosteroids mostly depends on their intraocular permeability through the cornea. Lipophile derivatives such as dexamethasone and prednisolone acetate penetrate better into the anterior chamber than hydrophilic derivatives. Prednisolone acetate 1% is the first choice in the therapy of patients with anterior uveitis. Loteprednole and fluorometholone have a slightly weaker anti-inflammatory effect, but they induce less elevation of intraocular pressure and might be helpful in the treatment of patients with steroid response. Topical corticosteroid therapy has to be individually adapted, depending on the clinical course and severity of uveitis. The most common side effects of topical corticosteroids are corticosteroid-induced glaucoma and corticosteroid-induced cataracts. Non-steroidal anti-inflammatory drugs inhibit the enzyme cyclooxygenase that is responsible for the formation of pro-inflammatory prostaglandins. These have an adjunctive role in the treatment and prevention of post-operative inflammation after cataract surgery. A therapeutic role of topical NSAID to treat uveitis and cystoid macular oedema secondary to uveitis has not yet been established.

Formulation of a 3-months Stability Oral Viscous Budesonide Gel and Development of an Indicating Stability HPLC Method

Abstract Background Eosinophilic Esophagitis is an increasing pathology which can cause stomach symptom like dysphagia, vomiting, food blockage. The treatment consists in dietary therapy and topical corticosteroid therapy to avoid the important number of side effects of the oral corticosteroids. There is presently no available topical form adapted for treating esophageal pathology. Methods The aim of this work was to develop an oral viscous budesonide gel (OVBG). A focus on palatability was made in order to use OVBG in children. A stability indicating HLPC method able to quantify budesonide contained in our OVBG has been developed. Results Previous work of Hefner and Al. showed that xanthan gum had a longer esophageal mucosal contact time than sucralose. This encouraged the development of a xanthan gum-based formulation. This OVBG has also the advantage to facilitate compliance thanks to its taste and pleasant texture. The stability length of the preparation can be extended over a 3-months period, stored in a refrigerator at 2–8 °C. Conclusions An adapted pediatric formulation with a 3-months stability was developed. Furthermore, the formulation can be easily reproduced in community pharmacy. Regarding the increasing number of patients concerned OVBG is a good answer to a real clinical need.

Systematic review: adrenal insufficiency secondary to swallowed topical corticosteroids in eosinophilic oesophagitis.

Swallowed topical corticosteroids are prescribed for eosinophilic oesophagitis (EoE), but there is a theoretical risk of adrenal insufficiency from their use. To determine if the use of topical corticosteroids to treat EoE is associated with the development of adrenal insufficiency. We conducted a systematic review of the published literature from January 1, 1950 to April 1, 2017 using Pubmed, Embase, Web of Science and Cochrane Central. Studies and meeting abstracts were included that described patients with EoE who received swallowed topical corticosteroids and any investigation for adrenal insufficiency. The search revealed 1610 unique publications, and 17 met inclusion criteria. There were 7 randomised controlled trials (RCTs), 6 prospective observational studies, 3 retrospective observational studies, and 1 case report. Cortisol measurements were performed on 596 individuals with EoE who received topical corticosteroids. Adrenal testing was abnormal, as defined by each study, in 94/596 patients (crude rate of 15.8%). Only 2 studies were considered to have a low risk of bias, being randomised controlled trials that estimated adrenal insufficiency in the active treatment and placebo groups, before and after treatment. None of the seven randomised controlled trials demonstrated statistically significantly different rates of adrenal insufficiency between topical corticosteroid and placebo over treatment intervals of 2-12weeks. Topical corticosteroids were associated with adrenal insufficiency in a minority of patients. Most cases came from uncontrolled observational studies, with widely varying definitions of adrenal insufficiency. Longer follow-up and larger controlled studies are needed to quantify the risk of adrenal insufficiency with maintenance topical corticosteroid therapy in EoE.

Nasal IL-25 predicts the response to oral corticosteroids in chronic rhinosinusitis with nasal polyps

Nasal IL-25 predicts the response to oral corticosteroids in chronic rhinosinusitis with nasal polyps

A prospective, randomized clinical study comparing drug eluting stent therapy and intranasal corticoid steroid therapy in the treatment of patients with chronic rhinosinusitis.

To conduct the first prospective, randomized controlled clinical trial comparing the efficacy of a drug-eluting stent (DES) (the Relieva StratusTM MicroFlow Spacer) and topical intranasal corticosteroid therapy in patients with chronic rhinosinusitis (CRS). Sixty-three adult patients with ethmoiditis were randomized into either the DES group (n=34) or nasal spray group (n=29). The main outcome variable was the Sinonasal Outcome Test 22, Visual Analogue Scale, nasal endoscopy, rhinometric measurements were performed at the beginning of the study, after three months and six months of follow-up. Both treatments significantly improved quality of the life with no significant difference being found between the two groups. The VAS score decreased in both groups: improvements were significant at three and six months in the nasal spray group, but in the DES group a significant difference was noted only at three months. There was a statistically significant increase in total nasal cavity volumes in the corticosteroid spray group, but not in the DES group. We found that patients benefitted from DES and the corticosteroid nasal spray. We could not find any significant difference between the treatments, except the greater increase in the total nasal cavity volumes favouring the nasal spray group. Because of the very good results for the nasal spray and the much higher material and operating room costs associated with DES, we cannot recommend the use of DES over nasal spray as a monotherapeutic treatment for CRS.

Choroidal change in acute anterior uveitis associated with human leukocyte antigen-B27.

PurposeTo evaluate choroidal changes in eyes with acute anterior uveitis associated with human leukocyte antigen (HLA)-B27MethodsIn 44 patients with first-onset, unilateral, acute-onset (<1 week) anterior uveitis for which diagnostic work-ups revealed positivity only for HLA-B27, wide-field three-dimensional volumetric raster scan using swept-source optical coherence tomography was performed for both eyes. Choroidal thickness was measured by automated segmentation and thickness mapping and compared between eyes with uveitis and the fellow eyes at baseline. Choroidal thickness was compared before and after topical and/or systemic corticosteroid therapy. Relative choroidal thickening was defined as the choroidal thickness of the uveitic eye minus that of the corresponding eye and correlated with the degree of intraocular inflammation.ResultsCompared to the fellow eyes, eyes with acute anterior uveitis showed significant choroidal thickening on the subfoveal and parafoveal areas at baseline (all P <0.05). En face choroidal imaging showed dilation of large choroidal vessels on the macula. Relative choroidal thickening significantly correlated with the degree of anterior chamber inflammation at baseline (correlation coefficient = 0.341, P = 0.023). After treating inflammation, the choroid on the macula thinned significantly (from 262.1 ± 66.5 to 239.5 ± 61.0 μm in the subfoveal choroid, P<0.001).ConclusionsEyes with HLA-B27-associated anterior uveitis showed significant choroidal thickening at acute phase that subsequently decreased after treatment, indicating subclinical choroidal inflammation in the eyes. Choroidal thickness might indicate disease activity in acute anterior uveitis associated with HLA-B27.

Evaluation of O6-Benzylguanine−Potentiated Topical Carmustine for Mycosis Fungoides

In a phase 1 trial, single-dose O6-benzylguanine with topical carmustine for patients with early stage (stage IA through stage IIA) cutaneous T-cell lymphoma, mycosis fungoides (MF) type, resulted in clinical responses proportional to inhibition of O6-alkylguanine-DNA alkyltransferase activity, but a maximum tolerated dose (MTD) was not reached. To determine whether dose escalation of carmustine in combination with dual-dose O6-benzylguanine to prolong alkyltransferase inhibition could reach an MTD. A single-arm, phase 1-2 clinical trial conducted at a university teaching hospital enrolled 17 adults with stage IA through stage IIA cutaneous T-cell lymphoma, MF type, to evaluate treatment using topical carmustine plus 2 subsequent daily doses of intravenous O6-benzylguanine, administered every 2 weeks for up to 24 weeks (12 cycles). All patients who received treatment were included in an intent-to-treat analysis of the response rate. The study was conducted from February 17, 2010, to April 8, 2014. Data analysis was performed from May 1, 2014, to December 1, 2015. Topical carmustine and intravenous O6-benzylguanine. Clinical disease response was assessed by the Severity-Weighted Assessment Tool (score range, 0-400; higher score indicates worse disease). Safety data were acquired by review of adverse events at study visits. Of the 17 patients enrolled, 12 (71%) were men; mean (SD) age was 45.2 (14.6) years. There were 7 complete responses and 8 partial responses to combination carmustine and O6-benzylguanine treatment. The overall clinical response rate was 88%, with a mean (SD) duration of complete response of 14.43 (6.6) months. The MTD was 20 mg of carmustine applied once in combination with 2 daily doses of 120 mg/m2 of O6-benzylguanine. Most adverse events (112 [67%]) were grade I. Of 15 patients with dermatitis, 5 individuals (33%) demonstrated grade II dermatitis that was unresponsive to topical corticosteroid therapy. The dermatitis was characterized by high levels of macrophage activation, and clearance was associated with vitamin D3 administration. Compared with single-dose O6-benzylguanine and carmustine, dual-dose O6-benzylguanine resulted in higher overall response rates and reduced total carmustine doses but was associated with more cutaneous adverse events. The MTD for dual-dose O6-benzylguanine plus carmustine was also ascertained. clinicaltrials.gov Identifier: NCT00961220.

Medical therapy, refractory chronic rhinosinusitis, and productivity costs.

The purpose of this review is to address the most recent advances in the medical therapy for chronic rhinosinusitis (CRS), define recalcitrant and refractory CRS, and discuss the productivity costs associated with CRS. Recent studies evaluating anti-IL-4 receptor α antibodies and calcium channel blockers have demonstrated promising early results during management of CRS. Recent appropriateness criteria have been developed to assist clinicians with defining which patients have 'refractory' CRS and may be considered candidates for endoscopic sinus surgery. Productivity costs appear to be associated with disease severity and can be reduced with appropriate interventions. Topical corticosteroid therapy and high volume saline irrigation continue to be the cornerstone to medical therapy, whereas use of systemic corticosteroids and antibiotics depends on CRS phenotype and presence of acute exacerbation. More research is needed before routine use of novel immunomodulatory therapies such as anti-IL5, anti-IgE, anti-IL4, and calcium channel blockers. Clinicians should apply an appropriate definition for refractory CRS when discussing role of sinus surgery. Assessing the degree of work productivity impairment can assist in treatment decision-making and may help predict treatment outcomes.

Incidence and Clinical Course of Immune Reactions after Descemet Membrane Endothelial Keratoplasty: Retrospective Analysis of 1000 Consecutive Eyes

To analyze the incidence and clinical course of graft rejection episodes after Descemet membrane endothelial keratoplasty (DMEK). Retrospective analysis of a consecutive, interventional case series. One thousand eyes that underwent DMEK from July 2011 through August 2015 at the Department of Ophthalmology, University of Cologne. All cases with follow-up of at least 1 month were included (mean follow-up, 18.5 months). Patients with a graft rejection episode were followed up for 1 additional year. Incidence of graft rejection, best spectacle-corrected visual acuity (BSCVA), central corneal thickness (CCT), endothelial cell density (ECD), and need for regraft. Nine hundred five cases met the inclusion criteria. A graft rejection episode developed in 12 patients (estimated probability of rejection at 1 year, 0.9%; at 2 years, 2.3%; at 4 years, 2.3%). At time of rejection, 9 of 12 patients had stopped corticosteroids. Five patients were symptomatic and 7 did not note the rejection episode. Intensified topical corticosteroid therapy was started immediately after diagnosis of rejection. Two eyes decompensated and required a regraft, whereas the remaining 10 eyes required no regraft (BSCVA, 0.27±0.28 logarithm of the minimum angle of resolution [logMAR]; CCT, 554.1±39.1 μm at last visit before rejection vs. BSCVA, 0.21±0.15 logMAR; CCT, 540.0±15.0 μm 3 months after rejection). One year after the rejection episodes, BSCVAand CCT in these eyes remained unchanged when compared with the last visit before rejection (BSCVA, 0.15±0.11 logMAR; CCT, 533.8±26.0 μm). Significant changes were observed for ECD values (1741±274.5 cells/mm2 at last visit before rejection vs. 1356±380.3 cells/mm2 after 3 months [P= 0.04] and 1290±359.0 cells/mm2 after 1 year [P= 0.01]). The risk for graft rejection after DMEK is low, and an even smaller minority requires a regraft. After intensified local corticosteroid therapy, most patients show stable visual acuity and CCT, although ECD decreases. The occurrence of immune reactions up to 2 years after surgery predominantly in patients not receiving corticosteroids supports the prolonged use of corticosteroids after DMEK.

A prospective, randomized clinical study comparing drug eluting stent therapy and intranasal corticoid steroid therapy in the treatment of patients with chronic rhinosinusitis

To conduct the first prospective, randomized controlled clinical trial comparing the efficacy of a drug-eluting stent (DES) (the Relieva StratusTM MicroFlow Spacer) and topical intranasal corticosteroid therapy in patients with chronic rhinosinusitis (CRS). Sixty-three adult patients with ethmoiditis were randomized into either the DES group (n=34) or nasal spray group (n=29). The main outcome variable was the Sinonasal Outcome Test 22, Visual Analogue Scale, nasal endoscopy, rhinometric measurements were performed at the beginning of the study, after three months and six months of follow-up. Both treatments significantly improved quality of the life with no significant difference being found between the two groups. The VAS score decreased in both groups: improvements were significant at three and six months in the nasal spray group, but in the DES group a significant difference was noted only at three months. There was a statistically significant increase in total nasal cavity volumes in the corticosteroid spray group, but not in the DES group. We found that patients benefitted from DES and the corticosteroid nasal spray. We could not find any significant difference between the treatments, except the greater increase in the total nasal cavity volumes favouring the nasal spray group. Because of the very good results for the nasal spray and the much higher material and operating room costs associated with DES, we cannot recommend the use of DES over nasal spray as a monotherapeutic treatment for CRS.

Rate of Rejection After Descemet Stripping Automated Endothelial Keratoplasty in Fuchs Dystrophy: Three-Year Follow-up.

To evaluate the rate of rejection after Descemet stripping automated endothelial keratoplasty (DSAEK) in patients with Fuchs endothelial dystrophy (ED) and to analyze potential risk factors for rejection. An observational retrospective chart review of 400 patients with Fuchs ED was performed. The primary outcome was the rate of endothelial graft rejection. Secondary outcomes included graft clarity after rejection, medications at the time of rejection, and preoperative graft thickness. A total of 400 consecutive eyes with at least 1 year of follow-up were evaluated with an average follow-up of 38 months (range 12-95 months). The cumulative rate of rejection at 1 year was 1%; 2 years, 2.9%; and 3 years, 4.8%. The greatest number of rejection episodes occurred between postoperative months 19 and 30 (N = 7). There was a statistically significant association of developing a rejection episode when a patient was off of topical steroids (P = 0.001, odds ratio = 6.25, 95% confidence interval = 2.03-19.3) or had a donor graft thickness greater than 145 μm (P = 0.011, odds ratio = 5.03, 95% confidence interval, 1.28-23.1). Corneal graft rejection is an uncommon but important complication after DSAEK. This study reports a lower rejection rate in Fuchs ED than that reported in previous studies. Risk factors for developing a rejection episode include discontinuation of topical steroids and a graft thickness greater than 145 μm. Maintaining patients on indefinite topical corticosteroid therapy and using thinner donor tissue will likely result in an even lower rate of rejection.

Tacrolimus for the management of psoriasis: clinical utility and place in therapy.

Psoriasis affects 1%–3% of the population in the United Kingdom and can convey significant detriment to the physical and mental health of sufferers. Plaques of psoriasis typically affect the extensor skin surfaces and scalp. Less frequently inverse psoriasis can affect more sensitive skin such as the face, genitals, and intertriginous areas. Psoriasis is incurable, but there are a range of treatment modalities that can be used to manage the condition. Treatment options include topical preparations, phototherapy, systemic therapy, and biological agents. Tacrolimus is a macrolide calcineurin inhibitor licensed for immunosuppression in transplant patients and topical administration in atopic dermatitis. Tacrolimus administered orally and in topical form has been shown to produce successful outcomes in patients with psoriasis. Topical tacrolimus is particularly effective for inverse psoriasis, which is likely to be due to the reduced level of induration seen in these psoriatic lesions, which allows greater skin penetrance, compared with hyperkeratotic plaques of psoriasis on the body. It is also notable that the areas affected by inverse psoriasis are more susceptible to adverse effects of topical corticosteroid therapy, and thus a topical preparation without the risk of skin atrophy, telangiectasia, and striae could be a valuable addition to current topical treatment options. Oral tacrolimus has shown efficacy in the treatment of severe, refractory psoriasis. Compared to ciclosporin, systemic tacrolimus may be more suited to a patient population with increased cardiovascular risk. This review will draw together the current literature on topical and oral tacrolimus for the treatment of psoriasis. Efficacy and safety have been evaluated by case reports and randomized controlled trials and comparisons have been made between tacrolimus therapy and standard treatment.