Download PDF

SHORT COMMUNICATION
ARCH SOC ESP OFTALMOL 2006; 81: 661-664
TOPICAL CYCLOSPORINE IN THE TREATMENT OF
OCULAR ACTINIC PRURIGO
CICLOSPORINA TÓPICA COMO TRATAMIENTO DEL PRÚRIGO
ACTÍNICO OCULAR
ORTIZ-CASTILLO JV1, BOTO-DE-LOS-BUEIS A2, DE-LUCAS-LAGUNA R2, PASTOR-NIETO B1,
PELÁEZ-RESTREPO N1, FONSECA-SANDOMINGO A1
ABSTRACT
RESUMEN
Case report: A 14-year-old girl from Peru suffered
severe limbitis and conjunctivitis. She also presented with clinical skin features diagnosed as actinic
prurigo (AP). Her symptoms were successfully
controlled with sustained topical therapy of 2%
Cyclosporine A.
Discussion: AP is an idiopathic photodermatosis
that affects mainly the hispanic population of Latin
America. There are ocular signs of severe limbitis
and conjunctivitis (like atopic keratoconjunctivitis)
in 45% of cases. Literature on the subject is very
limited and currently topical cyclosporine seems to
be the best therapy available (Arch Soc Esp Oftalmol 2006; 81: 661-664).
Caso clínico: Presentamos el caso de una mujer de
14 años latinoamericana, con una limbo-conjuntivitis severa. Habia sido diagnosticada de prúrigo actínico (PA) por el dermatólogo. Con el diagnóstico de
PA ocular se inició tratamiento con colirio de
ciclosporina A 2% con buena respuesta.
Discusión: El PA es una fotodermatosis idiopática
que afecta principalmente a la población mestiza de
Latino América. Los ojos se ven afectados en el
45% de los casos, como una limbo-conjuntivitis
severa semejante a la atópica. A pesar de la escasa
bibliografía existente, la ciclosporina tópica representa la mejor alternativa en el tratamiento del PA
ocular.
Key words: Actinic prurigo, topical cyclosporine,
conjunctivitis, limbitis, photodermatosis.
Palabras clave: Prúrigo actínico, ciclosporina tópica, conjuntivitis, limbitis, fotodermatosis.
Received: 27/3/06. Accepted: 20/11/06.
Ophthalmology Service. La Paz Hospital Madrid. Spain
1 Graduate in Medicine.
2 Ph.D. in Medicine.
Communication presented at the LXXX Congress of SEO (Córdoba 2004).
The authors state they have no commercial interest and have not received financial support.
Correspondence:
Ana Boto de los Bueis
C/. O'Donnell 32, 1.º B
28009 Madrid
Spain
E-mail: [email protected]
ORTIZ-CASTILLO JV, et al.
INTRODUCTION
Actinic prurigo (AP) is a photodermatosis typical
of Latin American countries. The ocular expressions of this dermatosis can simulate an atopical
conjunctivitis (1). This communication presents the
case of a girl with severe limbus conjunctivitis due
to AP.
CASE REPORT
A 14 year-old female from Perú who in the last 6
months exhibited severe episodes of reddening and
photophobia. She was not responsive to dexametasone (Colircusí Dexametasona® 0,1 %, Alcon Cusi,
Spain) and levocabastine (Bilina®, Esteve, Barcelona, Spain). She referred suffering atopical conjunctivitis and dermatitis since age 7 as well as a herpetic keratitis outbreak in the left eye (LE) 4 years
ago and a corneal ulcer in the right eye (RE) two
months ago.
The patient exhibited erithematous and flaking
skin lesions in the malar, frontal and perilabial areas
as well as the sides of the nose and hands. There
was not palpebral involvement (fig. 1). The ophthalmological exploration evidenced a corrected
visual acuity of CD at 2 mt in RE and 2/3 in LE,
while biomicroscopy showed that in both eyes (BE)
the patient had a papillar reaction in the superior
tarsal conjunctiva (fig. 2), gelatinous limbar hypertrophy, bulbar conjunctival hyperpigmentation
spots (fig. 3) and superficial dotted keratitis. The
RE exhibited pannus and a central leucoma, and the
LE a small paracentral leucoma.
She did not refer familial atopy history and did
not show other atopy systemic expressions. The
allergy study discarded sensitivity to common allergens. The serum IgE was normal as was the tear IgE
(Lacrytest, Adiatec lab, France).
Fig. 2: Papillar hypertrophy in superior RE tarsum.
Fig. 1: Erithematous and flaking facial lesions due to
actinic prurigo.
662
Fig. 3: RE limbus conjunctivits due to AP, and vascularized central corneal leucoma secondary to previous
infectious ulcer.
ARCH SOC ESP OFTALMOL 2006; 81: 661-664
Topical cyclosporine for treatment of ocular actinic prurigo
The dermatology service was consulted. They
referred substituting the atopic dermatitis diagnosis
established two years ago by AP after the results of
triple cutaneous biopsy. Topical treatment was initiated with tacrolimus ointment 0.03% continued to
this date, which led to a stabilization of the skin
condition.
With the ocular AP diagnostic, in Sept. 2004 we
began treatment with cyclosporine A eye drops 2%,
prepared in polyvinyl alcohol by the pharmacy service, with expiry date at 28 days. The initial dosage
was 1 drop/8 hours in BE, leading to an improvement two weeks later. In April 2005 and while in
treatment with 1% cyclosporine every 12 hours, the
patient exhibited a reactivation of the condition in
BE, which was controlled increasing the eye drops
to cyclosporine 2%/8h. One week later she exhibited a central herpetic dendrite in the LE which was
resolved with acyclovir cream (Zovirax ophthalmic
cream®, Glaxo-Wellcome, Tres Cantos, Madrid,
Spain) 5 times a day for 21 days. Since then, she
continues treatment with 1% cyclosporine eye
drops every 12 hours and valaciclovir 500 mg/day
(Valtrex®, GlaxoSmithKline, USA). In Feb. 2006
the patient exhibited a corrected VA in RE of 1/8
and 1/2 in LE, with the only inflammatory finding of
slight temporal-inferior limbitis in BE.
DISCUSSION
This communication presents the case of a
young Latin American female with a severe bilateral limbal conjunctivitis condition, initially attributed to atopia and associated to chronic dermatitis.
The final diagnostic was AP, a recurring chronic
idiopathic photodermatosis caused by an immune
reaction by the skin and mucous to UVA and UVB
radiation. This condition occurs almost exclusively
in Latin American countries where the population
lives at a height exceeding 1,000 m above sea level and it usually expresses between the ages of 6
and 8. The skin is affected in areas exposed to light
such as the nose, malar regions and lips (2). The
eyes are involved in 45% of cases, primarily affecting the conjunctiva and the limbus, which exhibited diffuse hyperemia, aqueous secretion, hyperpig-
mented bulbar conjunctival areas, hypertrophic
tarsal papillae, follicles, focal limbitis and
pseudopterigium.
The AP diagnostic is based on the clinical presentation and the anatomic-pathological study of
mucose of the lips, the conjunctiva or the skin. The
tarsal conjunctival histology typically exhibits
epithelium thinning and atrophy, vacuolization of
basal cells with lymphocyte infiltrates organized in
sub-mucous follicles, conjunctival pigmentation
and eosinophiles, while the most characteristic
histopathological finding of AP, in mucous and in
conjunctiva, is the presence of lymphoid follicles in
the laminae itself (2).
The tacrolimus ointment is the best option for
dermatosis. Eye lesions call for a different therapeutic approach. At present and notwithstanding
the scarce amount of literature on the subject, studies point to topical cyclosporine as the best option
for treating ocular actinic prurigo (3). In our case,
the patient improved with this treatment in about 2
weeks but it was necessary to continue it to avoid
recurrences. Although there is no experience in the
utilization of topical tactrolimus in ocular AP,
recently this collyrium has proved to be efficient in
chronic blepharoconjunctivitis (4) and severe atopical conjunctivitis (5). In the future, this power
immunosuppressant macrolide could be a therapeutic alternative for ocular AP cases resistant to treatment with cyclosporine.
REFERENCES
1. Magana M, Mendez Y, Rodriguez A, Mascott M. The conjunctivitis of solar (actinic) prurigo. Pediatr Dermatol
2000; 17: 432-435.
2. Hojyo-Tomoka T, Vega-Memije E, Granados J, Flores O,
Cortes-Franco R, Teixeira F, et al. Actinic prurigo: an
update. Int J Dermatol 1995; 34: 380-384.
3. McCoombes JA, Hirst LW, Green WR. Use of topical
cyclosporin for conjunctival manifestations of actinic prurigo. Am J Ophthalmol 2000; 130: 830-831.
4. Joseph MA, Kaufman HE, Insler M. Topical tacrolimus
ointment for treatment of refractory anterior segment
inflammatory disorders. Cornea 2005; 24: 417-420.
5. Rikkers SM, Holland GN, Drayton GE, Michel FK, Torres
MF, Takahashi S. Topical tacrolimus treatment of atopic
eyelid disease. Am J Ophthalmol 2003; 135: 297-302.
ARCH SOC ESP OFTALMOL 2006; 81: 661-664
663