In an elderly patient with pyoderma gangrenosum and significant renal impairment, is topical tacrolimus ointment a safer alternative to systemic immunosuppressants for ulcer control

What is known

- Local immunosuppression with topical agents has been proposed as an alternative to systemic steroids, particularly for mild or early lesions. ¹ - Topical tacrolimus 0.1% ointment was reported as safe and effective for cutaneous manifestations including pyoderma gangrenosum, though it seldom cleared the condition and relapses occurred without maintenance. ² - Because tacrolimus was applied to ulcerated and mucosal surfaces, systemic levels were monitored; blood pressure, urinalysis and renal function remained constant in that study. ² - Elderly and comorbid patients face increased risk of serious infections and cancer from systemic immunosuppressants, motivating the search for safer alternatives. ³

What is unknown / caveats

- One report documented temporary renal insufficiency associated with topical tacrolimus for multilocal pyoderma gangrenosum ⁴, whereas a Crohn's cutaneous study found renal function unchanged ² - Evidence is limited to case reports and small series; no controlled comparison of topical tacrolimus vs systemic immunosuppressants for renal safety - No excerpt specifically studies elderly patients with pre-existing renal impairment - Systemic absorption through broken/ulcerated skin is a recognized concern - The excerpts do not establish that topical tacrolimus is definitively safer for the kidneys, since systemic absorption and at least one report of renal insufficiency undercut a blanket safety claim.

## References

1. Petering H, Kiehl P, Breuer C, Kapp A, Werfel T. [Pyoderma gangrenosum: successful topical therapy with tacrolimus (FK506)]. Hautarzt. 2001. PMID: 11220239.

2. Rice SA, Woo PN, El-Omar E, Keenan RA, Ormerod AD. Topical tacrolimus 0.1% ointment for treatment of cutaneous Crohn's Disease. BMC Res Notes. 2013;6:19. PMID: 23331739.

3. Mastronardi M, Cavalcanti E, Labarile N, Armentano R, Gabriele F, Curlo M. Pyoderma gangrenosum in ulcerative colitis patient treated with vedolizumab: adsorptive granulocyte/monocyte apheresis as a new therapeutic option refractory cases - a case report and literature review. Ther Adv Chronic Dis. 2023. PMID: 37928629.

4. [No authors listed]. Diagnosis and management of peristomal pyoderma gangrenosum: A systematic review. J Am Acad Dermatol. 2018;78:1195-1204.e1. PMID: 29288099.

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_Draft, generated by the IBDology RAG and not yet clinician-reviewed. Answers are grounded in the retrieved literature listed above; a high faithfulness score means the answer matches its sources, not that the sources are correct._