Successful treatment of nodular actinic reticuloid with tacrolimus ointment

Actinic reticuloid (AR) is the severest clinical variant of chronic actinic dermatitis (CAD) and describes a persistent photoinduced skin disorder often associated with delayed-type hypersensitivity reactions. Histopathologically, AR resembles pseudolymphoma and may also show features of cutaneous lymphoma. In contrast to other UV-induced skin diseases, AR patients show persistent photosensitivity to UV radiation and visible light parallel to permanent changes of skin texture with infiltrated papules and thickened plaques. Therapeutically, CAD is a problematic condition. Daily application of sun protection has to be combined with local or systemic immunosuppression. However, various therapeutic approaches including systemic corticosteroids and other systemic immunosuppressive agents are limited by severe side effects. Tacrolimus, a Streptomyces-derived immunosuppressive macrolide antibiotic and inhibitor of calcineurin, has been proven successful in various inflammatory skin diseases including atopic eczema, allergic contact dermatitis and photodermatoses without undesired side effects. We present a case of severe recalcitrant and nodular chronic actinic dermatitis responding to topically applied tacrolimus (Protopic). To avoid further relapses we continued this therapy twice a day over a period of 2 years.