Short-Term Efficacy of Tacrolimus Ointment in Severe Uremic Pruritus

Editor: Uremic pruritus (UP) is still one of the most vexing and disabling symptoms in chronic renal failure, afflicting up to 85% of patients on dialysis (1). The pathogenesis of UP is obscure and effective therapeutic strategies are elusive. Deducted from partially successful treatment modalities, there is evidence that immunologic impairment might play a role in the evolution of UP. It has been reported that UVB phototherapy of half the body leads to a generalized improvement in UP (2). Exposing subjects to UVB light inhibits the T helper cells type 1 (Th1) and, in part, Th2 lymphocyte-mediated immune response (3). Similar effects can be achieved by administering thalidomide (4), which has also been reported to be effective in the treatment of UP (5), and tacrolimus, which has not been evaluated in UP so far. Therefore, we tested whether short-term administration of tacrolimus ointment is effective in reducing UP. Three patients on peritoneal dialysis, severely tormented by UP and previously treated, to no avail, with other potentially effective modalities were recruited. The patients documented pruritus using a visual analog scale (VAS), ranging from 0 to 10, and a detailed pruritus score 3 days prior to and during the treatment phase. Patients were instructed to apply a 0.03% tacrolimus ointment twice daily, for a period of 7 days, to areas most affected by UP. In all 3 patients, UP could be reduced dramatically right from the start of treatment (Figure 1). Two days after treatment was stopped, pruritus slowly recurred. No side effects could be monitored during or after the treatment period. Tacrolimus ointment seems to be a safe and highly effective short-term treatment option for patients suffering from severe UP. However, considering the potential carcinogenic effect of systemically administered tacrolimus, one should be cautious to treat patients over a longer period of time. Our observation adds evidence to the suggestion that an immunologic impairment conveyed by uremia itself or by dialysis might play a role in the pathogenesis of uremic pruritus.