Cyclosporine in Dermatology
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Direct answer
Cyclosporine in dermatology is a calcineurin inhibitor that suppresses T-cell activation and is used systemically for severe psoriasis, atopic dermatitis, pemphigus and refractory chronic urticaria. Its main hazard is dose-related nephrotoxicity with hypertension, so serum creatinine and blood pressure are checked regularly. Dosing is weight-based, and courses are usually limited in duration because renal damage can accumulate.
What you must remember
- Mechanism: binds cyclophilin, and the complex inhibits calcineurin, blocking NFAT-driven interleukin-2 transcription.
- Indications: severe plaque psoriasis, atopic dermatitis, pemphigus and refractory chronic urticaria.
- Psoriasis dose: about 2.5 mg per kg per day in divided doses, titrated to response up to about 4 to 5 mg per kg per day.
- Nephrotoxicity: afferent arteriolar vasoconstriction, dose-related and often reversible on dose reduction.
- Creatinine rule: a rise of more than 25 percent above baseline on repeat testing prompts dose reduction.
- Hypertension: common and needs treatment; hyperkalaemia and hypomagnesaemia also occur.
- Interactions: NSAIDs and aminoglycosides add nephrotoxicity, while azoles, macrolides and grapefruit juice raise cyclosporine levels.
- Other effects: gingival hyperplasia and hypertrichosis are typical.
A monitored course of cyclosporine
Cyclosporine can be used safely only with planned monitoring, because renal damage can develop without symptoms. The sequence below reflects the usual approach in psoriasis.
- Screen first: record blood pressure, serum creatinine and electrolytes, and exclude active infection and uncontrolled hypertension before starting.
- Dose by weight: start at about 2.5 mg per kg per day in two divided doses, aiming for the lowest effective dose.
- Recheck early: repeat creatinine and blood pressure about every two weeks during the first months, then less often, as the local protocol directs.
- Act on the creatinine: if the rise exceeds 25 percent above baseline, reduce the dose and repeat the test, and stop if the change does not reverse.
- Control blood pressure: treat hypertension promptly, and avoid NSAIDs and other nephrotoxic drugs during therapy.
- Plan the exit: limit the course, taper or switch to a steroid-sparing agent, and avoid indefinite use.
Patients should know that the drug is powerful, and that reduced urine output or new swelling needs prompt review. Clear counselling improves adherence to the monitoring schedule.
Where the exam tries to catch you
Cyclosporine questions usually hinge on the creatinine threshold, the interacting drugs and the duration rule.
- Trap: ignoring a creatinine rise because the value is still within the normal range Correct: the threshold is a rise of more than 25 percent above baseline, which matters even when the value remains normal.
- Trap: giving NSAIDs for joint pain in a patient on cyclosporine Correct: NSAIDs add to renal vasoconstriction, so they are avoided or used with great caution.
- Trap: assuming cyclosporine can be continued indefinitely Correct: renal toxicity accumulates, so courses are limited and a steroid-sparing agent is planned.
Frequently asked questions
What creatinine rise prompts dose reduction with cyclosporine?
Cyclosporine dose reduction is usually triggered when serum creatinine rises more than 25 percent above the baseline value on repeat testing. Cyclosporine nephrotoxicity is dose-related and often reverses after dose reduction. Persistent rises need specialist review before treatment continues.
Why is blood pressure monitored in patients on cyclosporine?
Cyclosporine causes hypertension through renal afferent arteriolar vasoconstriction and sodium retention. Blood pressure is checked at each visit and treated when raised. Hypertension on cyclosporine also adds to the risk of kidney damage.
What is a typical starting dose of cyclosporine for psoriasis?
Cyclosporine for psoriasis is usually started at about 2.5 mg per kg per day in two divided doses, then titrated to response up to about 4 to 5 mg per kg per day. The lowest effective dose is preferred to limit renal toxicity. Doses should follow current guidelines and the local formulary.
Which drugs interact with cyclosporine?
Cyclosporine interacts with NSAIDs and aminoglycosides, which add to nephrotoxicity, and with azoles, macrolides and grapefruit juice, which raise cyclosporine levels. Interacting drugs should be reviewed before cyclosporine is started. Dose adjustment may be needed when they are added later.