Systemic calcineurin inhibitors tacrolimus and voclosporin: A review of off-label dermatologic uses

Background: Systemic calcineurin inhibitors, cyclosporine, tacrolimus, and voclosporin, have been utilized in various dermatologic conditions. Although there have been numerous off -label dermatologic indications with published guidelines for cyclosporine, there is no established strong consensus for tacrolimus and voclosporin. Objective: To conduct a review of off -label use of systemic tacrolimus and voclosporin in various dermatoses to better inform treatment methods. Methods: A literature search was conducted using PubMed and Google Scholar. Relevant clinical trials, observational studies, case series, and reports regarding off -label dermatologic uses of systemic tacrolimus and voclosporin were included. Results: Tacrolimus shows promise for numerous dermatologic conditions, including psoriasis, atopic dermatitis/eczema, pyoderma gangrenosum, chronic urticaria, and Behcet's disease. Randomized controlled trial data are only available for voclosporin in psoriasis, which showed efficacy but did not meet noninferiority to cyclosporine. Limitations: Data were limited and extracted from published papers. Studies differed in methodology, and nonstandardized outcomes limited the conclusions drawn. Conclusions: In comparison to cyclosporine, tacrolimus can be considered for treatment -refractory disease or in patients with cardiovascular risk factors or inflammatory bowel disease. Voclosporin has only been utilized in psoriasis currently, and clinical trials in psoriasis show voclosporin's efficacy. Voclosporin can be considered for patients with lupus nephritis. ( J Am Acad Dermatol 2024;90:358-67.)