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Cyclosporine A

Cyclosporin is an immunosuppressant that acts by inhibiting T-cell functions and interleukin (IL-2) synthesis. It has been FDA approved for severe, recalcitrant psoriasis in non-immunocompromised adults and in treatment of transplant rejection in children > 6 months of age. It is an off label, short-term crisis management drug producing rapid clinical response in children within 4-8 weeks.

Its use is limited by a dose dependent risk of nephrotoxicity, hypertension, and immunosuppression. Hence, close monitoring of the dose based on clinical response, blood pressure, serum creatinine levels and other blood parameters is required. Doses of 3-5 mg/kg/day generally produce rapid clearing of pustular or erythrodermic psoriasis. The dose needs to be reduced if the base line creatinine increases by a third. Risk of malignancy is observed to be minimal at 5mg/kg/day or less, in patients who are not on concomitant immunosuppressive drugs.

Gradual tapering of dose should start after 1-3 months of clinical stability but psoriasis rebounds are common during taper or withdrawal of the drug. Hence it needs to be effectively used in sequential therapy with acitretin or combined with other systemic and topical therapies to prevent rebound, increase efficacy and decrease end organ toxicity.