SIR, We report four patients with extensive facial psoriasis who responded to treatment with topical tacrolimus. Tacrolimus, a calcineurin inhibitor, is effective against a wide range of inflammatory dermatoses including psoriasis, when given systemically. 1 Topical tacrolimus has been shown to be ineffective in treating psoriasis, 2 although one report from Japan claimed benefit in facial psoriasis, 3 and descaling and occlusive dressings have been shown to increase the effects of topical pimecrolimus on psoriatic lesions. 4 More recently, animal models have shown that a liposomal tacrolimus lotion may increase the penetration of tacrolimus into the skin and allow for slow release of the active compound locally. 5 Facial skin is highly sensitive due to its anatomy which includes a high density of appendages, an elaborate network of sensory nerves and a more permeable horny layer, 6 and studies have demonstrated increased penetration in persons with sensitive skin. Facial and intertriginous skin is more susceptible to corticosteroidinduced atrophy, 7 a problem not associated with use of topical tacrolimus.

The first patient, a 65-year-old woman with chronic psoriasis who had been previously treated with psoralen plus ultraviolet (UV) A, UVB, methotrexate, ciclosporin and acitretin at various times, was admitted with an acute exacerbation of psoriasis. It was noted on admission that she had marked facial psoriasis that had proven resistant to treatment with various topical agents. During her admission she was commenced on 0Æ1% topical tacrolimus for facial psoriasis. At 1-month follow-up the facial psoriasis had improved considerably (Figs 1 and 2). The second patient was a 20-year-old man with extensive psoriasis, who is maintained on ciclosporin 150 mg twice daily. He continued to have marked facial psoriasis and this proved to be psychologically disabling. He was commenced on 0Æ1% topical tacrolimus for the facial psoriasis and at 2-month follow-up his facial psoriasis had improved dramatically and for the first time in many years his face was clear from psoriasis. The third patient was a 30-yearold woman with chronic psoriasis who also had severe facial involvement. During an admission she was commenced on 0Æ1% topical tacrolimus for her facial psoriasis. The response to tacrolimus was dramatic, leading to complete clearance of the skin condition. The fourth patient was a 6-year-old girl