Cyclosporine Protocol for Acute Generalized Exanthematous Pustulosis (AGEP)

Indications and Pre-treatment Monitoring

The American Academy of Dermatology recommends cyclosporine for severe or recalcitrant cases of AGEP that require rapid control of severe, unstable disease 1
Pre-treatment monitoring should include complete blood count, comprehensive metabolic panel, serum creatinine, blood urea nitrogen, blood pressure measurement, fasting lipid profile, serum magnesium, potassium, and uric acid levels, urinalysis, hepatitis B, hepatitis C, and tuberculosis screening, varicella serology, and pregnancy test for women of childbearing potential 2, 3, 4, 5

The initial dose of cyclosporine should be 3-5 mg/kg/day divided into two doses, with severe AGEP starting at the higher end of the dosing range (5 mg/kg/day) and less severe cases starting at a lower dose (3 mg/kg/day) 2, 3
Monitoring during treatment should include blood pressure, serum creatinine, complete blood count, liver function tests, potassium, and lipids, with frequency depending on the duration of treatment and stability of the patient 2, 3

Contraindications to cyclosporine use include history of systemic malignancy, renal insufficiency, uncontrolled hypertension, uncontrolled infections, hypersensitivity to cyclosporine, and pregnancy (unless benefit justifies risk) 3, 5
Drug interactions to avoid include medications that interfere with CYP3A4 metabolism, aminoglycosides, amphotericin, trimethoprim, ketoconazole, non-steroidal anti-inflammatory drugs, and potassium-sparing diuretics 2, 3, 4

Hypertension should be managed by decreasing the cyclosporine dose, and if necessary, using calcium channel blockers (preferably isradipine) 3
Nephrotoxicity should be managed by reducing the dose by 25-50% if serum creatinine increases >30% above baseline, and discontinuing cyclosporine if renal function does not improve 2, 4

The modified cyclosporine microemulsion formulation should be used, and women of childbearing potential must use effective contraception during treatment and for at least one month after discontinuation 1, 4, 5
Live vaccinations are contraindicated during cyclosporine therapy, and patients should be provided with written information about potential side effects and drug interactions 2, 3