Colchicine in Dermatology
Role in Specific Dermatological Conditions
Colchicine has a well-established role in treating recurrent aphthous ulcers (oral ulcers) and erythema nodosum associated with Behçet's disease, but its efficacy in palmoplantar pustulosis is questionable and not recommended as first-line therapy. 1, 2
Aphthous Ulcers (Recurrent Aphthous Stomatitis)
Colchicine should be considered as first-line systemic therapy for recurrent aphthous stomatitis, particularly when patients experience ≥4 episodes per year or when topical treatments have failed. 2
- Start colchicine after topical corticosteroids (clobetasol 0.05% gel or dexamethasone 0.1 mg/ml rinse) prove insufficient 2
- Colchicine significantly relieves pain, decreases the number of lesions, and increases the free interval between eruptive episodes 3
- The mechanism involves blocking multiple inflammatory pathways with antimitotic and antifibrotic action 3
- For refractory cases not responding to colchicine, escalate to azathioprine, interferon-alpha, or TNF-alpha antagonists 2
Behçet's Disease with Mucocutaneous Involvement
For Behçet's disease, colchicine should be the preferred systemic agent when the dominant lesion is erythema nodosum or when patients have recurrent oral and genital ulcers. 1, 2
- Begin with topical corticosteroids for isolated oral ulcers 1
- Add colchicine for recurrent mucocutaneous involvement, particularly effective for erythema nodosum lesions and genital ulcers among women 1
- Sucralfate suspension has demonstrated efficacy in randomized controlled trials for oral and genital ulcers in Behçet's disease 1
- Reserve azathioprine, interferon-alpha, or TNF-alpha antagonists for resistant cases 1, 2
Critical warning: Colchicine should NOT be used in Behçet's patients with central nervous system involvement unless absolutely necessary for intraocular inflammation, due to potential neurotoxicity. 1
Palmoplantar Pustulosis
Colchicine is NOT recommended for palmoplantar pustulosis based on conflicting evidence and superior alternatives. 4, 5, 6
The evidence is contradictory and concerning:
- A 1984 double-blind crossover trial showed only 10 of 27 patients experienced halt of pustule formation, with no improvement in redness, scaling, or subjective symptoms 5
- A Cochrane systematic review concluded colchicine has significant side effects and unclear efficacy for palmoplantar pustulosis 4
- Conversely, a 1982 study reported 13 of 32 patients showed complete clearing and 14 showed remarkable reduction, but 8 relapsed within three months after stopping treatment 6
Instead, use systemic retinoids or oral PUVA as first-line therapy for palmoplantar pustulosis (improvement rate difference 44% for both), with combination therapy being superior to individual treatments. 4
- Topical steroids under hydrocolloid occlusion are beneficial 4
- Low-dose ciclosporin, tetracycline antibiotics, or Grenz Ray Therapy may be useful alternatives 4
Other Dermatological Conditions
Colchicine has been reported in case series and case reports for various skin conditions, though evidence quality is limited 7:
- Hidradenitis suppurativa
- Pyoderma gangrenosum
- Erythema induratum
- Perforating dermatosis
- Bullous diseases
- Vasculitis
- Acne and urticaria
However, these applications lack high-quality guideline support and should be considered only after conventional therapies fail. 7
Practical Dosing and Monitoring Algorithm
Pre-Treatment Evaluation
Before initiating colchicine for any dermatological condition 8:
- Obtain baseline complete blood count, liver enzymes (AST, ALT), creatinine phosphokinase, and renal function tests (serum creatinine, calculated creatinine clearance) 8
- Perform urinalysis to screen for proteinuria 8
- Screen for medications that interact via CYP3A4 or P-glycoprotein pathways (macrolides, azole antifungals, protease inhibitors, verapamil, cyclosporine, statins) 8
Dosing for Adults
Start with 1.0-1.5 mg daily for adults, with a maximum dose of 3 mg daily or the maximum tolerated dose. 1
- Increase dose gradually based on response and tolerance 1
- Monitor CRP or SAA protein every 3 months during dose escalation in patients with active disease 1
Monitoring During Treatment
Monitor every 6 months minimum with complete blood count, liver enzymes, creatinine phosphokinase, and renal function tests. 8
- Increase monitoring frequency to every 3 months during dose escalation or in patients with active disease 8
- Perform urinalysis at least yearly, more frequently if disease is poorly controlled 8
- If liver enzymes exceed 2-fold the upper limit of normal, reduce colchicine dose and investigate further 1, 8
Critical Toxicity Warning Signs
Discontinue colchicine immediately if any of the following develop 8:
- Gastrointestinal symptoms (abdominal cramping, vomiting, diarrhea) that may herald serious toxicity 8
- Progressive muscle weakness or elevated creatinine phosphokinase 8
- Cytopenias or bone marrow suppression 8
- Neuropathy or acute worsening of renal function 8
Special Populations
In patients with renal impairment (CrCl <50 mL/min), the risk of toxicity is very high; closely monitor for signs of colchicine toxicity and reduce dose accordingly. 1, 8
Colchicine should NOT be discontinued during conception, pregnancy, or lactation; current evidence supports safety during these periods. 1
- Men generally do not need to stop colchicine prior to conception 1
- In rare cases of azoospermia or oligospermia proven related to colchicine, temporary dose reduction or discontinuation may be needed 1
Common Pitfalls to Avoid
- Never combine colchicine with strong CYP3A4 inhibitors in patients with renal or hepatic impairment—this can be fatal 8
- Do not assume gastrointestinal symptoms are benign; they may herald serious toxicity requiring immediate discontinuation 8
- Avoid premature tapering before disease control is established 2
- Do not use colchicine in Behçet's patients with neurological involvement unless absolutely necessary for eye disease 1