Localized Tacrolimus Delivery for Peripheral Nerve Regeneration: Molecular Mechanisms, Biomaterial Platforms, and Translational Strategies

Peripheral nerve injuries cause profound medical and socioeconomic consequences. Despite substantial microsurgical advances, including nerve autografting, nerve transfers, and the commercial availability of effective conduits, functional recovery remains incomplete for most patients. Current outcomes underscore the need for novel adjunctive therapies capable of enhancing axonal regeneration, accelerating reinnervation, and mitigating denervation-induced target atrophy. Tacrolimus, a calcineurin inhibitor widely used in organ transplantation, has emerged as a potent immunomodulatory and neuroregenerative agent. However, its systemic use is constrained by severe dose-limiting toxicities and metabolic derangements. This limitation has driven a paradigm shift toward localized tacrolimus delivery, leveraging biomaterials to achieve therapeutic drug concentrations at the repair site while minimizing systemic toxicity. This review synthesizes the state-of-the-art advances in biomaterial-based tacrolimus local delivery systems. We highlight biological mechanisms underlying tacrolimus-mediated neuroregeneration and immunomodulation. Engineering strategies including nerve conduits, wraps, injectable hydrogels, electrospun scaffolds, and stimuli-responsive carriers are discussed, with attention to polymeric composition, fabrication technologies, degradation kinetics, and pharmacological performance. We also explored the regulatory, manufacturing, and scalability challenges inherent to drug–device combination products. Finally, we identify emerging directions including multimodal biomaterials that integrate tacrolimus with trophic factors, extracellular vesicles, or bioelectrical stimulation. Collectively, biomaterial-enabled tacrolimus delivery represents a transformative strategy to bridge traditional nerve surgical repair and functional recovery. This review provides a roadmap for future interdisciplinary innovation at the interface of biomaterials science, neurobiology, pharmacology, and surgery.