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Gary M. White & Neil H. Cox

Diseases of the Skin

3	Topical Therapy

CALCINEURIN INHIBITORS

These are topical agents primarily used for treatment of eczema (mainly atopic dermatitis), although benefit has also been recorded in several other dermatoses, such as psoriasis, vitiligo, discoid lupus erythematosus, and oral lichen planus.

Tacrolimus is a calcineurin inhibitor that is effective in treating atopic dermatitis in both adults and children. It has been shown effective in both the 0.1% and 0.03% ointments, applied b.i.d. It is particularly effective for the face and neck but, unlike with topical steroids, there is no risk of skin atrophy. Patients given it for the first time should be told to expect itching and/or burning. Significant improvement occurs within 1 week, and the majority of improvement within 4–6 weeks. Patients may apply the medication several times a week to normal skin during maintenance therapy to prevent relapse. It appears approximately equivalent in strength to betamethasone valerate. Recent studies have found tacrolimus combined with phototherapy to improve vitiligo, and personal experience supports the benefit reported anecdotally or in small studies in discoid lupus erythematosus and oral lichen planus.

Pimecrolimus is formulated as a 1% cream applied b.i.d. for atopic dermatitis. As with tacrolimus, its great advantage over steroids is its lack of atrophic side effects. It can be used on the neck and face without concern of skin thinning, in contrast to topical steroids. Clinical studies show it to be slightly less effective than tacrolimus.

Because of their safety and efficacy, some view pimecrolimus and tacrolimus as first-line agents in the treatment of atopic dermatitis. However, their cost and concerns over their possibility to promote skin malignancy in the long term (they are related to immunosuppressive agents used in prevention of organ transplant rejection) has led others to be more cautious in recommending such widespread use.