Topical calcineurin inhibitors for eczema

Topical calcineurin inhibitors work by altering the immune system and it helps to treat atopic eczema. There are two types of topical calcineurin inhibitors (TCIs):

  1. Tacrolimus ointment (Protopic) used for treating moderate to severe eczema.
  2. Pimecrolimus cream (Elidel) used for treating mild to moderate eczema.

Topical calcineurin inhibitors are used to treat atopic eczema in adults and children over 2 who don’t respond or who cannot tolerate conventional therapies such as topical steroids. They are used to treat and prevent flares.

When can topical calcineurin inhibitors be used?

TCIs are suitable for delicate areas of the skin, such as the face, eyelids, neck, skin folds, and outer genital skin, where prolonged treatment with topical steroids may be inappropriate.

Tacrolimus and pimecrolimus can be used both long-term and short-term to treat flares and also prevent them.

How do TCIs work?

In atopic eczema, the immune system is very overactive (hence the inflammation). TCIs work by suppressing this overactivity by acting on the T-cells to calm the immune system. This helps to reduce inflammation and itchiness.

How are they used?

For flare treatment:

TCIs need to be applied thinly to the skin affected with eczema for 30 days. The treatment should begin when you see signs of active inflamed eczema. In lighter skin, this will be seen as red and itchy skin. In darker skin, redness can be seen and skin will have darker patches and be itchy. The treatment will continue till the red or dark patches have subsided.

Make sure to not apply TCIs inside the mouth or nose, eyes, or moist genital skin. After 6 weeks of treatment, the TCI can be used for maintenance treatment.

Tacrolimus (Protopic):

It comes in two strengths, 0.1% which is stronger, and 0.03% which is weaker. Adults and young people should start with the stronger version and apply it twice a day. After a treatment period of 6 weeks, 0.1% can be prescribed to use just twice a week (this helps to prevent or lessen flares).

0.1% tacrolimus has shown to be effective for a 1-year period, but you should make sure to switch to 0.03% tacrolimus if flares start to occur frequently as the 0.1% version can be strong.

Children (aged 2-15) should use the weaker version ie. 0.03%. It can be applied twice a day for 3 weeks and then reduce to once a day until eczema clears.

If there are no signs of improvement within the first 2 weeks, then other treatment options should be considered.

Pimecrolimus (Elidel):

Pimecrolimus can be applied twice daily (at the first appearance of inflammation or itching). It should be used for a short period of time. If it is used for maintenance (ie, long term to prevent the progression of flares) then you can apply it only twice a week.

If there is no improvement after 6 weeks, then the pimecrolimus cream should be stopped.

Can TCIs be used along with other treatments?

Yes, TCIs can be used along with other treatments, but do consult a doctor about the medications you’re planning to use. Also do use emollients.

The manufacturer of tacrolimus says that emollients should be used within 2 hours of applying tacrolimus. That means you should use an emollient after bathing/showering and then leave a 2-hour gap before applying tacrolimus.

In case of pimecrolimus, apply it to dry skin and then apply an emollien after a short gap.

Make sure to not use TCIs and topical steroids at the same time on the same areas of the body, but it is likely that the doctor will tell you to use TCIs along with topical steroids on different parts of the body. While TCIs work to dampen the immune system, they could worsen skin infections by reducing the skin’s natural resistance. For these reasons, TCIs should not be applied to skin that is infected with bacteria. It is also not suitable to use under wet wraps.

What else do I need to be aware of when using TCIs?

  • You might experience a mild burning sensation when applying TCI in the first week.
  • Make sure to avoid strong sun exposure and ultraviolet light because TCIs can make you sensitive to light, so do make sure to apply sunscreen and wear protective clothing (hats, caps, etc).
  • Also avoid tanning beds and phototherapy treatment.
  • TCIs should not be used in people with people who can get superficial skin infections, including inflamed or infected hair follicles, cold sores, and generalised herpes simplex infections.

Do TCIs work?

Tacrolimus (0.1%) has shown to be more effective than hydrocortisone butyrate (a potent topical steroid) in treating atopic eczema, but hydrocortisone butyrate was more effective than 0.03% tacrolimus.

Pimecrolimus has been shown to work in people with mild to moderate eczema and also reduce flare-ups.

What are the side effects?

  • Short-term side effects are itching, burning, and irritation.
  • Changes in skin coloration (skin becoming red or dark).
  • Some people experience blocked skin pores and viral skin infections (like warts and cold sores).
  • Impetigo can be common in children who use TCIs.
  • Some people can experience skin irritation and facial flushing when they consume alcohol.
  • There were studies conducted to see whether TCIs can thin the skin and they showed that it does not happen.
  • The chances of TCIs getting into the bloodstream was very small.

Dermatologists may also prescribe TCIs to patients with other types of eczema.