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Topical pimecrolimus and tacrolimus

Bite-sized advice for busy GPs

A new group of topical compounds has become available for treating the inflammation associated with atopic eczema. These are the calcineurin inhibitors, otherwise known as topical immunomodulators

or topical immunosuppressants. Pimecrolimus has also been placed as an anti-inflammatory.

Calcineurin inhibitors are an alternative to topical steroids. Some authorities advise that tacrolimus should be specialist use only but the division between specialist and GP care is becoming blurred with intermediate care and GPwSIs. GPs need to continue to keep up to date with the latest prescribing advice.

There are certain groups of patient for whom these new therapies may be especially relevant. These include those with steroid atrophy or at high risk of steroid atrophy, such as those with eyelid and facial eczema. There also patients who do not respond well to topical steroids, or those who will not use them.

While topical steroids are an effective intervention for atopic eczema, they can cause side-effects. Topical steroids can produce local side-effects such as atrophy, telangiectasia and rosacea. Systemic absorption, especially in children using more potent steroids, can be a problem.

Pimecrolimus is indicated as a treatment for children and adults two years upwards with mild to moderate eczema. Tacrolimus is indicated for patients aged two and upwards with moderate to severe atopic eczema that has not responded to conventional therapies.

There are no head-to-head studies, but tacrolimus appears to be more potent that pimecrolimus and tends to produce more side-effects. Both these drugs are much more expensive than topical steroids.

Pimecrolimus can be used by adults and children from two years upwards, a 1 per cent cream that is applied as a thin film twice daily till signs and symptoms of eczema resolve. Minimal pimecrolimus is absorbed and there is no interaction with alcohol. Emollients can be used in conjunction as part of a treatment plan.

Children over two can use tacrolimus 0.03 per cent ointment twice daily, reducing to once daily. Patients over 16 can initiate treatment with the more potent 0.1 per cent tacrolimus ointment for up to three weeks, then reducing strength. Don't use emollients within two hours of topical tacrolimus.

Apply calcineurin inhibitors as a thin film on affected skin. Patients can experience a transient sensation of warmth at site of application. Those using topical tacrolimus experience alcohol intolerance. Patients should be advised to avoid excessive sun exposure and not use these therapies with phototherapy.

Calcineurin inhibitors should not be used in the presence of any viral infections. Any secondary bacterial infection needs treating with a course of appropriate antibiotic, such as flucloxacillin. Pimecrolimus and tacrolimus need to be used as part of a treatment regime.

Thomas Poyner is a GP and hospital practitioner in Stockton-on-Tees

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