Topical calcineurin inhibitors (TCIs)

TCIs should only be used if the eczema has not shown a satisfactory clinical response to adequate use of the maximum strength and potency of topical steroid that is appropriate for the patient's age and the area being treated, and/or if there is risk of important adverse effects from topical corticosteroid treatment.

Consider TCI therapy particularly for eczema of the face (especially eyelids) or flexures in children or adults requiring long term or frequent use of mild or moderate potency topical corticosteroids.

Topical calcineurin inhibitors (TCI) and topical steroids should not be used at the same time on the same area of the body. However, a TCI and a topical steroid may be used on different parts of the body, for example, a TCI may be used for unresponsive facial eczema, and a topical steroid may be used for flexures.

Topical calcineurin inhibitors should only be applied as a thin layer to the affected areas to areas of active atopic eczema, which may include areas of broken skin.

Mild and short acting skin irritation (itching and burning sensation) is very common during the first 1-2 weeks of TCI therapy and usually improves with time.

Exposure of the skin to sunlight, UV light from a solarium, therapy with UVB or UVA in combination with psoralens should be avoided during treatment.

Appropriate sun protection methods should be advised including minimising time spent in direct sunlight, use of sunscreen products, and keeping the skin covered with appropriate clothing.

Do not use topical tacrolimus or pimecrolimus:

• for the treatment of mild atopic eczema
• as first-line treatment for atopic eczema of any severity
• under occlusion (bandages and dressings) without specialist dermatological advice

Pimecrolimus

• Cream 1% (£19.69 = 30g)

Indications and dose

• Treatment of moderate or severe atopic eczema (including flares):
  • Apply twice daily until symptoms resolve (stop if eczema worsens or no response after 6 weeks). Reduce to once daily if symptoms allow.
    • For facial atopic eczema, apply once daily for 1 month, then reduce to twice per week and review need for facial atopic eczema at 4 months.

Notes

1. Advice and guidance is available for GPs requiring specialist input when considering initiating topical calcineurin inhibitors.
2. NICE TA82: Tacrolimus and pimecrolimus for atopic eczema (August 2004):
   1. Topical pimecrolimus (Elidel) is recommended, within its licensed indications, as an option for the second-line treatment of moderate atopic eczema on the face and neck in children aged 2 to 16 years that has not been controlled by topical corticosteroids, where there is a serious risk of important adverse effects from further topical corticosteroid use, particularly irreversible skin atrophy
   2. Topical pimecrolimus (Elidel) is not recommended for the treatment of mild atopic eczema or as first-line treatment for atopic eczema of any severity.

Tacrolimus

• Ointment 0.1% (adults and child over 16 years) (£17.08 = 30g)
• Ointment 0.03% (child aged 2 to 16 years) (£23.33 = 30g)

Indications and dose

• Treatment of moderate or severe atopic eczema (including flares):
• Adults and adolescents aged 16 years and above: 0.1% ointment to be applied thinly twice daily until lesion clears (consider other treatment if eczema worsens or no improvement after 2 weeks), reduce frequency to once daily or strength of ointment to 0.03% if condition allows.
• For facial atopic eczema, apply once daily for 1 month, then reduce to twice per week and review treatment at 4 months.
• Children aged 2 to <16 years: 0.03% ointment to be applied thinly twice daily for up to 3 weeks (consider other treatment if eczema worsens or if no improvement after 2 weeks), then reduced to once daily until lesion clears.
• For facial atopic eczema, apply once daily for 1 month, then reduce to twice per week and review treatment at 4 months.
• Prevention of flares in patients with moderate to severe atopic eczema and 4 or more flares a year who have responded to initial treatment with topical tacrolimus:
• Adults and adolescents aged 16 years and above: 0.1% ointment to be applied thinly twice weekly, with an interval of 2–3 days between applications, use short-term treatment regimen during an acute flare; review need for preventative therapy at 12 months.
• Children aged 2 to <16 years: 0.03% ointment to be applied thinly twice weekly, with an interval of 2–3 days between applications, use short-term treatment regimen during an acute flare; review need for preventative therapy after 1 year.

Notes

1. Advice and guidance is available for GPs requiring specialist input when considering initiating topical calcineurin inhibitors.
2. NICE TA82: Tacrolimus and pimecrolimus for atopic eczema (August 2004):
   1. Topical tacrolimus (Protopic) is recommended, within its licensed indications, as an option for the second-line treatment of moderate to severe atopic eczema in adults and children aged 2 years and older that has not been controlled by topical corticosteroids, where there is a serious risk of important adverse effects from further topical corticosteroid use, particularly irreversible skin atrophy
   2. Topical tacrolimus (Protopic) is not recommended for the treatment of mild atopic eczema or as first-line treatment for atopic eczema of any severity.

Oral retinoids for eczema

Alitretinoin

• Capsules 10mg, 30mg

Indications

• Severe chronic hand eczema refractory to potent topical corticosteroids

Dose

• 30 mg once daily, reduced to 10mg once daily if not tolerated
• Patients with diabetes, history of hyperlipidaemia, or risk factors for cardiovascular disease: initially 10mg once daily, increased if necessary up to maximum 30mg daily

Notes

1. Specific information regarding oral alitretinoin and the use of remote consultations for monitoring safety requirements (from the Medicines and Healthcare products Regulatory Agency (MHRA)) during the Coronavirus (COVID-19) pandemic can be found here.
2. NICE TA177: Alitretinoin (Toctino) is recommended as a treatment option for adults with severe chronic hand eczema, in accordance with the criteria in the NICE TA (August 2009)
3. MHRA Drug Safety Update (June 2019): Oral retinoid medicines: revised and simplified pregnancy prevention educational materials for healthcare professionals and women, and advise about the risk of neuropsychiatric reactions
   1. Due to a high risk of serious congenital malformations, alitretinoin must not be used in pregnancy, and any use in women and girls must be within the conditions of a Pregnancy Prevention Programme (PPP)
   2. Patients treated with an oral retinoid should be monitored or signs of depression or suicidal ideation and refer for appropriate treatment, if necessary; particular care needs to be taken in patients with history of depression
   3. Advise patients taking an oral retinoid that they may experience changes in their mood or behaviour and that they should speak to their doctor if their mood is affected; they should be encouraged to let family and friends know they are taking an oral retinoid so they can look out for any change in mood
4. See also resources for: contraception for drugs with teratogenic potential, and prescribing in pregnancy and lactation