Topical immunosuppressants

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Tacrolimus (Protopic, Fujisawa) has recently become available as an ointment in two strengths, 0.03% and 0.1%. It has not been evaluated in children under the age of two or in pregnant women. It is recommended that it is only used by dermatologists or those with considerable experience in treating eczema. Although the exact mode of action is unknown it does diminish T cell stimulation by Langerhan cells and diminishes the production of inflammatory mediators from mast cells. It should be used in moderate to severe atopic eczema that has not responded to either treatment. Skin irritation with burning, erythema, and pruritis are the most common side effects. In view of its immunosuppressive activity any infection should be treated first and it should be used with caution if there is a risk of viral infection or if inoculations using attenuated or live organisms are being used.

Pimecrolimus (Elidel, Steeple Novartis) is a similar preparation recommended for intermittent treatment of eczema can also be used as an initial treatment for any flare up of eczema. It diminishes cytokine activity long term relieving both the erythema and pruritis of eczema.

In common with topical steroids any immunosuppressive drug should be used with caution as viral infections are likely to be present or the patient is undergoing inoculation with live or attenuated organisms.

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