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Topical Treatment – how and when Calcineurin Inhibitors and Topical Steroids should be used

The topical immunomodulators, calcineurin ihibitors (TCI) are non-steroidal agents that act via immunologic pathways. Targeted reduction of pro-inflammatory cytokines is responsible for the itch and rash of atopic dermatitis. Tacrolimus is one of two lags more potent than cyclosporine and very effective in moderate to severe atopic dermatitis (AD), especially for face, neck and trunk lesions. During remission, dosing may be reduced in frequency. About 25 percent of patients with severe disease do not have a satisfactory therapeutic response. The main advantage of topical tacrolimus is the provision of chronic maintains therapy without the need for continuous topical corticosteroids. Adverse effect (burning and itching) after 18 months using tacrolimus where very rare in patients older than 2 years of age and less in children (as prior infection) (1). Post-marketing reports of lymphoma or malignancy in patients using tacrolimus topically had risk related to TCI. Pimecrolimus has a similar structure to tacrolimus and interacts with same binding protein to inhibit calcineurin activation of the nuclear factor of activated T cell (2). Skin effects are lower, however a higher drug concentration in the topical cream (3). Pimecrolimus has little systemic immunosuppressive effect which is proven in children from 3 moths of age and duration after 2 years of pimecrolimus therapy. Post-marketing reports of lymphoma and malignancy warning is the same according FDA as for tacrolimus.Indications of pimecrolimus and tacrolimus in AD according US FDA are: second-line therapy in children older than 2 years ; in adults ; short-term, non-continuous chronic therapy. Contraindications are: immunocompromised patients, Netherthon`s syndrome, active bacterial or viral infection and phototherapy.Pimecrolimus or tacrolimus are indicated when standard therapy including topical steroids and emollients are either ineffective or harmful. In comparison with topical corticosteroids (TC) and standard therapy, TCI have not shown reactive clinical or pharmacoeconomic benefit (1). TCI for initiate therapy: pimecrolimus 1% cream for mild to moderate AD or tacrolimus 0, 03% ointment for children ages 2 to 15 years old and 0, 1% in patients 16 years and older for moderate to severe AD. Both products have excellent safety and efficacy records compared to placebo in the short time. Both TCI should be applied sparingly only to effected areas of excoriated skin twice daily after bathing mostly. Emollients should be continued on unaffected areas.Pre-treating for 2 to 7 days with topical steroid may improve treatment results. Effective monitoring therapy with TCI is long-term regimen intermittently for active AD. Patients should be evaluated for cutaneous infections and signs of skin malignancy. In clinical evidence of systemic immunosuppressing serum levels of tacrolimus or pimecrolimus may be obtained. Ongoing vigilance for potential TCI adverse effects must continue. TC are still choice of appropriate management of AD depending on disease activity (ointment or cream with adequate potency of TC).

topical immunomodulators; calcineurin ihibitors; atopic dermatitis

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