Synopsis
Use tacrolimus and pimecrolimus as steroid-sparing topical immunomodulators for supported indications, select age and strength correctly, counsel about burning, infection and ultraviolet exposure, and review non-response or persistent lesions safely.
- Tacrolimus and pimecrolimus inhibit calcineurin-dependent T-cell signalling and cytokine release without causing corticosteroid skin atrophy.
- They are not first-line treatment for ordinary atopic eczema: NICE positions them second line when appropriate topical corticosteroid control fails or serious atrophy risk is important.
- Initiation should be by a clinician with a special interest and experience in dermatology after the diagnosis, severity, site and prior corticosteroid technique are confirmed.
- Tacrolimus 0.03% ointment is used from age 2 years; 0.1% is an adult and age-16-and-over strength under its licensed eczema pathway.
- Pimecrolimus 1% cream is a NICE second-line option for mild or moderate facial and neck eczema in children aged 2–16 years when steroid atrophy risk is serious.
- Transient warmth, stinging or burning is common during the first days and usually reduces; severe pain, vesicles or deterioration is not routine adjustment.
- Do not apply to clinically infected skin, beneath occlusion, or directly to mucosa, and use handwashing and a mapped treatment area.
- Minimise natural and artificial ultraviolet exposure, avoid sunbeds and use clothing and broad-spectrum protection; combining treatment with phototherapy needs specialist direction.
- Twice-weekly tacrolimus maintenance on non-consecutive days can prevent flares in selected frequent relapsers who responded to induction, with formal review rather than indefinite automatic repeats.
- Vitiligo, genital or facial psoriasis and several other dermatoses may use calcineurin inhibitors off label; record the evidence, alternatives, consent and outcome separately from licensed eczema use.
Key red flags
Painful vesicles, punched-out erosions, fever, eye symptoms, spreading bacterial infection, persistent or unexplained lymphadenopathy, an indurated or ulcerated lesion, immune compromise outside the treatment plan, or major photosensitivity requires prompt reassessment before further application.
A lasting indurated, ulcerated, bleeding or otherwise atypical lesion should be biopsied or referred rather than suppressed repeatedly with local immunomodulation.
Investigation priorities
Ensure a supported inflammatory diagnosis and treatment threshold before initiation.
Show that appropriate first-line corticosteroid and emollient care genuinely failed or carried serious risk.
Management branches
A topical calcineurin inhibitor is being considered for atopic eczema.
- Confirm diagnosis, severity and sensitive-site burden and review a correctly delivered topical corticosteroid and emollient plan.
- Establish inadequate control or a serious corticosteroid adverse-effect risk and have an experienced clinician select tacrolimus or pimecrolimus by age, site and severity.
- Discuss licence, expected burning, infection actions, ultraviolet avoidance, amount, duration and alternatives and record any off-label element.