Atopic dermatitis: Topical calcineurin inhibitors recommendations

  • TCI are recommended and effective for acute and chronic treatment, along with maintenance, in both adults and children with AD, and are particularly useful in selected clinical situations. 
Clinical situations in which topical calcineurin inhibitors may be preferable to topical steroids
  • Recalcitrance to steriods
  • Sensitive areas (e.g., face, anogenital, skin folds)
  • Steriod-induced atrophy
  • Long-term uninterrupted topical steriod use

Level of Evidence: I Strength of Recommendation: A

  • TCI are recommended for use on actively affected areas as a steroid-sparing agent for the treatment of AD.
Level of Evidence: I Strength of Recommendation: A
  • For patients with AD <2 years of age with mild to severe disease, off-label use of 0.03% tacrolimus or 1% pimecrolimus ointment can be recommended.
Level of Evidence: I Strength of Recommendation: A

  • Pimecrolimus cream and tacrolimus ointment may cause skin burning and pruritus, especially when applied to acutely inflamed skin. Initial treatment of patients with AD using topical corticosteroids should be considered to minimize TCI application site reactions. Patients with AD should be counseled about the possibility of these reactions.
Level of Evidence: II Strength of Recommendation: B
  • Proactive, intermittent use of TCI as maintenance therapy (2-3 times per week) on areas that commonly flare is recommended to help prevent relapses while reducing the need for topical corticosteroids, and is more effective than the use of emollients alone.
Level of Evidence: I Strength of Recommendation: A
  • The concomitant use of a topical corticosteroid with a TCI may be recommended for the treatment of AD.
Level of Evidence: II Strength of Recommendation: B

  • No consistent increases in the prevalence of cutaneous viral infections have been seen with continuous or intermittent use of TCI for up to 5 years; however, physicians should inform their patients of these theoretical cutaneous risks, given the lack of safety data for longer periods of time.
Level of Evidence: III Strength of Recommendation: C

  • Clinicians should be aware of the black-box warning on the use of TCI for patients with AD and discuss as warranted.
Level of Evidence: III Strength of Recommendation: C

  • Routine blood monitoring of tacrolimus and pimecrolimus levels in patients with AD who are applying these agents is not recommended at this time.

Level of Evidence: I Strength of Recommendation: A

Navigate section 2 of the AD guideline: Topical therapy 

Citation note 

When referencing this guideline in a publication, please use the following citation: Eichenfield LF, Tom WL, Berger TG, Krol A, Paller AS, Schwarzenberger K, et al. Guidelines of care for the management of atopic dermatitis: section 2. Management and treatment of atopic dermatitis with topical therapies. J Am Acad Dermatol. 2014 Jul;71(1):116-32.


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