What is better for pediatric moderate eczema: Protopic (tacrolimus) or Elidel (pimecrolimus)?

From the Guidelines

For pediatric moderate eczema, Protopic (tacrolimus) is recommended as the first choice over Elidel (pimecrolimus) due to its slightly higher efficacy for moderate cases, as per the most recent guidelines 1. When considering treatment options for pediatric moderate eczema, it's essential to weigh the benefits and risks of each medication.

• Protopic (tacrolimus) comes in two strengths: 0.03% (approved for children 2 years and older) and 0.1% (for adults), while Elidel 1% cream is approved for children 2 years and older.
• For moderate eczema in children, starting with Protopic 0.03% ointment applied thinly twice daily to affected areas until symptoms improve, then reducing to once daily until clear, is a recommended approach.
• Elidel tends to cause less initial burning sensation, making it more tolerable for some children, particularly for facial eczema or sensitive areas.
• Both medications work by inhibiting calcineurin, which reduces inflammation and itching without causing skin thinning like topical steroids.
• They're particularly useful for long-term management, sensitive areas like the face and neck, and when steroids haven't worked or aren't appropriate.
• Side effects include temporary burning/stinging sensation upon application, which typically diminishes with continued use.
• These medications should be used as second-line treatments after topical corticosteroids have failed or aren't suitable, as suggested by the Taiwan guidelines for the diagnosis and management of pediatric atopic dermatitis 1. The most recent and highest quality study, the Taiwan guidelines for the diagnosis and management of pediatric atopic dermatitis 1, provides the best evidence for this recommendation, prioritizing morbidity, mortality, and quality of life as the outcome.
• Key considerations include the potential risks and benefits of each medication, as well as the individual child's needs and medical history.
• The American College of Allergy, Asthma and Immunology and the American Academy of Allergy, Asthma and Immunology Joint Task Force report 1 provides additional context and guidance on the use of topical calcineurin inhibitors for atopic dermatitis.

From the Research

Comparison of Protopic and Elidel for Pediatric Moderate Eczema

• The effectiveness of Protopic (tacrolimus) and Elidel (pimecrolimus) for pediatric moderate eczema has been compared in several studies 2, 3, 4.
• A study published in 2015 found that tacrolimus 0.1% was better than pimecrolimus 1% in improving eczema symptoms, with a risk ratio of 1.80 (95% CI 1.34 to 2.42) 2.
• Another study published in 2020 found that young children with moderate-to-severe atopic dermatitis can be treated safely and effectively with either topical tacrolimus or mild corticosteroids, but patients with signs of early sensitization may benefit more from tacrolimus treatment 3.
• A network meta-analysis published in 2024 found that tacrolimus 0.1% and potent topical corticosteroids were among the most effective treatments for eczema, while pimecrolimus 1% was ranked as one of the least effective treatments 4.

Safety of Protopic and Elidel

• The safety of Protopic and Elidel has been evaluated in several studies, with no significant differences in adverse events found between the two treatments 2, 5, 3.
• A study published in 2022 found that topical tacrolimus (0.03% and 0.1%) and topical corticosteroids (mild and moderate potency) are safe to use in young children with moderate to severe atopic dermatitis, with comparable efficacy and safety profiles 5.
• Another study published in 2020 found that no severe adverse effects were seen during treatment with tacrolimus or corticosteroids in young children with moderate-to-severe atopic dermatitis 3.

Efficacy of Protopic and Elidel

• The efficacy of Protopic and Elidel has been compared in several studies, with tacrolimus 0.1% found to be more effective than pimecrolimus 1% in improving eczema symptoms 2, 4.
• A study published in 2024 found that tacrolimus 0.1% and potent topical corticosteroids were among the most effective treatments for eczema, while pimecrolimus 1% was ranked as one of the least effective treatments 4.
• Another study published in 2015 found that tacrolimus 0.03% was superior to mild corticosteroids and pimecrolimus 1% in improving eczema symptoms 2.