How often should topical calcineurin inhibitors (TCIs) be used to treat psoriasis or atopic dermatitis on the eyelids?

From the Guidelines

Topical calcineurin inhibitors (TCIs) such as tacrolimus (0.03% or 0.1%) and pimecrolimus (1%) should be applied twice daily to affected eyelid areas when treating psoriasis or atopic dermatitis, as recommended by the most recent guidelines 1.

Key Considerations

• Treatment typically continues until symptoms resolve, usually within 2-4 weeks, after which frequency can be reduced to maintenance therapy as needed to prevent flares.
• For sensitive eyelid skin, these medications are preferred over topical corticosteroids because they don't cause skin thinning, glaucoma, or cataracts with prolonged use.
• Start with a thin layer of medication on clean, dry skin, avoiding contact with the eyes themselves.
• Patients may experience temporary burning or stinging upon application, which typically subsides with continued use.

Mechanism of Action

• TCIs work by inhibiting calcineurin, which blocks T-cell activation and inflammatory cytokine production, effectively reducing inflammation without the side effects associated with steroids.

Monitoring and Follow-up

• If symptoms don't improve after 2 weeks of consistent use, patients should consult their healthcare provider for alternative treatment options.
• Frequency of follow-up visits is based on the severity of disease presentation, etiology, and treatment, and may involve consultation with a dermatologist 1.

Safety and Efficacy

• The most common side effect for both medications is burning and itching, which generally reduces with ongoing usage and can also be mitigated by not applying immediately after bathing 1.
• Clinical evidence to date does not reveal any causal link between an increased risk of cancer and the use of either of the topical calcineurin inhibitors 1.

From the FDA Drug Label

The patient or care giver should apply a thin layer of ELIDEL (pimecrolimus) Cream 1% to the affected skin twice daily. Continuous long-term use of ELIDEL Cream should be avoided, and application should be limited to areas of involvement with atopic dermatitis.

Topical calcineurin inhibitors should be used twice daily to treat atopic dermatitis on the eyelids. However, continuous long-term use should be avoided. The treatment should be stopped when signs and symptoms resolve, and limited to areas of involvement with atopic dermatitis 2.

• Key points:
  • Apply a thin layer twice daily
  • Avoid continuous long-term use
  • Limit application to areas of involvement with atopic dermatitis
  • Stop use when signs and symptoms resolve
  • Re-examine patients if signs and symptoms persist beyond 6 weeks 2

From the Research

Topical Calcineurin Inhibitors Usage

• The frequency of using topical calcineurin inhibitors (TCIs) to treat psoriasis or atopic dermatitis on the eyelids is not explicitly stated in the provided studies, but the studies suggest that TCIs can be used as an alternative treatment to topical corticosteroids 3, 4, 5, 6, 7.
• According to the studies, TCIs such as tacrolimus and pimecrolimus can be used to treat atopic dermatitis and psoriasis, especially in areas where topical corticosteroids may not be suitable, such as the face and eyelids 3, 4, 5, 6, 7.
• The American Academy of Dermatology recommends the use of topical corticosteroids as the first-line treatment for atopic dermatitis flare-ups, but also suggests that TCIs can be used in conjunction with topical corticosteroids as first-line treatment 5.
• A study published in 2015 found that tacrolimus 0.1% was better than low-potency topical corticosteroids and pimecrolimus 1% in treating atopic dermatitis, but the results were equivocal when comparing both dose formulations to moderate-to-potent corticosteroids 3.
• Another study published in 2012 found that TCIs are safe and efficacious in treating atopic dermatitis, and can be used advantageously in problem zones such as the eyelids 4.
• A study published in 2020 found that TCIs can be used as a maintenance therapy to prevent, delay, and reduce exacerbations of atopic dermatitis 5.
• The studies also suggest that TCIs do not cause cutaneous atrophy, which makes them a suitable option for long-term use in sensitive areas such as the eyelids 6, 7.

Safety and Efficacy

• The safety and efficacy of TCIs in treating psoriasis and atopic dermatitis have been demonstrated in several studies 3, 4, 5, 6, 7.
• A study published in 2014 found that topical tacrolimus and pimecrolimus have efficacy in the treatment of psoriasis, especially for facial, genital, and intertriginous psoriasis 7.
• The studies also suggest that TCIs are well-tolerated and have a low risk of adverse effects, such as burning and skin infections 3, 4, 5, 6, 7.