Can tacrolimus and topical steroids (corticosteroids) be used together to manage eczema?

Using Tacrolimus and Topical Steroids Together for Eczema Management

Tacrolimus and topical corticosteroids can be used together effectively to manage eczema, with tacrolimus being particularly useful for sensitive areas like the face and intertriginous regions while corticosteroids are used for other body areas. 1

Combination Therapy Approach

• Topical corticosteroids remain the mainstay of treatment for atopic eczema flares, providing rapid symptom relief 1
• Tacrolimus (a calcineurin inhibitor) can be used as a steroid-sparing agent, particularly for areas where steroid-induced skin atrophy is a concern 2
• Sequential or combination therapy allows for reduced steroid exposure while maintaining effective disease control 3

Specific Recommendations for Combined Use

• For acute flares: Begin with a topical corticosteroid of appropriate potency for the affected area to quickly control inflammation 1
• For maintenance: Transition to tacrolimus (0.03% for children 2-15 years, 0.1% for adults) to prevent rebound and maintain remission 2
• For sensitive areas (face, neck, intertriginous regions): Use tacrolimus preferentially as it doesn't cause skin atrophy 1
• For trunk and extremities: Use topical corticosteroids as first-line, with tacrolimus as an alternative for long-term management 1

Evidence for Efficacy

• Combination therapy with tacrolimus and topical steroids has been shown to reduce the overall amount of steroids needed while maintaining disease control 3
• Studies show that sequential use of corticosteroids followed by tacrolimus leads to longer disease-free periods than corticosteroid monotherapy 1
• The combination approach reduces the incidence of steroid-induced adverse effects by decreasing the total steroid exposure 3

Safety Considerations

• Tacrolimus may cause transient burning or pruritus in approximately 50% of patients upon application, which typically improves with continued use 1
• The FDA has issued a black box warning for tacrolimus due to theoretical concerns about malignancy risk, though clinical evidence has not established a causal link 1, 2
• Avoid applying tacrolimus to infected areas, as it may exacerbate existing infections 1
• Gradual reduction in topical corticosteroid frequency is recommended after clinical improvement to prevent rebound flares 1

Practical Application

• Apply corticosteroids no more than twice daily during active flares 1
• Apply tacrolimus twice daily to affected areas until eczema clears 2
• For long-term management, consider using tacrolimus for 2-3 days per week as maintenance therapy to prevent flares 4
• Do not apply tacrolimus to wet skin as this may increase burning sensation and systemic absorption 1

Common Pitfalls to Avoid

• Avoid abrupt discontinuation of topical corticosteroids, which can lead to rebound flares that are more severe than the original condition 1
• Do not use tacrolimus under occlusion as this may increase systemic absorption 1
• Avoid using tacrolimus in children under 2 years of age, as it is not approved for this population 2
• Be aware that tacrolimus is not FDA-approved specifically for eczema treatment but is widely used off-label with substantial evidence supporting its efficacy 1

By strategically combining tacrolimus and topical corticosteroids, clinicians can optimize eczema management while minimizing the adverse effects associated with long-term corticosteroid use.