After the initial eczema flare-up has resolved, should I apply tacrolimus (immunosuppressant) to the whole body and continue using topical corticosteroids (e.g. hydrocortisone) twice a week on the entire face and body?

Maintenance Therapy After Eczema Flare Resolution

You should choose ONE anti-inflammatory agent for proactive maintenance therapy—either topical corticosteroids twice weekly OR tacrolimus 2-3 times weekly to previously affected areas, but not both simultaneously on the whole body. 1

The Evidence-Based Approach

Option 1: Topical Corticosteroid Maintenance (Preferred by Guidelines)

Apply a mid-potency topical corticosteroid (such as fluticasone propionate or methylprednisolone aceponate) twice weekly to previously affected areas for 16-20 weeks. 1 This approach:

• Reduces flare risk by 54% compared to stopping treatment entirely (pooled relative risk 0.46) 1
• Has been studied for up to 44 weeks with minimal adverse effects 1
• Does not cause skin atrophy when used on this intermittent schedule 1
• Apply to areas that were previously inflamed, even if they now appear normal 1

Important safety consideration: Two studies found no adrenal suppression after 16 weeks, but one study noted abnormal cortisol testing in 2 of 44 patients after 44 weeks of intermittent use 1. The risk-benefit ratio beyond 44 weeks is unknown, suggesting potential transition to tacrolimus if longer maintenance is needed. 1

Option 2: Tacrolimus Maintenance (Alternative)

Apply tacrolimus 0.03% (children) or 0.1% (adults) 2-3 times weekly to previously affected sites for up to 40-52 weeks. 1, 2 This approach:

• Reduces flare risk by 22% compared to vehicle (pooled relative risk 0.78) 1
• Provides significantly more disease-free days than vehicle 2
• Does not cause skin atrophy, making it suitable for face and sensitive areas 3
• Main side effect is transient burning (52-60% of patients), typically mild and resolving within the first week 4, 5

Critical safety note: Given the FDA black box warning against continuous tacrolimus use, intermittent application (not daily) is prudent to minimize potential long-term risks. 1

Why Not Both Simultaneously?

The guidelines describe these as alternative strategies, not concurrent therapies. 1 No studies have evaluated using both topical corticosteroids and tacrolimus simultaneously for whole-body maintenance. The evidence supports choosing one agent based on:

• Disease location: Tacrolimus preferred for face, neck, and intertriginous areas where steroid atrophy risk is higher 3
• Duration needed: Steroids have better efficacy data but unclear safety beyond 44 weeks; tacrolimus studied safely up to 52 weeks 1, 2
• Patient tolerance: Tacrolimus causes more burning initially but no atrophy risk 4

The Complete Maintenance Algorithm

1. Apply moisturizers daily to all skin (this is non-negotiable and continues indefinitely) 1

2. Choose your anti-inflammatory maintenance:

   • For trunk/extremities: Mid-potency steroid twice weekly for 16-20 weeks 1, 6
   • For face/neck/folds: Tacrolimus 2-3 times weekly 1, 2
   • For whole body with mixed areas: Consider tacrolimus 2-3 times weekly to avoid steroid exposure on sensitive areas 2

3. Apply only to previously affected areas, even if skin appears normal 1

4. Duration: Continue for 16-20 weeks minimum, up to 40-52 weeks if using tacrolimus 1, 2

Common Pitfall to Avoid

Do not apply anti-inflammatory agents to the entire body surface if only certain areas were previously affected. 1 The proactive approach targets "previously involved and newly involved skin," not all skin indiscriminately. This minimizes medication exposure while maintaining efficacy. 1