What's the next step to decrease symptoms in a patient with flexural eczema who is already using local cortisone (corticosteroid) and a topical emollient?

Treatment Escalation for Flexural Eczema Already on Topical Corticosteroids and Emollients

For flexural eczema inadequately controlled with topical corticosteroids and emollients, add tacrolimus 0.1% or pimecrolimus 1% as the next step—not oral corticosteroids or dietary changes. 1

Why Topical Calcineurin Inhibitors (Tacrolimus/Pimecrolimus) Are the Correct Next Step

• Tacrolimus 0.1% and pimecrolimus 1% are specifically recommended by the American Academy of Dermatology for moderate flexural eczema not adequately controlled with topical corticosteroids alone. 1

• Flexural areas (skin folds) are ideal sites for topical calcineurin inhibitors because these areas are more susceptible to topical corticosteroid side effects like skin thinning. 2

• Tacrolimus 0.1% ranks among the most effective treatments in network meta-analysis, with effectiveness comparable to potent topical corticosteroids (OR 5.06,95% CI 3.59 to 7.13) for achieving treatment success. 3

• Pimecrolimus 1% has demonstrated efficacy specifically for flexural psoriasis, seborrhoeic eczema, contact eczema, and hand eczema—making it particularly suitable for flexural areas. 2

Why NOT Oral Corticosteroids

• Systemic steroids (oral corticosteroids) are reserved exclusively for severe, life-threatening cases and should never be used as first-line or second-line treatment for flexural eczema. 1

• The British Medical Journal guidelines emphasize that topical corticosteroids are the mainstay of treatment for atopic eczema and can be used safely with proper precautions, without needing to escalate to systemic therapy. 4

Why NOT Dietary Changes

• Dietary modifications are not recommended as a treatment to decrease established eczema severity. 1

• The British Medical Journal guidelines note that dietary manipulation should be assessed but is not a treatment intervention for active eczema. 4

Why Intensifying Emollients Alone Is Insufficient

• While emollients are fundamental to managing atopic dermatitis, simply increasing emollient use (even to 200-400 g per week) without adding anti-inflammatory therapy will not adequately control moderate flexural eczema that has failed topical corticosteroids. 1

• Emollients work synergistically with anti-inflammatory agents but cannot replace them for active disease control. 4

Practical Implementation Algorithm

Step 1: Add Topical Calcineurin Inhibitor

• Start tacrolimus 0.1% ointment or pimecrolimus 1% cream applied twice daily to flexural areas. 5

• Continue the existing topical corticosteroid regimen for 2-3 weeks during the initial flare while starting the calcineurin inhibitor. 1

• Apply the topical corticosteroid first, then the calcineurin inhibitor. 1

Step 2: Optimize Emollient Use

• Ensure emollients are being applied liberally (at least 200-400 g per week for adequate coverage) and multiple times daily, particularly after bathing. 1

• Apply emollients 15-30 minutes after applying the calcineurin inhibitor. 1

• Use urea- or glycerin-based moisturizers for better hydration of dry skin. 1

Step 3: Sun Protection

• Patients must minimize sun exposure and use SPF 30 UVA/UVB sunscreen while using topical calcineurin inhibitors. 1

• Avoid sun lamps, tanning beds, or ultraviolet light therapy during treatment. 5

Step 4: Reassessment

• Reassess after 2 weeks—if no improvement, refer to dermatology. 1

• If symptoms worsen, the patient develops skin infection, or symptoms don't improve after 6 weeks, contact the physician. 5

Important Safety Considerations

Application-Site Reactions

• Tacrolimus 0.1% and pimecrolimus 1% are most likely to cause local application-site reactions (burning, stinging) compared to topical corticosteroids. 3

• These reactions are typically mild to moderate, occur during the first 5 days of treatment, and usually resolve within a few days. 5

• Burning sensation occurs in 8-26% of patients treated with pimecrolimus. 5

Infection Risk

• Before starting topical calcineurin inhibitors, bacterial or viral infections at treatment sites should be resolved. 5

• Treatment with topical calcineurin inhibitors may be associated with increased risk of varicella zoster virus infection, herpes simplex virus infection, or eczema herpeticum. 5

• In clinical studies, 15/1,544 (1%) cases of skin papilloma (warts) were observed with pimecrolimus use. 5

Long-Term Safety

• The FDA medication guide emphasizes that the safety of using topical calcineurin inhibitors for long periods is not fully known, and a very small number of people have developed cancer (skin or lymphoma), though a causal link has not been established. 5

• Use topical calcineurin inhibitors only on areas with active eczema, for short periods with breaks in between, and stop when symptoms resolve. 5

Common Pitfalls to Avoid

• Do not use topical calcineurin inhibitors on children under 2 years old. 5

• Do not use in patients with Netherton's Syndrome or other conditions with potential for increased systemic absorption. 5

• Do not apply to eyes—if contact occurs, rinse with cold water. 5

• Do not cover treated areas with bandages, dressings, or wraps (normal clothing is acceptable). 5

• Do not bathe, shower, or swim immediately after application as this could wash off the medication. 5