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Eczema is the most common chronic skin disease, affecting 15 to 20% children in developed countries.1 Altered T cell function appears to be the primary immunological abnormality and patients have raised levels of IgE.2 Most patients are managed by their general practitioner, with only a minority referred to secondary care, representing 10–20% of specialist dermatologist referrals.3 One third of patients have persistent disease throughout adulthood4 with a prevalence of about 2% in adults in the UK.3
Bath oils, emollients and topical corticosteroids are the mainstay of treatment. Other treatments include minimising exacerbating factors, systemic antihistamines, phototherapy, and oral immunosuppressants such as azathioprine and ciclosporin.5,6 Tacrolimus and pimecrolimus are two new topical preparations widely advertised in medical and pharmaceutical journals for the treatment of eczema.
Tacrolimus is a macrolide lactone, an immunosuppressive agent currently used systemically to treat graft rejection in liver and kidney transplant patients. It is produced by Streptomyces tsukabaensis a fungus found in the soil of Mount Tsukuba in Japan.2 Systemic administration causes a number of side effects including liver enzyme, renal and electrolyte disturbances, and blood disorders such as anaemia, leukocytosis and thrombocytopenia. Therefore a topical preparation has been developed.
The mechanism of action of tacrolimus in eczema is not fully understood. It is thought that tacrolimus inhibits calcium dependent signal transduction pathways in T cells via its binding to a specific cytoplasmic immunophilin. This prevents the transcription and synthesis of a number of interleukins and other cytokines such as GM-CSF and TNF-α all of which participate in the early immune response and are postulated to play a role in the pathogenesis of eczema.2,7
Studies of topical tacrolimus
A number of industry sponsored studies have been conducted examining the safety and efficacy of tacrolimus ointment in patients of different ages and …
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