Key points

• It is heartening to see the advent of a new effective topical treatment for people with moderate-to-severe atopic eczema.

• Topical tacrolimus (0-03% and 0-1%) has been shown to be effective when compared with vehicle only in five RCTs.

• Topical tacrolimus has been shown to be superior to a very weak topical corticosteroid (1% hydrocortisone) in children with moderate-to-severe atopic eczema.

• 0-1% topical tacrolimus appears to be equivalent in efficacy to a potent topical steroid (hydrocortisone butyrate), although the 0-03% preparation is inferior to both these preparations.

• 0-1% topical tacrolimus is of similar potency to betamethasone valerate but it is at least ten times more expensive.

• Topical tacrolimus appears to be safe in the short term.

• Transient burning occurs in about half of adults, but is rarely severe enough to warrant stopping the preparation.

• Long-term data are needed on local and systemic infection, and internal and skin cancer rates.

• All of the studies released to date into the public domain have been sponsored by the manufacturer.

• There is a need to test topical tacrolimus as a second-line treatment for atopic eczema in an RCT setting.

• There is a need for a head-to-head comparison of the cost-effectiveness of topical tacrolimus against topical pimecrolimus and intermittent use of potent modern topical steroids.

In relation to the child described in the case scenario, we would use topical tacrolimus only when standard therapy with short bursts of once daily potent topical steroids (or very mild preparations for the face), emollients and educational support had failed.

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