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13.5.3 Drugs affecting the immune response (specialist treatments)

(a) Topical calcineurin inhibitors

Specialist Initiation

Tacrolimus (Protopic®) ointment 0.03%, 0.1%

Prescribing notes

  • Immunomodulatory agents (e.g. tacrolimus, or pimecrolimus for short-term use) are an alternative to topical steroids in eczema. They should be considered if the patient is intolerant to or has failed with conventional corticosteroid therapy. Refer to NICE TA82
  • Calcineurin inhibitors are also an option for the treatment of psoriasis of the face, flexures or genitals if the response to short-term moderate potency corticosteroids is unsatisfactory, or they require continuous treatment to maintain control and there is a serious risk of local steroid-induced side-effects. They should be initiated by healthcare professionals with expertise in treating psoriasis
  • Treatment with tacrolimus or pimecrolimus should be initiated only by physicians (including general practitioners) with a special interest and experience in dermatology
  • Calcineurin inhibitors should not be used in the context of recurrent herpes simplex infection, and patients should be advised on photoprotection
  • The long-term adverse effects of tacrolimus and pimecrolimus are unknown. The MHRA Drug Safety Update December 2014 reminded prescribers of a possible risk of malignancies including lymphomas and skin cancer with the use of tacrolimus ointment. Since then, further studies have provided more reassurance regarding their safety, with no causal link with cancer shown. However longer term data is needed

b) Oral agents

  • A number of disease modifying anti-rheumatic drugs (DMARDs) are used in the management of dermatological conditions. DMARDs on the AMBER list are initiated by specialists in secondary care and can be prescribed by GPs under a shared care arrangement. Please refer to Red Amber List for further details including shared care guidelines as appropriate