Topical Calcineurin Inhibitors for Eczema

Medically Reviewed by Stephanie S. Gardner, MD on March 10, 2024
4 min read

Topical calcineurin inhibitors (TCIs) are a type of treatment that alters your immune system. You can use TCIs for atopic eczema. These therapies are “topical,” which means you put them on your skin. “Calcineurin inhibitor” means that the therapies work with your immune system to stop a certain chemical that can lead to eczema flares.

There are two TCIs approved by the FDA. You can use them both to treat or prevent flares:

  • Tacrolimus ointment (Protopic) for moderate to severe types of eczema
  • Pimecrolimus cream (Elidel) for mild to moderate forms of eczema

TCIs are for adults and children older than 2. Your doctor will usually suggest this type of therapy if other common eczema treatments, like topical steroids, don't work well enough or the side effects are too much. They may also suggest you use TCIs with another treatment. Because of this, experts refer to TCIs as “second-line” treatments for atopic eczema.

You can use TCIs on all infected areas of your skin. This includes more delicate parts like your:

  • Face
  • Eyelids
  • Skin folds
  • Genital skin
  • Neck

Tacrolimus and pimecrolimus are both useful for short-term treatment and long-term prevention of eczema.

If you have atopic eczema, certain things in the environment cause your immune system to react. These can include allergens like pollen, some foods, or dust mite droppings. But sometimes, there’s no clear reason for your eczema flares.

With eczema, your immune system is overactive. This causes inflammation, the red or discolored patches on your skin. Calcineurin inhibitors help control your overactive immune system. They tell your T cells to calm down, which lessens inflammation. This makes your skin less itchy.

To treat flares, use the TCI as soon as you see the first sign of active eczema. This will look different based on your skin tone. If you have lighter skin, flares will show up as red, itchy skin. If you have darker skin, you may not see as much redness. Instead, you may see dark patches that are itchy.

You’ll put a thin layer of the TCI over the inflamed area. Do this twice a day until your eczema has cleared. Be careful not to use TCIs on mucous membranes. Those are the moist areas inside your mouth, eyes, nose, and genitals.

Your doctor will prescribe tacrolimus in a stronger version (0.1%) or a weaker one (0.03%). Experts suggest that people over the age of 16 start with the stronger one and apply it twice a day.

Your treatment will last as long as 6 weeks. After that, your doctor may have you continue tacrolimus, but only twice a week. This will help prevent future eczema flares. If your flares do start up again, you can restart 0.1% tacrolimus. But if flares are common, experts suggest you use the 0.03% form.

For kids ages 2 to 15, it’s better to use 0.03% tacrolimus instead of the 0.1% version. The treatment can be applied twice a day for 3 weeks and then once a day until the eczema goes away.

Your flares should improve within 1 week after you start tacrolimus treatment. If your skin doesn’t get any better within 2 weeks, talk to your doctor about other options.

Your doctor may suggest you use a different TCI, pimecrolimus, to stop a flare or control older eczema. Experts suggest that you use this treatment for short periods and only until your eczema is under control. If your doctor prescribed pimecrolimus to keep long-term eczema from getting worse, only use it twice a week. If you don’t notice any improvement after 6 weeks, stop the treatment.

You can use TCIs with other treatments as long as your doctor says it’s safe. Be sure not to use TCIs and topical steroids on the same part of your body at the same time. You can, however, use them at the same time on different areas of your body.

If you use multiple eczema therapies, you should also use emollients. These are moisturizers and cleansing products important in your eczema care. Follow these rules for emollient use:

  • Apply emollients several times a day every day.
  • Use them often and cover the area completely.
  • With tacrolimus and pimecrolimus, use the treatment first, then wait a short amount of time before you apply your emollient.

TCIs affect your immune system and could make certain skin conditions worse. Because of this, some people shouldn’t use this treatment. Don’t use TCIs on skin that’s:

  • Infected with bacteria, like impetigo
  • Infected with viruses, like cold sores, warts, or chickenpox
  • Under a wet wrap

You also shouldn’t use TCIs if you’re likely to develop a local skin infection like inflamed or infected hair follicles, cold sores, or generalized herpes infections.

TCIs can cause your skin to be more sensitive to sunlight. If you’re using a TCI, stay away from strong sun exposure or ultraviolet light. Follow these guidelines to keep yourself protected:

  • Avoid staying in the sun for long periods.
  • Avoid direct sunlight in the hottest part of the day (usually 11 a.m.-3 p.m.).
  • Stay away from tanning beds or phototherapy treatments that use ultraviolet light.
  • Use a broad-spectrum sunscreen with SPF 30 to 50 and 8% zinc oxide.
  • Wear protective, loose clothing like sun hats, long sleeves, long pants, and gloves.

You may notice some side effects after using TCIs. Commonly reported ones include:

  • Burning or stinging when you apply the TCI, which should stop as your skin heals
  • Fever
  • Itchiness in the area where the TCI is used

Other side effects could include:

  • Skin discoloration in the areas you use a TCI (your skin may become red or darker)
  • Warmth or a “pins and needles” feeling on the area where you apply the TCI
  • Blocked skin pores
  • Cold sores or warts
  • Skin irritation or facial redness after drinking alcohol