Lawrence Charles Parish, M.D.
Did you ever see it fail? A new treatment is introduced that provides commendable remedy for a troublesome disease. Then, the alleged downsides are hyped beyond belief. Let's see if this is the case with the newer treatments for eczema.
Background
The topical immunomodulators (a new class of drugs), pimecrolimus (Elidel) cream and tacrolimus (Protopic) ointment have been a boon to children with eczema (atopic dermatitis). Over 35 million children and adults are afflicted with this itchy dermatitis that has been likened to having poison ivy twenty four-hours a day.
This eczematous scourge with itching, redness, and oozing, plus sleepless nights for children and parents alike, has met its match many times with these two dermatologic products. Their advantages over topical steroids which, for the past half century, have been the mainstay of treatment for this allergic disorder, include lack of worry about thinning of the skin or stretch marks (striae). The concern about systemic absorption from topical application or the accentuation of infection has been greatly exaggerated.
The story begins of February 15, 2005, when the Pediatric Advisory Committee of the Food and Drug Administration discussed the possibility of cancer developing in children exposed to these agents. It seems that cutaneous T-cell lymphoma (CTCL) appeared in a few patients who had received one of these topical agents. The clinical picture of CTCL can't be distinguished from atopic dermatitis in its early stage so it is most likely the children involved had CTCL in the first place. In addition, one of the patients was immunocompromised.
While the way these drugs work is not clear, the type of lymphoma found is not associated with suppression of immune functions. When applied to the skin, these drugs don't cause a person to become immunocompromised, a condition which is linked to cancer. Finally, there is no new or previously documented data to show significant absorption of either of these drugs when applied to the skin.
Tacrolimus is also used orally and by injection for patients receiving organ transplants. A few of these patients have developed lymphoma-like tumors. Topical administration permits very little drug to be absorbed and so the risk from topical application is miniscule. Neither tacrolimus nor pimecrolimus has been shown directly to cause cancer in humans.
Recommendations
When a child has significant eczema, there should be no hesitation in using one of these drugs. The usual side effects are far less than with topical steroids which no one has suggested banning. To their credit, the makers of these drugs have embarked upon long-term studies. Would I still use these drugs? Yes, when needed and after other approaches have failed.
Lawrence Charles Parish, M.D., is a clinical professor of Dermatology and Cutaneous Biology and director of the Jefferson Center for International Dermatology, Jefferson Medical College, Philadelphia, PA. Please send your questions and comments to him care of Pediatrics for Parents, P.O. Box 63716, Philadelphia, PA 19147.
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