Pimecrolimus (Elidel) - is there a place for this?
Yes: For use on sensitive areas e.g. eyelids, groin if hydrocortisone is being used continuously,
or is not effective, on these areas.
No: if cheaper low potency topical corticosteroids are proving effective or where it is
safe to use more potent topical corticosteroids.
Pimecrolimus is classified as a calcineurin inhibitor. It works by inhibiting T cell cytokine production and prevents
the release of inflammatory mediators from mast cells.10 Pimecrolimus is less effective than 0.1% betamethasone
valerate (potent topical corticosteroid).14 However, unlike topical corticosteroids, pimecrolimus does not cause
skin atrophy which may be an advantage on sensitive areas such as the face, eyelids and groin.8
Pimecrolimus may cause local irritation (a short-lasting burning sensation) which can be particularly problematic in
children who have low tolerance for stinging preparations.15 The long term safety profile of pimecrolimus is
unknown and while the link is uncertain, there is concern that there may be an increased risk of skin cancer and lymphoma.16
For these reasons, topical corticosteroids are still considered the first line treatment for eczema.
Pimecrolimus is not currently subsidised – a 15 g tube costs approximately $50.
Antihistamines may be useful to aid sleep for those with severe pruritus
Evidence supporting the use of antihistamines for eczema is weak.8 However pruritus associated with eczema can
cause scratching, leading to excoriation, bleeding and infection. During a flare the itch can result in significant sleep
loss for which a short course of sedating antihistamine such as promethazine hydrochloride (Phenergan) may be useful.9
A trial of non-sedating antihistamines (e.g. cetirizine) may be of benefit for patients with allergic triggers as they
may reduce atopic disease with use over several months.9
Secondary infection may require topical or oral antibiotics
Eczema lesions are commonly colonised with Staphylococcus aureus.9 Signs that eczema is clinically
infected include; crusting, weeping, pustules or failure to improve with treatment.7
If there are extensive areas of infected eczema an oral antibiotic such as flucloxacillin is recommended. For localised
areas of infection a topical antibiotic may be used either in conjunction with a corticosteroid or as a combined product.
Limit the use of topical antibiotics to one to two weeks as resistance or sensitisation may occur.7
Evidence of effectiveness of topical antiseptics (e.g. chlorhexidine) for eczema is limited. However they can be
used to reduce bacterial load in infection-prone areas.5
Routine use of emollients containing antiseptics is not recommended because they may cause sensitisation.7
The “swimming pool water” method – sodium hypochlorite, as half a cup of household bleach in bathwater, may
reduce the severity of eczema.17 Patients should be advised to soak for five to ten minutes, and then thoroughly
rinse the skin with lukewarm, fresh water to prevent dryness and irritation. Pat dry and apply any prescribed medications
and/or emollients. Bleach baths can be used two to three times a week. Do not use if there are extensive areas of broken
Potassium permanganate is an antiseptic that is sometimes used to treat eczema that is weeping or has become infected.
Potassium permanganate crystals can be added to bath water at a concentration of 1:10000 (dissolve a few crystals in a
container of water until a light purple solution is formed and then add to bath water, which should turn light pink). However
the solution may cause brown staining to the skin and nails not to mention the bath so this method has fallen out of favour.
Wet wraps may be useful for severe or extensive eczema
Wet wraps are used to hydrate the skin and prevent scratching. They also enhance penetration of topical steroids
into the skin. They are effective for severe or extensive eczema.9,18
Adverse effects that may occur, especially with incorrect or excessive use, include maceration of the skin or secondary
Wet wraps are typically used overnight and removed in the morning. Emollients should continue to be applied frequently
throughout the day to the affected areas. Wet wraps may be used for a few nights (maximum five to seven consecutive nights)9 until
the redness, swelling and weeping has settled down (see opposite for instructions).19
The role of oral corticosteroids for treating eczema is limited
Oral corticosteroids may be used to quickly control an eczema flare however there is an associated risk of rebound
flares.18 Frequent or prolonged use can also increase the risk of adverse effects such as growth retardation
in children, osteoporosis or elevated blood pressure.1,7,8