NEW TREATMENTS-MORE OF THE SAME?

Not long ago, the 78 year old dermatologist Dr Jerome Z. Litt, author of one of the profession’s standard textbooks The Drug Eruption Manual (Parthenon Publishing, 1999) spoke out about the narrow minded approach taken by many dermatologists and physicians when treating eczema. According to Litt, there are literally hundreds of non steroidal topical treatments for eczema which are just as effective without the undesirable side effects. According to Dr Litt, of the 9500 dermatologists in the US, probably fewer than 200 have any knowledge of the older non steriodal topical treatments (Skin Allergy News, 1998; 29: 31).

Dr Litt’s personal pharmacopoeia is extremely wide ranging, encompassing everything from his personal favourite Vioform (clioquinol), a relatively strong antiinfective powder which can be mixed into a paste, to milder remedies such as zinc oxide, calamine lotion, wet teabags, yoghurt and milk.The message, however, has fallen on deaf ears. Instead, members of the medical press are falling over themselves to proclaim the new drug tacrolimus as a breakthrough in the treatment of moderate to severe eczema.

Tacrolimus, taken orally or applied topically, is a powerful immunosuppressant (Arch Dermatol, 1999; 135: 574-80) that is 10-100 times more potent than cyclosporin A and with similar adverse effects (Clin Exp Dermatol 2000; 25: 250-4).

Although the topical ointment is not thought to be absorbed into the system as easily as cortico steroids, this has yet to be conclusively proven. In one study, the higher the concentration of tacrolimus, the greater the drug concentration in the blood (N Engl J Med, 1997; 337: 816-21).

At present, tacrolimus is only approved for use in transplant patients and is still considered experimental for eczema. Nevertheless, some doctors are making up their own mixtures to give to their patients off label. Paediatric trials are sorely lacking for tacrolimus, and the side effects which lead to poor paediatric compliance seen with other ointments and creams are common. In one recent trial, 47 per cent of teenage recipients reported burning, 24 per cent itching and 12 per cent rashes (Arch Dermatol, 2000; 136: 999-1066).