Editor—Williams acknowledges the efficacy of tacrolimus and pimecrolimus in atopic dermatitis but subsequently his editorial is negative and lacks any patient perspective.1 The issue lies not in clinicians' disembodied comparisons of efficacy but in what treatment provides patients, or their affected children, with the most acceptable benefit : risk ratio.
Only 40% of patients with eczema are reportedly satisfied with their treatment, and work from Williams's own department has shown that in many cases using a topical corticosteroid produces risks, especially of skin thinning, which are unacceptably high to the patients, resulting in non-compliance and inadequate treatment.2
Patients' fears about steroids can hardly be dismissed as irrational, even though they may be exaggerated. Far from being rare, the risks of adverse events from the use of steroids are directly related to the duration, quantity, and potency of the steroid used. Thus today's patients are just as much at risk as before unless they choose to endure the misery of their condition and leave it undertreated. The main fear which patients had was of skin thinning. Topical tacrolimus and pimecrolimus are free of this and other risks associated with steroid use and offer a realistic alternative of proved efficacy whatever their potencies relative to each other or to corticosteroids.
Although the editorial declares the use of probiotics harmless, the long term risks of using such strategies are currently unknown and the subject of debate.3 Their safety has not been tested on anything like the 13 000 included in the trials of tacrolimus and pimecrolimus.
As with any new treatment, close monitoring will be mandatory, but longer term studies with pimecrolimus and tacrolimus show no clinically significant increase in infections or skin cancers.4,5 Since the drugs are non-mutagenic, are absorbed only slightly, and do not permanently impair primary immune responses, an increased risk of cancer either topical or visceral is most unlikely. It is of note that with over 40 years of use of potent topical steroids—which not only deplete cutaneous Langerhans cells but are highly immunosuppressant as well as being systemically absorbed—there is no evidence that they predispose to cancer either cutaneous or systemic. These new drugs for atopic dermatitis are welcomed by patients, parents, and doctor as a wholly new treatment option for this demoralising disease. They are the first major advance in its management in half a century.
Footnotes
The authors have received funding from Fujisawa and Novartis to advise on and carry out clinical studies on tacrolimus and pimecrolimus.
References
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