Dermatology
This interactive case study was funded by Viatris. UK Prescribing Information for pimecrolimus can be found here. For any HCPs outside of the UK, please refer to your local SmPC, as information may vary.
An Itchy Rash Under
START
1/12
the Microscope
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These interactive case studies were developed with expert support from Giuseppe Micali and Francesco Lacarrubba, Dermatology Clinic, University of Catania, Italy.
2/12
Patient Background
A 16-year-old girl presented with red, itchy patches on both antecubital fossae that had developed over the past week. She reported a family history of allergic rhinitis and asthma.
She mentioned having experienced similar but milder flares in the past, which resolved spontaneously.
Right arm
Left arm
3/12
Examination
On examination, erythematous eczematous plaques were noted on both flexural folds. The lesions were mildly lichenified. There were no signs of secondary infection such as oozing, crusting, or pustules.
4/12
Investigations
A non-invasive skin imaging technique, line-field confocal optical coherence tomography (LC-OCT), was used to evaluate the lesions. In the present case, LC-OCT revealed the presence of spongiosis, inflammatory cells, and intraepidermal vesicles in all affected areas.
Vertical imaging
Horizontal imaging
LC-OCT Image
5/12
Line-Field Confocal Optical Coherence Tomography
LC-OCT combines the principles of confocal microscopy and optical coherence tomography.1 Provides real-time, high-resolution imaging of skin layers down to the dermis.2 Enables non-invasive, in vivo visualisation of skin architecture.3 Offers biopsy-like diagnostic insights without tissue removal or damage.3
LC-OCT device
1. Latriglia F et al. Life (Basel). 2023;13(12):2268. 2. Monnier J et al. J Eur Acad Dermatol Venereol. 2020;34(12):2914-21. 3. Cappilli S et al. Diagnostics (Basel). 2024;14(16):1821.
Normal skin
Vertical view
LC-OCT
Conventional histopathology (haemotoxylin and eosin)
6/12
Question 1: What is your diagnosis?
Based on the clinical presentation and LC-OCT findings, a diagnosis of moderate atopic dermatitis (AD) was made.
A
Psoriasis
B
Allergic contact dermatitis
C
Atopic dermatitis
D
Fungal infection
The patient presented with erythematous, pruritic eczematous plaques in the flexural folds, a distribution typical of AD in adolescents.
She had no prior personal history of AD, but reported a family history of allergic rhinitis and asthma consistent with an atopic background.
The presence of spongiosis, inflammatory cells, and intraepidermal vesicles on LC-OCT are typical histopathological signs of acute eczema.
7/12
Question 2: How would you treat this patient?
According to EU expert recommendations in a new practical algorithm for the management of mild-to-moderate AD in paediatric patients, pimecrolimus is advised for use in moderate AD affecting sensitive skin areas.
Topical corticosteroids
Pimecrolimus cream
Tacrolimus ointment
Crisaborole
Learn more about the Treatment Algorithm
It may be initiated: At the first signs and symptoms of AD To treat acute flares before resorting to topical corticosteroids (TCS)
8/12
Algorithm for the Treatment of Mild Atopic Dermatitis in Paediatric Patients
The EU experts recommended the use of pimecrolimus:1 at initial signs and symptoms of AD to treat acute flares, before resorting to TCS
*Pimecrolimus 1% cream is indicated for treatment of mild-to-moderate AD in infants aged ≥3 months. Acute flare is defined as a clinically significant worsening of signs and symptoms of AD requiring therapeutic intervention.
Mild Atopic Dermatitis
Pimecrolimus* twice daily to affected areas until signs and symptoms of AD disappear AND Emollients as required
Acute flares
Moderate Atopic Dermatitis
1. Augustin M et al. J Dermatolog Treat. 2025;36(1):2503281.
Infants (>3 months old), children, and sensitive skin areas (any age)
Algorithm for the Treatment of Moderate Atopic Dermatitis in Paediatric Patients
The EU experts considered that pimecrolimus tended to have a greater effect on the head/neck versus tacrolimus ointment and is more suitable to be used on sensitive facial skin.1
Infants (>3 months old)
*Pimecrolimus 1% cream is indicated for treatment of mild-to-moderate AD in infants aged ≥3 months. †Pimecrolimus 1% cream from age ≥3 months; tacrolimus 0.03% ointment from age 2–15 years. ‡Pimecrolimus is recommended as a first-line treatment of mild-to-moderate AD in the 2022 European guidelines. Acute flare is defined as a clinically significant worsening of signs and symptoms of AD requiring therapeutic intervention.
Low-to-moderate TCS to control the acute flare THEN Pimecrolimus* twice daily to affected areas until signs and symptoms of AD disappear
Children (≥2 years old)
Topical calcineurin inhibitors† twice daily to affected areas until signs and symptoms of AD disappear AND Emollients as required
Low-to-moderate TCS to control the acute flare THEN Topical calcineurin inhibitors† twice daily to affected areas until signs and symptoms of AD disappear
Sensitive skin areas (any age)
Pimecrolimus‡ twice daily to affected areas until signs and symptoms of AD disappear AND Emollients as required
Pimecrolimus‡ twice daily to affected areas until signs and symptoms of AD disappear
9/12
Treatment
The patient was prescribed pimecrolimus 1% cream, to be applied twice daily to the right arm. The left arm was treated with moisturisers only.
She was advised to avoid potential triggers and use a gentle moisturiser regularly.
No systemic treatments were initiated as the condition was localised.
Treatment duration was planned for 4 weeks with follow-up every 2 weeks.
10/12
Post-treatment Evaluation - 1
At the 2-week follow-up:
The treatment was continued without modification
Left arm (treated with moisturisers): the affected area remained unchanged both clinically and at LC-OCT exam.
Right arm (treated with pimecrolimus): complete clinical resolution of the affected area. LC-OCT, however, showed persistent intraepidermal vesicles, indicating subclinical inflammation.
11/12
Post-treatment Evaluation - 2
At the 4-week follow-up:
Left arm (treated with moisturisers): the affected area remained unchanged both clinically and at LC-OCT exam. Treatment with pimecrolimus was started.
Right arm (treated with pimecrolimus): the area remained free of visible skin lesions. LC-OCT now showed resolution of vesicles and a return to normal epidermal architecture. Pimecrolimus was stopped, and maintenance with moisturisers was advised.
12/12
Take-Home Messages
Pimecrolimus 1% cream was effective and well-tolerated in this adolescent patient with moderate AD.
LC-OCT showed that clinical resolution may precede histological resolution, highlighting the value of imaging in treatment monitoring.
Pimecrolimus treatment led to complete clinical and imaging clearance, reinforcing the role of non-steroidal treatment options when managing AD in sensitive skin areas.
