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Systemic Immunosuppressant — Eczema / Psoriasis Pregnancy: Use with caution — crosses placenta; used in organ transplant recipients in pregnancy with acceptable outcomes; discuss risk/benefit with dermatologist and obstetrician

Ciclosporin

Brand names: Neoral, Capimune, Sandimmun

Adult dose

Dose: 2.5–5 mg/kg/day
Route: Oral
Frequency: Divided into two doses daily
Max: 5 mg/kg/day; limit treatment courses to maximum 2 years continuously
Used for severe atopic eczema (short-term — maximum 2 years continuous) and severe psoriasis (cyclic treatment recommended). Start at 2.5 mg/kg/day and titrate by 0.5–1 mg/kg/day every 4 weeks based on response and tolerability. Neoral (microemulsion) preferred — more consistent bioavailability.

Paediatric dose

Dose: 2.5–5 mg/kg/day mg/kg
Route: Oral
Frequency: Twice daily
Max: 5 mg/kg/day
BNFc: severe atopic eczema in children — same weight-based dose as adults. Short courses only. Monitor renal function and BP closely.

Dose adjustments

Renal

Avoid if baseline creatinine >30% above normal — nephrotoxic; if creatinine rises >30% above baseline on two measurements, reduce dose by 25–50%

Hepatic

Use with caution in hepatic impairment — hepatic metabolism; dose reduction may be required

Paediatric weight-based calculator

BNFc: severe atopic eczema in children — same weight-based dose as adults. Short courses only. Monitor renal function and BP closely.

Clinical pearls

  • Maximum continuous treatment 2 years for atopic eczema — beyond this, cumulative nephrotoxicity risk outweighs benefits; consider transition to biologic (dupilumab, tralokinumab)
  • Renal monitoring is mandatory: baseline creatinine (average of two readings), then every 2 weeks for first 3 months, then monthly
  • Hypertension: if BP rises above 140/90 mmHg on two readings, reduce dose by 25–50%; add amlodipine if persistent (avoid diltiazem — drug interaction)
  • MHRA: increased NMSC risk with ciclosporin — avoid concomitant PUVA; sun protection essential; regular skin surveillance
  • Neoral (microemulsion formulation) vs Sandimmun: NOT interchangeable — different bioavailability; specify brand on prescription
  • Grapefruit juice increases ciclosporin levels — advise patients to avoid

Contraindications

  • Uncontrolled hypertension
  • Significant renal impairment
  • Active malignancy or history of malignancy (especially skin cancer)
  • Uncontrolled infection
  • Pregnancy (relative)
  • Concomitant PUVA or UVB (increases NMSC risk)

Side effects

  • Nephrotoxicity (dose-dependent, cumulative — most important limitation)
  • Hypertension
  • Hypertrichosis
  • Gingival hyperplasia
  • Tremor
  • Paraesthesia
  • Headache
  • Increased infection risk
  • Non-melanoma skin cancer (NMSC — with prolonged use or prior PUVA)

Interactions

  • NSAIDs — additive nephrotoxicity; avoid
  • ACE inhibitors/ARBs — additive renal impairment
  • Diltiazem, verapamil — increase ciclosporin levels (CYP3A4 inhibition)
  • Rifampicin, carbamazepine — reduce ciclosporin levels
  • Simvastatin — increased myopathy risk; max 10 mg/day
  • St John's Wort — significantly reduces levels

Monitoring

  • Serum creatinine (every 2 weeks × 3 months, then monthly)
  • Blood pressure
  • FBC
  • LFTs
  • Electrolytes (K⁺, Mg²⁺)
  • Ciclosporin trough levels (if dose optimisation needed)
  • Annual skin cancer surveillance

Reference: BNFc; BNF 90; BNFc; BAD Atopic Eczema Systemic Guidelines 2020; BAD Psoriasis Guidelines; MHRA Drug Safety Update. Verify against your local formulary and the latest BNF before prescribing.

Related

Curated clinical cross-links plus same-class fallbacks.

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