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Original Investigation
August 12, 2020

Association Between Topical Calcineurin Inhibitor Use and Keratinocyte Carcinoma Risk Among Adults With Atopic Dermatitis

Author Affiliations
  • 1Department of Dermatology, Massachusetts General Hospital, Boston
  • 2Department of Population Medicine, Harvard Medical School, Boston, Massachusetts
  • 3Division of Research, Kaiser Permanente Northern California, Oakland
JAMA Dermatol. Published online August 12, 2020. doi:10.1001/jamadermatol.2020.2240
Key Points

Question  Is exposure to topical calcineurin inhibitors among adult patients with atopic dermatitis associated with increased keratinocyte carcinoma risk?

Findings  In this large, health plan–based cohort study of 93 746 adults with atopic dermatitis, there was no increased risk of keratinocyte carcinoma overall among topical calcineurin inhibitor–exposed patients compared with topical corticosteroid–exposed patients or patients unexposed to topical calcineurin inhibitors or topical corticosteroids. In addition, no increased risk was noted when data were examined by subtype of keratinocyte carcinoma (basal cell carcinoma or squamous cell carcinoma).

Meaning  The findings of this study suggest that use of topical calcineurin inhibitors may not increase the risk of keratinocyte carcinoma risk among adults with atopic dermatitis.


Importance  Topical calcineurin inhibitors (TCIs), primarily used to treat atopic dermatitis (AD), carry a black box label warning users about the potential for increased skin cancer risk. The risk associated with keratinocyte carcinoma (KC), the most common cancer, defined as basal cell carcinoma (BCC) and squamous cell carcinoma (SCC), remains poorly defined because findings from large-scale postmarketing surveillance studies have not been reported.

Objectives  To examine KC risk overall and by subtype (BCC and SCC) among adults with AD exposed to TCIs compared with those exposed to topical corticosteroids (primary comparator group) and those unexposed to TCIs or topical corticosteroids (alternative comparator group) as well as alterations in risk with TCI dose, frequency, and duration of exposure.

Design, Setting, and Participants  A retrospective cohort study was conducted at Kaiser Permanente Northern California, a large, integrated health care delivery system, of adults 40 years or older (n = 93 746) with a physician-rendered diagnosis of AD or dermatitis. Patients who were diagnosed from January 1, 2002, to December 31, 2013, were included, with follow-up through December 31, 2017. Data analysis was conducted from June 1, 2016, to October 1, 2018.

Exposures  Time-varying pharmacy-dispensed TCI exposure (n = 7033) over the study period was compared with topical corticosteroids (n = 73 674) and no TCI or topical corticosteroid exposure (n = 46 141).

Main Outcomes and Measures  Electronic pathologic testing–validated incident KCs (n = 7744).

Results  Among a cohort of 93 746 members, the mean (SD) age was 58.5 (12.7) years, and 55 023 patients (58.7%) were women. Multivariable Cox proportional hazards regression revealed no association between TCI exposure and KC risk (adjusted hazard ratio [aHR], 1.02; 95% CI, 0.93-1.13) compared with topical corticosteroid exposure. Similarly, there were no significant differences in BCC risk (aHR, 1.01; 95% CI, 0.90-1.14, TCI vs topical corticosteroids) or SCC risk (aHR, 0.94; 95% CI, 0.82-1.08, TCI vs topical corticosteroids). Changing the comparator group to unexposed individuals yielded similar findings (aHR, 1.04; 95% CI, 0.91-1.19, TCI vs unexposed for basal cell carcinoma). There were no associations between TCI dose, frequency, and duration of use and BCC, SCC, or overall KC risk.

Conclusions and Relevance  The results of this postmarketing surveillance study of adult health plan members with AD revealed no apparent association between TCI exposure and overall KC, BCC, or SCC risk. Secondary analyses examining dose, frequency, and duration of TCI exposure revealed no associations. These findings suggest that use of TCIs may be safe with respect to KC risk among adults with AD.

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