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13.0 Skin

13.0 Skin

13.0 Skin
Wherever possible the use of licensed medicines is encouraged to assure safety and efficacy. For many common dermatological
diseases including psoriasis and eczema, the range of licensed medicines is limited. As a result, Dermatology prescribing may 
rely significantly on unlicensed creams and ointments (known as ‘Specials’) containing tars, dithranol, salicylic acid, steroids and
other active constituents in a range of concentrations and bases. This is of particular concern in primary care where lack of
effective price controls and a mechanism to ensure independent scrutiny of product quality has increased costs and concern about
standards. To address these concerns and help to optimise quality of care Dermatology 'Specials' should only be prescribed from the document: 
  'Specials Recommended by the British Association of Dermatologists for Skin Disease' 
 
The prescribing of such products may be continued in Primary Care. When a product is required that is not included in the 'BAD'
 list then the prescribing of such will remain with the Consultant/Prescriber and may not be continued in Primary Care.  Where a 
preparation is required that is not listed in the BAD document then there is a requirement to submit a request to East Lancashire
 Medicines Management Board (ELMMB) for the product to be considered for inclusion in the formulary. 
 
 Infantile Haemangiomas
 There is evidence for the use of oral propranolol for those haemangiomas with a potential to impair function or cause permanent
 disfigurement [off licence use]
 AMBER   Propranolol oral solution

Severe [refractory] Pyoderma Gangrenosum
 
 See attachment [British Association of Dermatologists]
 RED     Infliximab [including biosimilars]
 
13.2 Emollient and barrier preparations
Patient concordance and compliance with prescribed dermatology treatments is largely dependent on the cosmetic
acceptability of the preparations concerned.  The dermatology section of the formulary contains a full range of
suitable products to meet the needs of the vast majority of patients. Fragrances are a major cause of skin sensitization, and as a general principle, products containing fragrance should not be prescribed. Patients insisting on using
fragranced products should be advised to purchase their own supply.  
 
New information about risk of severe fatal burns with paraffin-based containing and paraffin-free emollients
Warnings about the risk of severe and fatal burns are being extended to all paraffin-based emollients regardless of paraffin
concentration. Data suggests there is also a risk for paraffin-free emollients. Advise patients who these products not to smoke or
go near naked flames, and warn about the easy ignition pf clothing, bedding, dressings, and other fabric that have dried residue of an emollient product on them. Further advice for healthcare professionals can be accessed here.
 
The following actions should apply to all patients in all settings being dispensed, or treated with, large quantities (100g 
or more) of paraffin based products: 
       º     Information should be given about the potential fire risks of smoking (or being near to people who are
             smoking), or exposure to any open flame or other potential cause of ignition during treatment; and about
             regularly changing clothing or bedding impregnated with paraffin based products (preferably on a daily basis) 
             as the paraffin soaks into the fabrics and can potentially be a fire hazard.
       º     This information should be given on the first occasion that such treatment is prescribed, dispensed or 
             administered by a healthcare professional and a record kept confirming that such advice has been given. 
             A check should be made on subsequent occasions that the advice has been received previously and 
             understood.
      º      Fire safety information should be displayed prominently in every clinical area where patients may be treated 
             with large quantities of paraffin based products.
      º      If, against advice, a hospitalised patient intends to leave the ward to smoke, they should be informed of the risk
             and advised to wear a thick outer covering that has not been contaminated with paraffin based products.
      º      Relatives or carers should be informed if a patient does not comply with safety advice.
      º      To implement the NPSA alert, patients who require large quantities of emollient (100g or more) should use a
             water based  product (e.g. cream or lotion) rather than a paraffin based one (e.g. ointment) to reduce the fire 
             risk.
 
NPSA Managing the Fire Hazard with Paraffin Based Skin Products on Dressings and Clothing 
NPSA Fire Hazard Poster 
NPSA Patient Information Leaflet 


13.2.1 Emollients

Emollient Prescribing Guidelines 
Emollient Guidelines for Dry Skin 
Emollients Patient Information Leaflet
Eczema Guidelines
Emollients: new information about risk of severe and fatal burns with paraffin-containing and paraffin-free emollients
 
Emollients are used to hydrate the skin. Their effects are short lived and they should be applied frequently. To be effective, adequate  quantities of emollients should be prescribed. 
 
Suitable quantities to prescribe - These recommended amounts are for twice daily application for an adult. To keep the skin well hydrated, leave-on emollients should be applied in adequate amounts to sufficiently cover dry and 
inflamed areas. 500g = 1 tub or pump dispenser. Quantities required will vary with the size of the patient, the severity 
and extent of skin dryness. For children approximately half this amount is suitable. See Emollient Prescribing 
Guidelines.
 
Body site  Creams or Ointments    Lotions   
   One week supply  One month supply   One week supply   One month supply 
 Face  15 - 30g   60 -120g   100ml   400ml 
 Both hands  25 - 50g  100 - 200g  200ml   800ml
 Scalp  50 -100g  200 - 400g   200ml  800ml
 Both arms and legs  100 - 200g  400 -800g  200ml  800ml
 Trunk  400g  1600g  500ml  2000ml
 Groin and genitalia  15 -25g  60 -100g  100ml   400ml 


 
 NEW CAMPAIGN FROM MHRA 'SKIN CREAMS DRIED ON FABRIC CAN LEAD TO FIRE DEATHS' JULY 2020
 A new campaign to raise awareness of the fire risk and the precautions that need to be taken by users of skin creams 
 has been launched  <click here to view>
 
Light emollients  
GREEN       Zerocream®  50g, 500g [equivalent to E45 cream]  
GREEN      ExoCream® 50g, 500g pump [E45® equivalent] 
GREEN      Epimax® ExCetra cream 100g, 500g [Previously ExCetra® Cream, equivalent to Cetraben cream]
 
Medium emollients
GREEN      Epimax® Oatmeal  Cream  500g flexidispenser (equivalent to Aveeno Cream) 
GREEN      Epimax® Original cream 100g, 500g [previously Epimax® Cream, equivalent to Diprobase cream] 
GREEN      Zero® Double gel 100g, 500g [equivalent to Doublebase gel]
GREEN      Aveeno® cream 100ml, 500ml (consider trial with Epimax oatmeal cream before Aveeno cream) 
GREEN     Epimax™ paraffin-free ointment**
 (All the above products (except Zero®double gel) can be added to the bath).
 ** This product is especially suitable for use in:
                  >  Elderly patients requiring large amount of ointment
                  >  Use under wet wrapping
                  >  Patients requiring ointment for night use
                  >  Patient using Medical Oxygen Therapy
                  >  Patients who smoke
 
Heavy emollients - effective but not as cosmetically acceptable.
GREEN      Zeroderm® ointment  125g, 500g [Hydromol® ointment and Epaderm ointment equivalent]
GREEN      Epimax® ointment 125g, 500g [Hydromol® ointment and Epaderm ointment equivalent]
GREEN      Cetraben® ointment  125g, 450g 
AMBER     Hydromol® ointment 125g, 500g 
AMBER     Epaderm® ointment (Consider using Hydromol - same formula, but less expensive) 125g, 500g
AMBER     Liquid paraffin 50% / white soft paraffin 50%  
Containing urea 
GREEN      Urea 25% Heel Balm (Flexitol® Heel Balm) - specific use only for diabetic patients
GREEN      Urea 10% cream (Flexitol® Cream)
 
With antimicrobial       
Appropriate for use if there are recurrent problems with infection.
GREEN      Dermol® cream
GREEN      Dermol 500® lotion
 
Soap substitutes 
All emollients, with the exceptions of Doublebase® and liquid paraffin, may be used as soap substitutes.  Aqueous cream may be used a soap substitute but is not recommended as an emollient because it may cause stinging  in a high proportion of patients.

13.2.1.1 Emollient bath additives
BLACK     Not to be prescribed in Primary Care

13.2.2 Barrier preparations 

Click here to access table of preparations and indications:      
GREEN      Metanium® ointment  
GREEN      Sudocrem® cream 
GREEN      Zinc and castor oil ointment    
 
Moisture Lesion Management    
 Management of Moisture Associated Skin Damage
 Management of Moisture Lesions and Incontinence Associated Dermatitis
Moderate skin damage and in skin folds 
GREEN      Medihoney® Barrier Cream 50g, 20 x 2g sachet  
 
Mild to moderate skin damage
GREEN      Medi derma-S barrier cream [pea size amount, twice daily]
GREEN      Medi derma S barrier film [per-wounds/stomas/fistula]
 
Moderate and severe skin damage - second line use,  following specialist advice
GREEN      Medi derma-Pro Spray Cleanser
GREEN      Medi derma-Pro protectant ointment
 
Liquid faecal incontinence, Severe skin damage that is not responding after 6 weeks
AMBER     Cavilon Advanced - specialist product to be used only on advice of tissue viability nurses only* 
                  see product advice sheet for use
 
 Dressing Request and  Exception Form* 
 13.3 Topical local anaesthetics and antipuritics
The underlying cause of the pruritus should be treated. Antipruritics are of limited value.
GREEN       Crotamiton cream 10%, lotion 10% (Eurax®)     
GREEN       Menthol 1% in aqueous cream 500gram (Arjun®)   
 
Facilitation of wound care, cleaning and suturing in A&E only 
RED            Lidocaine 4%, adrenaline 0.1%, tetracaine 0.5% w/v gel (LAT gel®)
                   (Unlicensed product. Approved for use in A&E Department only)  


 13.4 Topical corticosteroids

Potency of steroid required will depend on age, site and chronicity. Face, flexures, skin of the young and more acute eczemas require weaker preparations. Palms, soles and heavily lichenified chronic eczemas require more potent preparations. Try to use the weakest preparation which will keep the eczema in check, but if control is lost, use a short, sharp course of a potent preparation. 

Creams are best for wet and weepy lesions.
Ointments are best for dry and scaly lesions.
 
POTENCY – MILD 
First line:   
GREEN        Hydrocortisone cream 0.5%, 1%, 2.5% , ointment 0.5%, 1%, 2.5% 
GREEN       Hydrocortisone cream 0.25% & crotamiton 10% (Eurax-Hydrocortisone®)       
 
Second line:    
GREEN      Fluocinolone 0.0025%cream (Synalar 1 in 10 Dilution®)  
                  (for patients intolerant to hydrocortisone) 
 
POTENCY - MILD WITH ANTIMICROBIAL 
GREEN      Hydrocortisone 1% & miconazole 2% cream, ointment (Daktacort®)   
GREEN      Hydrocortisone 0.5% & nystatin 100,000 units/g cream (Timodine®)       
GREEN      Fusidic acid 2% and hydrocortisone acetate 1% [Fucidin® H]
 
POTENCY – MODERATE
First line:   
GREEN      Clobetasone butyrate 0.05% cream, ointment (Eumovate®) 

Second line:
GREEN      Betamethasone valerate 0.025% cream, ointment (Betnovate RD®)     
GREEN      Fluocinolone 0.00625% cream, ointment (Synalar 1 in 4 Dilution®)       
AMBER     Fludroxycortide occlusive tape 4micrograms/cm2 (Haelan®)  -  (Dermatology initiation/recommendation only)  
GREEN      Clobetasone butyrate with nystatin and oxytetracycline cream (Trimovate® cream)  - short term use only
 
POTENCY – MODERATE WITH ANTIMICROBIAL 
see below for alternative**
 
POTENCY - POTENT 
First line:
GREEN      Betamethasone valerate 0.1% cream, ointment (Betnovate®)  
 
Second line: 
GREEN      Fluocinolone 0.025% cream, ointment (Synalar®) 
AMBER     Mometasone furoate 0.1% cream, ointment, lotion (Elocon®)                                                                                                               (Dermatology initiation/recommendation only)     
GREEN      Betamethasone 0.1% with fusidic acid 2% cream

Scalp preparations
First line:

GREEN      Betamethasone valerate scalp application 0.1% (Betacap®)
GREEN      Betamethasone valerate mousse (Bettamousse®)
Second line:
GREEN      Fluocinolone 0.025% gel (Synalar®)
GREEN      Hydrocortisone butyrate 0.1% water miscible lotion (Locoid Crelo®)
 
POTENCY – POTENT WITH ANTIMICROBIAL 
GREEN      Betamethasone dipropionate 0.064% (≡ betamethasone 0.05%), clotrimazole 1%, cream (Lotriderm®)** 
GREEN      Fluocinolone acetonide 0.025% & Clioquinol 3% cream,ointment  (Synalar C®)     
 
POTENCY - POTENT WITH SALICYLIC ACID 
GREEN      Betamethasone valerate 0.05% & salicylic acid 3% ointment (Diprosalic®)      
 
POTENCY - VERY POTENT 
Avoid long-term use without dermatologist supervision
GREEN      Clobetasol 0.05%
                  cream, ointment (Dermovate®)    
                  scalp application (Dermovate®)   

AMBER     Clobetasol propionate 500micrograms/gram shampoo (Etrivex®) 

Clobetasol Propionate shampoo - Scalp Psoriasis
Clobetasol shampoo should be kept in place without covering for 15 minutes before rinsing. The treatment duration should be limited to a maximum of 4 weeks. As soon as clinical results are observed, applications should be spaced out or replaced, if needed, by an alternative treatment. If no improvement is seen within four weeks, reassessment of the diagnosis may be necessary. Repeated courses may be used to control exacerbations provided the patient is under regular medical supervision.
 
POTENCY – VERY POTENT WITH ANTIMICROBIAL
Avoid long-term use without dermatologist supervision
GREEN      Clobetasol 0.05% & neomycin/nystatin cream, ointment
                  (Dermovate-NN® brand discontinued prescribe as  generic)    

3.5.1 Preparations for eczema

Oral retinoids for severe hand eczema

Alitretinoin, for the treatment of Chronic Eczema (TAG 177)                                                                                                        Alitretinoin is recommended, within its licensed indication, as a treatment option for adults with severe chronic hand eczema that has not responded to potent topical corticosteroids if the persons has 

  • severe disease, as defined by the physician’s global assessment (PGA) and    
  • a dermatology life quality index (DLQI) score of 15 or more.  

Oral alitretinoin is licensed for the treatment of severe chronic hand eczema unresponsive to potent topical corticosteroids, in adults. Alitretinoin should only be prescribed by dermatologists, or physicians with experience in the use of systemic retinoids who have full understanding of the risks of systemic retinoid therapy and monitoring requirements. Prescriptions of alitretinoin for women of childbearing potential should be limited to 30 days of treatment and continuation of treatment requires a new prescription. Ideally, pregnancy testing, issuing a prescription and dispensing of alitretinoin should occur on the same day. 

Dispensing of alitretinoin should occur within a maximum of 7 days of the prescription. Pregnancy is an absolute contraindication to treatment with alitretinoin. Basilea Pharmaceuticals has put together a Pregnancy Prevention Programme, containing guidance on prescribing alitretinoin to women of childbearing potential and contraceptive precautions required. A treatment course of alitretinoin may be given for 12 to 24 weeks depending on response. Discontinuation of therapy should be considered for patients who still have severe disease after the initial 12 weeks of treatment. In the event of relapse, patients may benefit from further treatment courses of alitretinoin. Patients should still be advised to use daily emollients during therapy and once the eczema has cleared.  

RED        Alitretinoin (Toctino®) capsules 10mg, 30mg 

13.5.2 Preparations for psoriasis

Emollients may be sufficient for mild cases. For other cases the topical preparations may have a beneficial effect. Start with low concentrations and build up. See 'Psoriasis Management in Primary Care' for further information 

Topical preparations for psoriasis

Vitamin D and analogues
GREEN      Calcipotriol 50micrograms/gram (Dovonex®)    
                   cream, ointment, scalp solution 
GREEN      Calcipotriol 50 micrograms/gram & betamethasone 0.05% (Dovobet®) 
                   ointment, gel   
GREEN      Tacalcitol 4 micrograms/gram (Curatoderm®)  ointment
GREEN      Calcipotriol and betamethasone cutaneous foam (Enstilar®)                    
 
Coal tar 
GREEN      Licensed Coal tar products:  
                   lotion 5%  (Exorex®)    
                   scalp ointment, coal tar 12% & salicylic acid 2%, sulphur 4% (Sebco®) 
                   bath emulsion 40% (Psoriderm®)   
 
AMBER      Unlicensed Coal tar products -  Dermatology initiation/recommendation only                                                                               e.g. coal tar in yellow soft paraffin, various strengths       
 
Dithranol 
*Please note that Dithrocream® is being discontinued and will be replaced with Specials recommended by the  
British Association of Dermatologists for Skin Disease <click here> to access the document

GREEN      *Dithranol (Dithrocream®) cream 0.1%, 0.25%, 0.5%, 1%, 2%      
AMBER     Dithranol in Lassar's paste (unlicensed product)
                  (dermatology initiation/recommendation only) various strengths  
 
Oral retinoids for psoriasis - for severe resistant or complicated psoriasis, prescribed only by or under the supervision of a consultant dermatologist. 
RED         Acitretin capsules 10mg, 25mg (hospital only)  
 
Salicylic acid with lanolin
         Salicylic acid softens keratin and makes scales easier to remove and is appropriate for use in patients requiring a  
         keratolyticproduct  without a steroid component Indications for use include psoriasis, eczema, keratodermas, viral 
         warts, callosities
         AMBER       Salicylic acid 2% ointment BP [alternative to Lan Vas Sal ointment]

 

13.5.3 Drugs affecting the immune response
CSM Advice – Due to the risk of malignancy, Pimecrolimus 1% cream should be used as a second line treatment for 
mild or moderate atopic dermatitis where treatment with topical corticosteroids is either inadvisable or not possible. 
Tacrolimus ointment will remain a second line treatment for moderate or severe atopic dermatitis in patients who are
not adequately responsive to or are intolerant of topical corticosteroids. 
 
Treatment with pimecrolimus cream and tacrolimus ointment should:  
  • only be initiated or recommended by specialist physicians with experience in the diagnosis and treatment of atopic dermatitis
  • not to be given to patients with congenital or acquired immunodeficiencies, or to patients on therapy causing immunosupprerssion
  • not to be applied to malignant or to potentially malignant skin lesions.
The frequency of administration of Tacrolimus ointment 0.03% in children should be limited to once daily. The lower strength of tacrolimus ointment (0.03%), should be used in adults wherever possible.
 
Prescribers should use these products so as to minimise patient exposure and thereby reduce risk.  The following are recommended:   
       >    The medicines should be applied thinly and to affected skin surfaces only.
       >    Treatment should be short term; continuous longterm use should be avoided.
       >    If no improvement occurs (after 6 weeks for pimecroliums, or 2 weeks for tacrolimus), or if the disease 
             worsens, the diagnosis of atopic dermatitis should be reevaluated and other therapeutic options 
             considered. See age restrictions for each product before prescribing.

             NICE Guidance TA534: Dupilumab is recommended as an option for treating moderate to severe atopic                                 dermatitis in  adults only if: 
             >     the disease has not responded to at least 1 other systemic therapy, such as ciclosporin, methotrexate,   
                    azathioprine and mycophenolate mofetil, or these are contraindicated or not tolerated.
             >     the company provides dupilumab according to the commercial arrangement
 
           RED    Dupilumab solution for injection 300mg/2mL pre-filled pens (Dupixent®▼)      CCG Commissioned  
                                                                                                                                                                 (BlueTec form required)
 
 
          NICE Guidance TA681: Baricitinib is recommended as an option for treating moderate to severe  atopic dermatitis  
           in adults only if:
               >   the disease has not responded to at least 1 systemic immunosuppressant, such as ciclosporin, 
                   methotrexate, azathioprine and mycophenolate mofetil, or these are not suitable, and
               >   the company provides it according to the commercial agreement    
 
           RED   Baricitinib tablets 2mg, 4mg                                                                                         CCG Commissioned
                                                                                                                                                               (BlueTec form required)

 

NICE Guidance: Atopic Eczema in Children
       >    Only specialists with experience in dermatology should start treatment with tacrolimus or pimecrolimus after
             discussing the risks and benefits of all other options.
       >    If atopic eczema is not controlled by topical corticosteroids* or where there is a risk of serious adverse effects
             treatment options include:
                     >      tacrolimus (0.03%) for moderate to severe atopic eczema in children aged two years and over,
                     >      pimecrolimus for moderate atopic eczema on the face and neck in children aged two years and over.
       >    Consider for facial atopic eczema in children requiring long-term or frequent use of mild topical corticosteroids           >    Do not use topical tacrolimus or pimecrolimus:       
                     >      for mild atopic eczema,
                     >      as first-line treatment for atopic eczema of any severity,
                     >      under bandages or dressings without specialist dermatological advice.
 
AMBER      Tacrolimus (0.03%)
AMBER      Pimecrolimus
 
 *Unsatisfactory clinical response to adequate use of the maximum strength and potency of topical corticosteroids that is appropriate for the child's age and the area being treated.
NICE Guidance: Adalimumab, etanercept and ustekinumab for treating plaque psoriasis in children and young adults - NICE TA455 
 

Adalimumab is recommended as an option for treating plaque psoriasis in children and young people aged 4 years or older, only if the disease:
         >     is severe, as defined by a total Psoriasis Area and Severity Index (PASI) of 10 or
                more and
         >     has not responded to standard systemic therapy, such as ciclosporin, 
                methotrexate or phototherapy, or these options are contraindicated or not 
                tolerated.

Etanercept is recommended as an option for treating  plaque psoriasis in children and 
young people  aged 6years or older, only if the disease:
         >    is severe as defined by a total PASI of 10 or more and 
         >    has not responded to standard systemic therapy, such as ciclosporin,
               methotrexate or phototherpay, or these options are contraindicated or not 
               tolerated.
 
Ustekinumab is recommended as an option for treating plaque psoriasis in children and young people aged 12 years or older, only if the disease:
        >   is severe, as defined by a total PASI of 10 or more
        >   has not responded to standard systemic therapy, such as ciclosporin, methotrexate
             or phototherapy, or these options are contraindicated or not tolerated.
 
Stop etanercept treatment at 12 weeks, and adalimumab and ustekinumab treatment at 16 weeks, if the psoriasis has not responded adequately. An adequate response is defined as a 75% reduction in the PASI score from the start of treatment
 
RED      Adalimumab  (Amgevita -1st line choice in new patients, Humira®,)      NHS England Commissioned
RED      Etanercept (Enbrel®)                                                                                    NHS England Commissioned
RED      Ustekinumab (Stelara®)                                                                              NHS England Commissioned
 
NICE Guidance: Secukinumab for treating moderate to severe plaque psoriasis in children and young adults aged 6 to 17 years 
NICE TA734 Secukinumab is recommended as an option for treating plaque psoriasis in children and young people  
 aged 6 to 17 years, only if:
            > the disease is severe, as defined by a total Psoriasis Area and Severity Index (PASI) of 10 or more and
            > the disease has not responded to other systemic treatments, including ciclosporin, methotrexate and 
               phototherapy, or these options are contraindicated or not tolerated and
            > the company provides the drug according to the commercial arrangement.
        RED  Secukinumab (Cosentyx®)                                                                         NHS England Commissioned
 
 
Active plaque psoriasis in adults 
Ustekinumab is recommended as an option, alone or in combination with methotrexate, for treating active plaque psoriasis in adults as per NICE  TA340  (replaces TA313)

RED      Ustekinumab 
             solution for injection 45mg/0.5ml pfs (Stelara®)                                                              (CCG Commissioned)          

Moderate to severe psoriasis    NICE TA180  (updated)
NICE interactive flowchart - Psoriasis
RED Risankizumab
NICE TA596 recommended as an option for treating plaque psoriasis in adults only if:
                    >    the disease is severe, as defined by a total Psoriasis Area and Severity Index (PASI) of 10 or more and
                          a Dermatology Life Quality Index (DLQI) of more than 10 and
                    >    the disease has not responded to other systemic treatments, including ciclosporin, methotrexate and
                          phototherapy, or these options are contraindicated or not tolerated and
                    >    the company provides the drug according to the commercial arrangement.


RED Ustekinumab 
NICE TA180  recommended as a treatment option for adults with plaque psoriasis
      [Ustekinumab solution for injection 45mg/0.5ml pfs (Stelara®)                                             (CCG Commissioned) 
RED Dimethyl fumarate
NICE TA475  recommended as an option  for treating moderate to severeplaque psoriasis in adults
         [Dimethyl fumarate tablets 30mg, 120mg  (Skilarence®)]                              CCG Commissioned Bluetec form required) 
RED Ixekizumab
NICE TA442 recommended as an option for treating moderate to severe plaque psoriasis in adults
        [Ixekizumab solution for injection 80mg/1mL ]                                                                          CCG Commissioned  
 
RED Certolizumab pegol 
NICE TA574  recommended as an option for treating moderate to severe plaque psoriasis in adults, only if:
        >     the disease is severe, as defined by a total Psoriasis Area and Severity Index(PASI) of 10 or more and a 
               Dermatology Life Quality Index (DLQI) of more than 10 and
        >     the disease has not responded to other systemic treatments, including ciclosporin, methotrexate and 
               phototherapy, or hese are contraindicated or not tolerated and
        >     the lowest maintenance dosage of certolizumab pegol is used (200mg every 2 weeks) after the loading dosage
        >     the company provides the drug according to the commercial arrangement.
       [Certolizumab pegol 200mg/1mL solution for injection pfs (Cimzia)]                    CCG Commissioned Bluetec form required)

RED Tildrakizumab
NICE TA575 recommended as an option for treating moderate to severe plaque psoriasis in adults, only if:
       >     the disease is severe, as defined by a total Psoriasis Area and Severity Index(PASI) of 10 or more and a 
              Dermatology Life Quality Index (DLQI) of more than 10 and
       >     the disease has not responded to other systemic treatments, including ciclosporin, methotrexate and 
              phototherapy, or these are contraindicated or not tolerated and
       >     the company provides the drug according to the commercial arrangement.
       [Tildrakizumab 100mg/1mL pre-filled disposable injection (Ilumetri)                   CCG Commissioned Bluetec form required)

NICE Guidance TA511 - Brodalumab for treating moderate to severe plaque psoriasis
Brodalumab is recommended as an option for treating plaque psoriasis in adults, as  recommended in NICE TA511
RED      Brodalumab solution for injection pfs 210mg/1.5mL (Kyntheum▼) 
                                                                                                                                        (CCG Commissioned)
                                                                                                                                               (Bluetec form required)
NICE TA521 - Guselkumab for treating moderate to severe plaque psoriasis in adults.
Guselkumab is recommended, as an option in NICE TA521,for treating plaque psoriasis in adults only if:
 
     > the disease is severe, as defined by a total Psoriasis Area and Sensitivity Index (PASI) of 10 or more and
         Dermatology Life Quality Index (DLQI) of more than 10 and 
     >  the disease has not responded to other systemic therapies, including ciclosporin, methotrextae and PUVA 
          (psoralen and long-wave ultraviolet A radiation), or these options are contraindicated or not tolerated and
     > the company provides the drug according to the commercial arrangement.
                                                                                                                                        (CCG Commissioned Bluetec form required)
                                                                                                                                                  
 
NICE TA723  Bimekizumab for treating moderate to severe plaque psoriasis
 Bimekizumab is recommended as an option for treating plaque psoriasis in adults, only if:
    >     the disease is severe, as defined by a total Psoriasis Area and Severity Index (PASI) of 10 or more and a 
           Dermatology Life Quality Index (DLQI) of more than 10 and
    >     the disease has not responded to other systemic treatments, including ciclosporin, methotrexate and 
           phototherapy, or these options are contraindicated or not tolerated and
    >    the company provides the drug according to the commercial arrangement.
 RED    Bimekizumab 160mg solution for injection pfs (Bimzelx®)                       (CCG Commissioned Bluetec form required)    
 
 
Secukinumab for the treatment of Palmoplantar PsoriasisSecukinumab is recommended for the treatment of moderate to severe palmoplantar psoriasis that has not responded (refractory) to at least two standard systemic treatments and photochemotherapy, or when standard treatments cannot be used because of intolerance or contra-indications. 
RED        Secukinumab 
               150mg solution for injection pfs (Cosentyx▼)       
               150mg solution for injection pf pen (Cosentyx▼)
 
 
Severe (refractory) Pyoderma Gangrenosum
 
 See attachment [British Association of Dermatologists]
 RED     Infliximab [including biosimilars]
 
 

13.6.1 Topical preparations for acne

For mild and moderate acne a topical preparation is recommended.
Benzoyl peroxide & azelaic acid
Patients should be advised that, in some cases, 4-6 weeks of treatment may  be required before the full therapeutic effect is observed.
GREEN      Benzoyl peroxide (Acnecide®) gel 5%  
GREEN      Duac Once Daily®  (Benzyl peroxide 5% & clindamycin 1%) gel 
GREEN      Azelaic acid (Skinoren®) cream 20% 
 
Topical antibacterials for acne
GREEN      Dalacin T® aqueous lotion (clindamycin 1%)       
GREEN      Zineryt® topical solution (erythromycin 40mg & zinc acetate 12mg/ml)  
 
Topical retinoids and related preparations for acne
GREEN      Adapalene (Differin®) cream 0.1%, gel 0.1%
GREEN      Adapalene 0.1%/Benzoyl Peroxide 2.5% (Epiduo®Gel) 
GREEN      Adapalene 0.3%/Benzoyl Peroxide 2.5% (Epiduo®Gel) 
GREEN      Tretinoin and clindamycin (Treclin®) 0.025%/1% gel      
 
Preparations for rosacea
GREEN      Metronidazole (Rosex®) cream 0.75%
GREEN      Ivermectin (Soolantra®) cream 


13.6.2 Oral preparations for acne 


Oral antibacterials for acne
For moderate acne oral antibiotics are usually needed and should be prescribed alongside a topical retinoid or benzoyl peroxide. Oral antibiotics should be limited to the shortest possible period.
If the patient responds it may be continued for 4-6 months. (consider reducing the antibiotic dose by half for the latter period ) then stop completely. 
 
First line
GREEN        Tetracycline tablets 250mg (dose: 500mg twice daily)
GREEN       Oxytetracycline tablets 250mg (dose: 500mg twice daily)
 
For use in cases where first line drugs are not tolerated or ineffective
GREEN      Doxycycline capsules 100mg (dose: 100mg  daily)
GREEN      Lymecycline capsules 408mg (dose: 408mg daily)
GREEN      Trimethoprim tablets (dose: 300mg bd)

Hormone treatment for acne
Used as an alternative to oral antibiotics for female patients. 
Co-cyprindiol (Dianette®) - used primarily as a treatment for moderate acne or other androgenic conditions especially hirsutism (e.g in patients with PCOS) who also need contraception. It should be discontinued three to four months after the androgenic condition has resolved.   It may be continued/restarted, after counselling, if the androgenic condition recurs. It should not be used solely for contraception. 
 
Note: CSM advice is venous thromboembolism occurs  more frequently in women taking co-cyprindiol than those taking a low-dose combined oral contraceptive. See BNF for full details. 
 
GREEN       Co-cyprindiol tablets (cyproterone 2mg & ethinylestradiol 35mcg)   
                     (Prescribe generically, not as Dianette®)
 
Oral retinoid for acne

For severe acne which has not responded to oral antibiotics, prescribed only by or under the supervision of a consultant dermatologist.

RED           Isotretinoin capsules 5mg, 20mg        

 13.7 Preparations for warts and calluses

All warts are self-limiting and eventually disappear spontaneously. Salicyclic acid preparations are useful but may cause irritation of the treated area.
 
 
First line 
GREEN      Salactol® paint (contains salicylic acid 16.7%, lactic acid 16.7% in colloidon)
 
Second line
GREEN      Salicylic acid 50% ointment (Verrugon®)
GREEN      Salicylic acid 26% polyacrylic solution (Occlusal®)
 
Third line
GREEN      Formaldehyde 0.75% gel (Veracur®)
GREEN      Glutaraldehyde 10% solution (Glutarol®)
 
 
 Salicylic acid with lanolin
 Salicylic acid softens keratin and makes scales easier to remove and is appropriate for use in patients requiring a 
 keratolytic product  without a steroid component Indications for use include psoriasis, eczema, keratodermas, viral 
 warts, callosities
         AMBER       Salicylic acid 2% ointment BP [alternative to Lan Vas Sal ointment]
 
 
Anogenital warts 
Imiquimod cream (Aldara®) is also licensed for the treatment of superficial basal cell carcinomas (specialist use).  It is also used for actinic keratosis and external genital warts in adults
 
GREEN       Podophyllotoxin    0.15% cream (Warticon®) 
AMBER      Imiquimod 5% cream (Aldara®) -  (external genital warts and actinic keratosis) 

RED            Imiquimod 5% cream (Aldara®) - (superficial basal cell carcinoma)
 [Only to be prescribed by skin cancer specialists or a suitably qualified GP with specialist interest (GPwSI) with
  demonstrable clinical skills and competencies, training and experience]
 
 

13 8.1 Sunscreen preparations

All the sunscreens listed contain UVB and UVA protection. They are drugs when prescribed for skin protection against ultraviolet radiation in abnormal cutaneous photosensitivity. Need to be endorsed 'ACBS' on FP10 prescription. 
 
GREEN      Anthelios® melt in cream (UVA + UVB protection UVB-SPF 50+)          
GREEN      Sunsense® Sensitive Lotion (UVA +UVB protection UVB-SPF 50+)
GREEN      Uvistat®cream (UVB-SPF 30), Uvistat®cream (UVB-SPF 50) 
 
Sunscreen/ camouflagers
A combination product suitable for patients with darker skin tones which is available from Dundee Hospital only.
RED            Dundee Cream (UVB-SPF 50)  
 
Photodamage 
GREEN      Diclofenac sodium 3% gel (Solaraze®) - prescribe by brand
GREEN      Fluorouracil 5% cream (Efudix®)  - for actinic keratosis and Bowen's disease
RED           Fluorouracil 5% cream (Efudix®) - for basal cell carcinoma
AMBER     Imiquimod 5% cream (Aldara®) - (actinic keratosis and external  genital warts ) 
                   Protocol for using Efudix 5% for actinic keratosis and Bowen's disease
 
January 2020, Important Drug Alert; Ingenol mabuate (Picato®) gel) removed from formulary following recall by manufacturer as a precautionary measure  due to concerns on the possible risk of skin malignancy. See alert
                  
 

13 8.2  Hirsutism 

BLACK            Eflornithine (Vaniqa ® 11.5% cream) 
RED        Camouflage Creams and Powders
                Items recommended by the specialist nurse led service will remain RED traffic light with prescriptions
                from GPs dispensed via the IMOT service.

East Lancashire and BwD Clinical Commissioning Groups do not routinely commission cosmetic treatments.
Patients are able to purchase camouflage creams and powders on the high street, on-line and via local community pharmacies.

See Prescribing Policy: Camouflage (covering) Creams and Powders
 

13.9 SHAMPOOS AND SOME OTHER PREPARATIONS FOR SCALP AND HAIR CONDITIONS

GREEN      AlphosyI 2 in 1® shampoo 
GREEN      Capasal® shampoo     
GREEN      Polytar® liquid
GREEN      Selsun® shampoo 
 
Other scalp preparations see
13.4     Clobetasol propionate 500micrograms/gram shampoo  (Etrivex®)
 
13.5.2  Calcipotriol/ betamethasone scalp application  (Dovobet®) 

 

13.10.1 Antibacterial preparations 

13.10.1.1 Antibacterial preparations only used topically
To reduce the development of resistance it is advisable to limit the choice of antibiotic used topically to one not used systemically. Whenever possible, swabs for bacterial examination should be taken before treatment is started. Mupirocin is generally restricted to use in wounds that are MRSA positive. 
 
GREEN      Mupirocin 2% (Bactroban®) ointment / nasal ointment   
GREEN      Silver sulphadiazine 1% (Flamazine®) cream  

13.10.1.2.2 Preparations of antibacterials also used systemically

It is generally advised that topical antimicrobials are not used.  The exceptions to this are the use of metronidazole topically for acne rosacea, and in the management of malodorous wounds.  Topical fusidic acid should be reserved for impetigo, 2nd line use, where there are very localised lesions only. [Hydrogen peroxide 1% cream is 1st line use] 
In the presence of visible or proven infection, systemic antibiotics are to be used.  See antimicrobial guidelines.
 
GREEN      Fusidic acid 2% (Fucidin®) cream, ointment [see recommendations above] 
GREEN      Metronidazole (Anabact®) 0.75% gel  [see recommendations above] 


13.10.2 Antifungal preparations

Take scrapings, hair or nail clippings where possible before treatment is started. Local therapy is used when extent of infection is limited. Systemic therapy is required for widespread infections, or if topical treatment fails.  If treating pityriasis vesicolor and topical treatment fails, treat systemically with an azole antifungal (section 5.2). 
 
GREEN      Clotrimazole  cream 1%,  dusting powder 1%        
GREEN      Miconazole cream 2%           
GREEN      Terbinafine cream 1%          
 
For infected nails
GREEN     Amorolfine nail lacquer 5% (Loceryl®) [Consider OTC/Self care]   
 
Other antifungals (for azole antifungals see section 5.2) 
GREEN      Terbinafine tablets 250mg       
 

13.10.3 Antiviral preparations

Indicated for treatment of labial and genital herpes simplex infections.
GREEN     Aciclovir cream 5% 


13.10.4 Parasiticidal preparations

Head lice
Only treat those with living, moving lice present.  A course of treatment for head lice should be 2 applications of product 7 days apart to kill the lice emerging from any eggs that survive the first application. All affected household members should be treated simultaneously. 
 
Wet Combing
Head lice can be mechanically removed by combing wet hair meticulously with a plastic detection comb for at least 30 minutes over the whole scalp at 4-day intervals for a minimum of 2 weeks, and continued until no lice are found on 3 consecutive sessions. 
 
Dimeticone
Hedrin (4% dimeticone) lotion is a non-insecticide preparation that coats head lice and interferes with water balance in lice by preventing the excretion of water.  It can be used from age 6 months, and has shown similar efficacy to phenothrin 0.5% liquid (70% vs. 75% cure rate).  As with the other insecticide treatments this is a pharmacy only medicine and treatment should follow the same regime as is laid out for those other products i.e. treatment is 2 applications 7 days apart. The contact time for this product is 8 hours or overnight.  One 50ml bottle should be sufficient for two applications on short hair.
 
Refer to guidelines online here
 
First (or Second) Line
GREEN       Dimeticone lotion 4%, aqueous          
 
First (or Second) Line
Use alcohol based preparations where possible.  Use aqueous liquid for those with asthma and severe eczema, children under 5 years and pregnant & lactating women.
GREEN      Malathion liquid 0.5%, aqueous       
GREEN      Malathion lotion 0.5%, alcoholic        
 
Crab Lice
Permethrin or malathion are used to eliminate crab lice. An aqueous preparation should be applied, allowed to dry naturally and washed off after 12 hours. A second treatment will be needed after 7 days. 
 
Scabies
Permethrin is effective for scabies.  
GREEN        Permethrin cream 5%

13.11.1 Alcohols and saline

Suitable for general cleansing of skin and wounds.  
See Joint Wound Care Formulary for order of preference - click here to access it. 
GREEN     Sodium chloride 0.9% solution sachets (Irripod®, Normasol®)


13.11.2 Chlorhexidine salts

Suitable for disinfection of skin.
GREEN     Chlorhexidine cleansing solution (Hibiscrub®)
GREEN     Chlorhexidines Gluconate Alcoholic & Aqueous Solutions (Hydrex® & Unisept® respectively)
 
 Both products are for skin disinfection by primary care prescribers only (different preparations are routinely                      used in secondary care). Both are listed on the Nurse Practitioners Formulary.
 

13.11.4 Iodine

Suitable for disinfection of skin
GREEN       Povidone-iodine (Betadine®)
                    antiseptic paint 10%,  antiseptic solution 10%, dry powder spray 2.5%,  surgical scrub 7.5%

                  

13.11.5 Phenolics

Used as part of MRSA regimen
GREEN     Octenisan® skin cleanser  
GREEN     Triclosan skin cleanser


13.11.6 Astringents, oxidisers and dyes

GREEN       Hydrogen peroxide cream 1% [Crystacide®] 1st line topical use for localised non-bullous impetigo
GREEN       Hydrogen peroxide solution 3% (10 vols.)
GREEN       Potassium permanganate 400mg tablets for solution (Permitabs®)
                       - 1 tablet dissolved in 4 litres in water provides a 0.01% (1 in 10,000) solution 


 13.12 Antiperspirants
 
GREEN      Aluminium chloride 20% solution (Anhydrol Forte®)
                   A potent antiperspirant used in the treatment of severe hyperhidrosis 
 
 AMBER      Glycopyrronium Bromide powder (Robinul®)
 
 AMBER     Propantheline [Pro-banthine] tablets 15mg 
                   [Effectiveness should be reviewed at 3 months for individual patients]