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 |
For other dithranol preparations see appendix 3. |
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: 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 | | 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) | 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▼) | | | | | | |