| 13.5.1 Preparations for eczema |
Oral retinoids for severe hand eczema
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Alitretinoin, for the treatment of Chronic Eczema (TAG 177)
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Alitretinoin is recommended, within its licensed indication, as a treatment option for adults has not responded to potent
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topical corticosteroids if the persons has:
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| > severe disease, as defined by the physician’s global assessment (PGA) and |
| > a dermatology life quality index (DLQI) score of 15 or more. |
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Oral alitretinoin is licensed for the treatment of severe chronic hand eczema unresponsive to potent topical corticosteroids,
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in adults. Alitretinoin should only be prescribed by dermatologists, or physicians with experience in the use of systemic
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retinoids who have full understanding of the risks of systemic retinoid therapy and monitoring requirements. Prescriptions
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of alitretinoin for women of childbearing potential should be limited to 30 days of treatment and continuation of treatment
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requires a new prescription. Ideally, pregnancy testing, issuing a prescription and dispensing of alitretinoin should occur on
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the same day. Dispensing of alitretinoin should occur within a maximum of 7 days of the prescription. Pregnancy is an
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absolute contraindication to treatment with alitretinoin. Basilea Pharmaceuticals has put together a Pregnancy Prevention
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Programme, containing guidanceon prescribing alitretinoin to women of childbearing potential and contraceptive
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precautions required. A treatment course of alitretinoin may be given for 12 to 24 weeks depending on response.
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Discontinuation of therapy should be considered for patientswho still have severe disease after the initial 12 weeks of
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treatment. In the event of relapse, patients may benefit from further treatment courses of alitretinoin. Patients should still
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be advised to use daily emollients during therapy and once the eczema has cleared.
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RED Alitretinoin (Toctino®) capsules 10mg, 30mg
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| 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
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low concentrations and build up. See 'Psoriasis Management in Primary Care' for further information
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| Topical preparations for psoriasis | |
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Vitamin D and analogues
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GREEN Calcipotriol 50micrograms/gram ointment, scalp solution (prescribe generically)
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GREEN Calcipotriol 50 micrograms/gram & betamethasone 0.05% ointment, gel (prescribe generically)
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GREEN Calcipotriol 50 micrograms/gram and betamethasone 0.05% cream (Wynzora®)
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GREEN Calcipotriol50 micrograms/gram and betamethasone cutaneous 0.05% foam (Enstilar®)
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GREEN Tacalcitol 4 micrograms/gram ointment (Curatoderm®)
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Coal tar
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GREEN Licensed Coal tar products:
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| lotion 5% (Exorex®) |
| scalp ointment, coal tar 12% & salicylic acid 2%, sulphur 4% (Sebco®) |
AMBER Unlicensed Coal tar products - Dermatology initiation/recommendation only
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| e.g. coal tar in yellow soft paraffin, various strengths |
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Dithranol | *Please note that Dithrocream® has been discontinued and will be replaced with Specials recommended by the | | British Association of Dermatologists for Skin Disease <click here> to access the document. [AMBER traffic light] | |
GREEN Dithranol (Dithrocream®) cream 0.1%,
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AMBER Dithranol in Lassar's paste (unlicensed product)
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(Dermatology initiation/recommendation only) various strengths.
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Oral retinoids for psoriasis - for severe resistant or complicated psoriasis, prescribed only by or under the supervision of a
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consultant dermatologist.
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| 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 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] | |
| | | 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.
| | AMBER Tacrolimus 0.03% ointment | AMBER Pimecrolimus 1% cream
| | | 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 pimecrolimus, or 2 weeks for tacrolimus), or if the disease worsens, the | |
| diagnosis of atopic dermatitis should be re-evaluated and other therapeutic options considered |
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See age restrictions for each product before prescribing.
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NICE Guidance TA534: Dupilumab is recommended as an option for treating moderate to severe atopic dermatitis in adults
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| only if: |
> the disease has not responded to at least 1 other systemic therapy, such as ciclosporin, methotrexate, azathioprine
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| and mycophenolate mofetil, or these are contraindicated or not tolerated. |
| > the company provides dupilumab according to the commercial arrangement |
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RED Dupilumab solution for injection 300mg/2mL pre-filled pens (Dupixent®▼) CCG Commissioned
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| (BlueTec form required) |
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| 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 TA814: Abrocitinib, tarlokinumab or upadacitinib for treating moderate to severe atopic dermatitis |
| Abrocitinib [*see MHRA Drug Safety Update] and upadacitinib are recommended as options for treating moderate to severe |
| atopic dermatitis that is suitable for systemic treatment in adults and young people over 12 years and over, only if: |
| > the disease has not responded to at least 1 systemic immunosuppressant, or these are not suitable |
| > the company provide abrocitinib and upadicitinib according to the commercial arrangement. |
| Tralokinumab is recommended as an option for treating moderate to severe atopic dermatitis that is suitable for systemic |
| treatment in adults, only if: |
| > the disease has not responded to at least 1 systemic immunosuppressant, or these are not suitable |
| > the company provide abrocitinib and upadicitinib according to the commercial arrangement. |
| Stop *abrocitinib, upadacitinib or tralokinumab at 16 weeks if the atopic dermatitis has not responded adequately. |
| An adequate response is: |
| > at least 50% reduction in the Eczema Area and Severity Index Score [EASI 50] from when treatment started and |
| > at least a 4-point reduction in the Dermatology Life Quality Index {DLQI] from when treatment started. |
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| RED *Abrocitinib [Cibinqo] see SPC ICB Commissioned [formerly CCG] |
| RED Upadacitinib [Rinvoq] ICB Commissioned [formerly CCG] |
| RED Tralokinumab [Adtralza] ICB Commissioned [formerly CCG] |
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MHRA Drug Safety Update [APRIL 2023: Janus kinase (JAK) inhibitors: new measures to reduce risks of major cardiovascular
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events, malignancy, venous thromboembolism, serious infections and increased mortality.
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NICE Guidance: Atopic Eczema in Children
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> Only specialists with experience in dermatology should start treatment with tacrolimus or pimecrolimus after
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| 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
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| 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
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> Do not use topical tacrolimus or pimecrolimus:
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> for mild atopic eczema,
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| > as first-line treatment for atopic eczema of any severity, |
| > under bandages or dressings without specialist dermatological advice. |
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| AMBER Tacrolimus (0.03%) | | AMBER Pimecrolimus (1% cream) | |
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*Unsatisfactory clinical response to adequate use of the maximum strength and potency of topical corticosteroids that is
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appropriate for the child's age and the area being treated.
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Active plaque psoriasis in adults
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Ustekinumab is recommended as an option, alone or in combination with methotrexate, for treating active plaque psoriasis
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in adults as per NICE TA340 (replaces TA313)
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RED Ustekinumab solution for injection 45mg/0.5ml pfs (Stelara®) (CCG Commissioned)
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NICE Guidance: Adalimumab, etanercept and ustekinumab for treating plaque psoriasis in children and young adults -
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NICE TA455 Adalimumab is recommended as an option for treating plaque psoriasis in children and young people aged
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4 years or older, only if the disease:
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> is severe, as defined by a total Psoriasis Area and Severity Index (PASI) of 10 or more and
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| > has not responded to standard systemic therapy, such as ciclosporin, methotrexate or phototherapy, or these options |
are contraindicated or not tolerated.
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Etanercept is recommended as an option for treating plaque psoriasis in children and young people aged 6years or older,
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only if the disease:
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> is severe as defined by a total PASI of 10 or more and
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| > has not responded to standard systemic therapy, such as ciclosporin, methotrexate or phototherpay, or these options |
| are contraindicated or not tolerated. |
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Ustekinumab is recommended as an option for treating plaque psoriasis in children and young people aged 12 years or
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older, only if the disease:
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> is severe, as defined by a total PASI of 10 or more
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> has not responded to standard systemic therapy, such as ciclosporin, methotrexate or photo-therapy, or these options
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| are contraindicated or not tolerated. |
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Stop etanercept treatment at 12 weeks, and adalimumab and ustekinumab treatment at 16 weeks, if the psoriasis has not
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responded adequately. An adequate response is defined as a 75% reduction in the PASI score from the start of treatment
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RED Adalimumab (Amgevita -1st line choice in new patients, Humira®,) NHS England Commissioned
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RED Etanercept (Enbrel®) NHS England Commissioned
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RED Ustekinumab (Stelara®) NHS England Commissioned
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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 |
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Moderate to severe psoriasis NICE TA180 (updated)
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NICE interactive flowchart - Psoriasis
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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. |
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RED Ustekinumab
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NICE TA180 (updated) recommended as a treatment option for adults with plaque psoriasis
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[Ustekinumab solution for injection 45mg/0.5ml pfs (Stelara®)] (CCG Commissioned)
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RED Dimethyl fumarate
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NICE TA475 recommended as an option for treating moderate to severe plaque psoriasis in adults
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[Dimethyl fumarate tablets 30mg, 120mg (Skilarence®)] CCG Commissioned Bluetec form required)
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RED Ixekizumab
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NICE TA442 recommended as an option for treating moderate to severe plaque psoriasis in adults
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[Ixekizumab solution for injection 80mg/1mL ] CCG Commissioned
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| 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 |
| these 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) |
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| 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
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| 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) |
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NICE Guidance TA511 - Brodalumab for treating moderate to severe plaque psoriasis
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Brodalumab is recommended as an option for treating plaque psoriasis in adults, as recommended in NICE TA511
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RED Brodalumab solution for injection pfs 210mg/1.5mL (Kyntheum▼) (CCG Commissioned Bluetec form required)
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NICE TA521 - Guselkumab for treating moderate to severe plaque psoriasis in adults.
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Guselkumab is recommended, as an option in NICE TA521,for treating plaque psoriasis in adults only if:
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> the disease is severe, as defined by a total Psoriasis Area and Sensitivity Index (PASI) of 10 or more and Dermatology Life
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| 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) |
| |
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| 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)
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| |
| NICE TA907 Deucravacitinib for treating moderate to severe plaque psoriasis in adults |
| Deucravacitinib is recommended as an option for treating moderate to severe plaque psoriasis in adults, only if: |
| > the Psoriasis Area and Severity Index (PASI) score is 10 or more and the Dermatology Life Quality Index (DLQI) score is more |
| |
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| than 10 |
| > the condition has not responded to other systemic treatments, including ciclosporin, methotrexate and phototherapy, or |
| these options are contraindicated or not tolerated. |
| > the company provides deucravacitinib according to the commercial arrangement |
| RED Deucravacitinib ICB Commissioned Bluetec form required |
Secukinumab for the treatment of Palmoplantar Psoriasis |
| |
Secukinumab is recommended for the treatment of moderate to severe palmoplantar psoriasis that has not responded (refractory)
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to at least two standard systemic treatments and photochemotherapy, or when standard treatments cannot be used because of
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intolerance or contra-indications.
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RED Secukinumab
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150mg solution for injection pfs (Cosentyx▼)
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| 150mg solution for injection pf pen (Cosentyx▼) |
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| Severe (refractory) Pyoderma Gangrenosum |
| See attachment [British Association of Dermatologists] |
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| RED Infliximab [including biosimilars] |
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