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) |
Alitretinoin is recommended, within its licensed indication, as a treatment option for adults 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. |
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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 guidanceon 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 patientswho 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. |
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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 |
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 |
GREEN Calcipotriol 50micrograms/gram ointment, scalp solution (prescribe generically) |
GREEN Calcipotriol 50 micrograms/gram & betamethasone 0.05% ointment, gel (prescribe generically) |
GREEN Calcipotriol 50 micrograms/gram and betamethasone 0.05% cream (Wynzora®) |
GREEN Calcipotriol50 micrograms/gram and betamethasone cutaneous 0.05% foam (Enstilar®) |
GREEN Tacalcitol 4 micrograms/gram ointment (Curatoderm®) |
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Coal tar |
GREEN Licensed Coal tar products: |
lotion 5% (Exorex®) |
scalp ointment, coal tar 12% & salicylic acid 2%, sulphur 4% (Sebco®) |
AMBER Unlicensed Coal tar products - Dermatology initiation/recommendation only |
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%, |
AMBER Dithranol in Lassar's paste (unlicensed product) |
(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 |
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 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 |
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 |
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RED Dupilumab solution for injection 300mg/2mL pre-filled pens (Dupixent®▼) CCG Commissioned |
(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 |
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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 |
events, malignancy, venous thromboembolism, serious infections and increased mortality. |
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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. |
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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 |
appropriate for the child's age and the area being treated. |
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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) |
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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 - |
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: |
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> 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. |
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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. |
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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 photo-therapy, or these options |
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 |
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 |
RED Etanercept (Enbrel®) NHS England Commissioned |
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) |
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 |
NICE TA180 (updated) recommended as a treatment option for adults with plaque psoriasis |
[Ustekinumab solution for injection 45mg/0.5ml pfs (Stelara®)] (CCG Commissioned) |
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RED Dimethyl fumarate |
NICE TA475 recommended as an option for treating moderate to severe plaque psoriasis in adults |
[Dimethyl fumarate tablets 30mg, 120mg (Skilarence®)] CCG Commissioned Bluetec form required) |
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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 |
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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 |
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 |
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) |
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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: |
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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 |
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 | | | | |
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 |
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Secukinumab 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. |
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RED Secukinumab |
150mg solution for injection pfs (Cosentyx▼) |
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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