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BNSSG Adult Joint Formulary

13.3 Inflammatory skin conditions

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Last edited: 05-11-2024

13.3.1 Eczema and Psoriasis

First line drugs

Second line drugs

Specialist drugs

Secondary care drugs

Antracen Derivatives

Recommended:

Dithranol in Lassar’s paste 0.1 to 2% (TLS Red)

Only on prescription by a Clinician experienced in skin disease
Dithranol in Lassar’s Paste are only available as ‘special’ preparations (i.e. not proprietary products). These preparations are not cost-effective in primary care and there may be a significant delay in obtaining such preparations
Arachis oil (TLS Green) should be prescribed to remove the Dithranol in Lassar’s Paste. Arachis oil contains peanuts

Bacteriostatics

Zinc paste bandages (Ichthopaste^®, Viscopaste^®, Zipzoc^®) (TLS Green)

Calcineurin Inhibitors and Related Drugs

Pimecrolimus 1% cream (Elidel^®) (TLS Green)

Short term treatment of mild to moderate atopic eczema (including flares) when topical corticosteroids cannot be used
Outside of SPC indication, this is TLS RED

Tacrolimus 0.03% and 0.1% ointment (Protopic^®) (TLS Green)

For use in moderate to severe atopic dermatitis unresponsive to conventional therapies. Within SPC use only, in accordance with NICE TA82

Tacrolimus ointment is classified TLS green when used within the SPC and red when used outside of the SPC

Please refer to Chapter 8 for systemic preparations

Corticosteroids

Suitable quantities of corticosteroid preparations to be prescribed for specific areas of the body:

Amount of Steroid	Area	Weekly amount	Amount per application
Approximate This table is for an adult applying twice daily topical steroid.	Face & neck	15 to 30 grams per week	1½ fingertip units/application
	Trunk	100 grams per week	9 fingertip units/application
	One arm	15 to 30 grams per week	2 fingertip units/application
	One leg	30 to 60 grams per week	4 fingertip units/application

Mild

Hydrocortisone 0.5, 1% cream/ointment (TLS Green)

Hydrocortisone 1% / Miconazole nitrate 2% cream/ointment (Daktacort^®) (TLS Green)

Hydrocortisone 1% / Clotrimazole 1% cream (Canesten HC) (TLS Green)

Hydrocortisone 0.5% / Nystatin 100,000 units/g / Chlorhexidine hydrochloride 1% cream (Nystaform HC^®) (TLS Green)

Moderate

Clobetasone butyrate 0.05% cream/ointment (Eumovate^®) (TLS Green)

Betamethasone 0.025% cream/ointment (Betnovate RD^®) (TLS Green)

Clobetasone butyrate 0.05% / Oxytetracycline 3% / Nystatin 100,000 units/g cream (Trimovate^®) (TLS Blue)

Fluocinolone 0.00625% (Synalar® 1 in 4) ointment and cream (TLS Blue)

As per licensed indications

Potent

Betamethasone 0.1% cream/ointment/lotion (Betnovate^®) (TLS Green)

Betamethasone 0.05% / Salicylic acid 3% ointment (Diprosalic^®) (TLS Green)

Mometasone furoate 0.1% cream/ointment (Elocon^®) (TLS Green)

Fluocinolone acetonide 0.025% gel/ointment/cream (Synalar^®) (TLS Blue)

Fludroxycortide tape (Haelan^®) (TLS Green)

Betamethasone 0.1% / Clioquinol 3% cream/ointment (TLS Green)

Very Potent

Clobetasol propionate 0.05% cream/ointment (Dermovate^®) (TLS Green)

Diflucortolone 0.3% oily cream/ointment (Nerisone forte^®) (TLS Green)

Clobetasol propionate 0.05% / Neomycin sulphate 0.5% / Nystatin 100,000 units/g cream/ointment (TLS Green)

Other Preparations

Hydroquinone 5% / Hydrocortisone 1% / Tretinoin 0.1% cream (Pigmanorm^®) (TLS Red)

For Consultant Dermatologist use only, subject to the Cosmetic Surgery or Treatment Policy Cosmetic surgery or treatment | NHS Bristol, North Somerset and South Gloucestershire CCG (bnssgccg.nhs.uk)
See Cosmetic skin treatments page on Remedy: remedy pathway (bnssgccg.nhs.uk)

Specific indication:

Dermovate^® with 40% Propylene glycol (TLS Red)

Specialist Consultant use only for the treatment of Severe hyperkeratotic psoriasis and eczema of the palms and/or soles for 4 weeks (Unlicensed)

Retinoid and Related Drugs

Recommended:

Acitretin (TLS Red)

Specialist use only

Alitretinoin (TLS Red)

NICE TA177 For severe chronic hand eczema

Tars

Recommended: (TLS Green)

Sebco^® scalp ointment

Exorex^® lotion

Coal tar and Salicylic acid ointment

Coal Tar and Salicylic Acid ointments are only available as ‘special’ preparations (i.e. not proprietary products) These preparations are not cost-effective in primary care and there may be a significant delay in obtaining such preparations

Vitamin D and Analogues

Please refer to the BNF for information regarding vitamin D and analogues.

Recommended: (TLS Green)

Calcipotriol ointment

Calcipotriol / Betamethasone 0.05% gel & ointment (Dovobet^®)

Calcipotriol / Betamethasone 0.05% cream

Calcipotriol / Betamethasone 0.05% foam (Enstilar^®)

Drugs Affecting the Immune Response

Recommended:

Azathioprine (oral) (TLS Amber 3 months) (SCP Click here)

Ciclosporin (oral) (TLS Red)

Methotrexate (oral & subcutaneous) (TLS Amber 3 months) (SCP Click here)

Mycophenolate (oral) (TLS Amber 3 months) (SCP Click here)

N.B. unlicensed for eczema and skin conditions

Hydroxychloroquine (oral) (TLS Amber 1 month)

See Hydroxychloroquine Shared Care Protocol

Please refer to NPSA guidance on reducing the risks of oral methotrexate. Patients should have patient held records while they are receiving treatment with any DMARD requiring regular monitoring (record cards and GP protocol advice available from rheumatology)

Dapsone (oral) (TLS Amber 3 months) (SCP)

for treatment of dermatoses and oral ulceration
see 5.2 bacterial infection and 5.3 fungal infection for other indications

Cytokine Modulators

When local procurement has been finalised and as per NICE’s biosimilar position statement, if the originator biologic product is on the BNSSG joint formulary, the new biosimilar product will also be included on the formulary in accordance with its UK licence when it becomes commercially available

Recommended: (TLS Red)

Abrocitinib (oral)

NICE TA814 Abrocitinib, tralokinumab or upadacitinib for treating moderate to severe atopic dermatitis

Adalimumab (parenteral) - UHB only

Specify brand when prescribing Imraldi^®, Hyrimoz^®, Amgevita^®, Humira^®
For psoriasis in line with NICE TA146 and BNSSG ICB Recommended Commissioning Pathway
NICE TA392 For moderate to severe hidradenitis suppurativa, commissioned by NHS England

Baricitinib

NICE TA681 Baricitinib for treating moderate to severe atopic dermatitis

Dupilumab (parenteral)

NICE TA534 Dupilumab for treating moderate to severe atopic dermatitis

Etanercept (parenteral) - UHB only

Specify brand when prescribing Benepali^®, Enbrel^®
For psoriasis in line with NICE TA103 and BNSSG ICB Recommended Commissioning Pathway

Guselkumab (parenteral)

For psoriasis in line with NICE TA521 and BNSSG ICB Recommended Commissioning Pathway

Infliximab (intravenous & subcutaneous) - UHB only

Specify brand when prescribing - Remicade^®, Inflectra^®, Remsima^®
For psoriasis in line with NICE TA134 and BNSSG ICB Recommended Commissioning Pathway

Ixekizumab (parenteral)

For psoriasis in line with NICE TA442 and BNSSG ICB Recommended Commissioning Pathway

Lebrikizumab

NICE TA986 Lebrikizumab for treating moderate to severe atopic dermatitis in people 12 years and over

Omalizumab

NICE TA339 for previously treated chronic spontaneous urticaria

Risankizumab

For psoriasis in line with NICE TA596 and BNSSG ICB Recommended Commissioning Pathway

Secukinumab (parenteral) - UHB only

For psoriasis in line with NICE TA350 and BNSSG ICB Recommended Commissioning Pathway
NICE TA935 Secukinumab for treating moderate to severe hidradenitis suppurativa, commissioned by NHS England

Tildrakizumab (parenteral)

For psoriasis in line with NICE TA575 and BNSSG ICB Recommended Commissioning Pathway

Tralokinumab

NICE TA814 Abrocitinib, tralokinumab or upadacitinib for treating moderate to severe atopic dermatitis

Upadacitinib

NICE TA768 Upadacitinib for treating active psoriatic arthritis after inadequate response to DMARDs
NICE TA814 Abrocitinib, tralokinumab or upadacitinib for treating moderate to severe atopic dermatitis

Ustekinumab (parenteral) - UHB only

For psoriasis in line with NICE TA180 and BNSSG ICB Recommended Commissioning Pathway

Phosphodiesterase type-4 inhibitors

Apremilast (TLS Red)

For psoriasis in line with NICE TA419 and BNSSG ICB Recommended Commissioning Pathway

Immunomodulating Drugs

Dimethyl fumarate (oral) (TLS Red)

NICE TA475 Dimethyl fumarate for treating severe plaque psoriasis

13.3.2 Hidradenitis Suppurativa

Aldosterone Antagonists

Spironolactone (oral) (TLS Amber Specialist Initiated)

For treatment of Hidradenitis Suppurativa in female patients with coexisting acne and/or PCOS

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13.3 Inflammatory skin conditions

13.3.1 Eczema and Psoriasis

Antracen Derivatives

Dithranol in Lassar’s paste 0.1 to 2% (TLS Red)

Bacteriostatics

Zinc paste bandages (Ichthopaste®, Viscopaste®, Zipzoc®) (TLS Green)

Calcineurin Inhibitors and Related Drugs

Pimecrolimus 1% cream (Elidel®) (TLS Green)

Tacrolimus 0.03% and 0.1% ointment (Protopic®) (TLS Green)

Corticosteroids

Mild

Hydrocortisone 0.5, 1% cream/ointment (TLS Green)

Hydrocortisone 1% / Miconazole nitrate 2% cream/ointment (Daktacort®) (TLS Green)

Hydrocortisone 1% / Clotrimazole 1% cream (Canesten HC) (TLS Green)

Hydrocortisone 0.5% / Nystatin 100,000 units/g / Chlorhexidine hydrochloride 1% cream (Nystaform HC®) (TLS Green)

Moderate

Clobetasone butyrate 0.05% cream/ointment (Eumovate®) (TLS Green)

Betamethasone 0.025% cream/ointment (Betnovate RD®) (TLS Green)

Clobetasone butyrate 0.05% / Oxytetracycline 3% / Nystatin 100,000 units/g cream (Trimovate®) (TLS Blue)

Fluocinolone 0.00625% (Synalar® 1 in 4) ointment and cream (TLS Blue)

Potent

Betamethasone 0.1% cream/ointment/lotion (Betnovate®) (TLS Green)

Betamethasone 0.05% / Salicylic acid 3% ointment (Diprosalic®) (TLS Green)

Mometasone furoate 0.1% cream/ointment (Elocon®) (TLS Green)

Fluocinolone acetonide 0.025% gel/ointment/cream (Synalar®) (TLS Blue)

Fludroxycortide tape (Haelan®) (TLS Green)

Betamethasone 0.1% / Clioquinol 3% cream/ointment (TLS Green)

Very Potent

Clobetasol propionate 0.05% cream/ointment (Dermovate®) (TLS Green)

Diflucortolone 0.3% oily cream/ointment (Nerisone forte®) (TLS Green)

Clobetasol propionate 0.05% / Neomycin sulphate 0.5% / Nystatin 100,000 units/g cream/ointment (TLS Green)

Other Preparations

Hydroquinone 5% / Hydrocortisone 1% / Tretinoin 0.1% cream (Pigmanorm®) (TLS Red)

Dermovate® with 40% Propylene glycol (TLS Red)

Retinoid and Related Drugs

Acitretin (TLS Red)

Alitretinoin (TLS Red)

Tars

Sebco® scalp ointment

Exorex® lotion

Coal tar and Salicylic acid ointment

Vitamin D and Analogues

Calcipotriol ointment

Calcipotriol / Betamethasone 0.05% gel & ointment (Dovobet®)

Calcipotriol / Betamethasone 0.05% cream

Calcipotriol / Betamethasone 0.05% foam (Enstilar®)

Drugs Affecting the Immune Response

Azathioprine (oral) (TLS Amber 3 months) (SCP Click here)

Ciclosporin (oral) (TLS Red)

Methotrexate (oral & subcutaneous) (TLS Amber 3 months) (SCP Click here)

Mycophenolate (oral) (TLS Amber 3 months) (SCP Click here)

Hydroxychloroquine (oral) (TLS Amber 1 month)

Dapsone (oral) (TLS Amber 3 months) (SCP)

Cytokine Modulators

Abrocitinib (oral)

Adalimumab (parenteral) - UHB only

Baricitinib

Bimekizumab

Brodalumab

Certolizumab pegol (parenteral)

Deucravacitinib

Dupilumab (parenteral)

Etanercept (parenteral) - UHB only

Guselkumab (parenteral)

Infliximab (intravenous & subcutaneous) - UHB only

Ixekizumab (parenteral)

Lebrikizumab

Omalizumab

Risankizumab

Secukinumab (parenteral) - UHB only

Tildrakizumab (parenteral)

Tralokinumab

Upadacitinib

Ustekinumab (parenteral) - UHB only

Phosphodiesterase type-4 inhibitors

Apremilast (TLS Red)

Immunomodulating Drugs

Dimethyl fumarate (oral) (TLS Red)

13.3.2 Hidradenitis Suppurativa

Aldosterone Antagonists

Zinc paste bandages (Ichthopaste^®, Viscopaste^®, Zipzoc^®) (TLS Green)

Pimecrolimus 1% cream (Elidel^®) (TLS Green)

Tacrolimus 0.03% and 0.1% ointment (Protopic^®) (TLS Green)

Hydrocortisone 1% / Miconazole nitrate 2% cream/ointment (Daktacort^®) (TLS Green)

Hydrocortisone 0.5% / Nystatin 100,000 units/g / Chlorhexidine hydrochloride 1% cream (Nystaform HC^®) (TLS Green)

Clobetasone butyrate 0.05% cream/ointment (Eumovate^®) (TLS Green)

Betamethasone 0.025% cream/ointment (Betnovate RD^®) (TLS Green)

Clobetasone butyrate 0.05% / Oxytetracycline 3% / Nystatin 100,000 units/g cream (Trimovate^®) (TLS Blue)

Betamethasone 0.1% cream/ointment/lotion (Betnovate^®) (TLS Green)

Betamethasone 0.05% / Salicylic acid 3% ointment (Diprosalic^®) (TLS Green)

Mometasone furoate 0.1% cream/ointment (Elocon^®) (TLS Green)

Fluocinolone acetonide 0.025% gel/ointment/cream (Synalar^®) (TLS Blue)

Fludroxycortide tape (Haelan^®) (TLS Green)

Clobetasol propionate 0.05% cream/ointment (Dermovate^®) (TLS Green)

Diflucortolone 0.3% oily cream/ointment (Nerisone forte^®) (TLS Green)

Hydroquinone 5% / Hydrocortisone 1% / Tretinoin 0.1% cream (Pigmanorm^®) (TLS Red)

Dermovate^® with 40% Propylene glycol (TLS Red)

Sebco^® scalp ointment

Exorex^® lotion

Calcipotriol / Betamethasone 0.05% gel & ointment (Dovobet^®)

Calcipotriol / Betamethasone 0.05% foam (Enstilar^®)