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BNSSG Adult Joint Formulary

13.3 Inflammatory skin conditions

Last edited: 30-05-2024

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)

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)

 

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/scalp solution

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

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 & parenteral) 2.5mg tablets only - weekly dose (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)

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)

 

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

Baricitinib

  • NICE TA681 Baricitinib for treating moderate to severe atopic dermatitis

Bimekizumab

Brodalumab

Certolizumab pegol (parenteral)

Deucravacitinib

Dupilumab (parenteral)

  • NICE TA534 Dupilumab for treating moderate to severe atopic dermatitis

Etanercept (parenteral) - UHB only

Guselkumab (parenteral)

Infliximab (intravenous & subcutaneous) - UHB only

Ixekizumab (parenteral)

Omalizumab

  • NICE TA339 for previously treated chronic spontaneous urticaria

Risankizumab

Secukinumab (parenteral) - UHB only

Tildrakizumab (parenteral)

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

 

Phosphodiesterase type-4 inhibitors

Apremilast (TLS Red)

 

Immunomodulating Drugs

Dimethyl fumarate (oral) (TLS Red)

  • NICE TA475 Dimethyl fumarate for treating severe plaque psoriasis

 

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