Note Stains clothing FLUTICASONE PROPIONATE

13 Note Stains clothing FLUTICASONE PROPIONATE

Indications inflammatory skin disorders such as dermatitis and eczemas unresponsive to less potent

13.5 Preparations for eczema

corticosteroids

and psoriasis

Cautions see notes above Contra-indications see notes above

13.5.1 Preparations for eczema

Side-effects see notes above

13.5.2 Preparations for psoriasis

Dose

13.5.3 Drugs affecting the immune response

. Apply thinly 1–2 times daily Cutivate c (GSK) A

Cream , fluticasone propionate 0.05%, net price 15 g = £2.41, 50 g = £7.11. Label: 28, counselling, application,

13.5.1 Preparations for eczema

see p. 623. Potency: potent Excipients include cetostearyl alcohol, imidurea, propylene glycol

Eczema (dermatitis) has several causes, which may Ointment , fluticasone propionate 0.005%, net price

influence treatment. The main types of eczema are

15 g = £2.41, 50 g = £7.11. Label: 28, counselling, irritant, allergic contact, atopic, venous and discoid; application, see p. 623. Potency: potent

different types may co-exist. Lichenification, due to

Excipients include propylene glycol

scratching and rubbing, may complicate any chronic

BNF 57

13.5.1 Preparations for eczema 629

eczema. Atopic eczema is the most common type and it

A non-sedating antihistamine (section 3.4.1) may be of usually involves dry skin as well as infection and liche-

some value in relieving severe itching or urticaria asso- nification.

ciated with eczema. A sedating antihistamine (section Management of eczema involves the removal or treat-

3.4.1) may be used if itching causes sleep disturbance. ment of contributory factors including occupational and

Exudative (‘weeping’) eczema requires a potent cortico- domestic irritants. Known or suspected contact aller-

steroid initially; infection may also be present and gens should be avoided. Rarely, ingredients in topical

require specific treatment (see above). Potassium per- medicinal products may sensitise the skin; the BNF lists

manganate solution (1 in 10 000) can be used in exu- active ingredients together with excipients that have

dating eczema for its antiseptic and astringent effects; been associated with skin sensitisation.

treatment should be stopped when exudation stops. Skin dryness and the consequent irritant eczema

requires emollients (section 13.2.1) applied regularly Severe refractory eczema Severe refractory eczema is and liberally to the affected area; this can be supple-

best managed under specialist supervision; it may mented with bath or shower emollients. The use of

require phototherapy or drugs that act on the immune emollients should continue even if the eczema improves

system (section 13.5.3). Alitretinoin (see below) is or if other treatment is being used.

licensed for the treatment of severe chronic hand ecz- ema refractory to potent topical corticosteroids;

Topical corticosteroids (section 13.4) are also required patients with hyperkeratotic features are more likely to in the management of eczema; the potency of the

respond to alitretinoin than those with pompholyx. corticosteroid should be appropriate to the severity

and site of the condition. Mild corticosteroids are gen- Seborrhoeic dermatitis Seborrhoeic dermatitis (seborr- erally used on the face and on flexures; potent corti-

hoeic eczema ) is associated with species of the yeast costeroids are generally required for use on adults with

Malassezia and affects the scalp, paranasal areas, and discoid or lichenified eczema or with eczema on the

eyebrows. Shampoos active against the yeast (including scalp, limbs, and trunk. Treatment should be reviewed

those containing ketoconazole and coal tar, section regularly, especially if a potent corticosteroid is

13.9) and combinations of mild corticosteroids with required. Bandages (including those containing zinc

suitable antimicrobials (section 13.4) are used. and ichthammol) are sometimes applied over topical corticosteroids or emollients to treat eczema of the limbs.

Topical preparations for eczema

For the role of topical pimecrolimus and tacrolimus in atopic eczema see section 13.5.3.

ICHTHAMMOL

Infection Bacterial infection (commonly with Staphy- Indications chronic lichenified eczema lococcus aureus and occasionally with Streptococcus pyo-

Side-effects skin irritation genes ) can exacerbate eczema and requires treatment

Dose

with topical or systemic antibacterial drugs (section . Apply 1–3 times daily

13.10.1 and section 5.1). Antibacterial drugs, particu- larly fusidic acid, should be used in short courses

Ichthammol Ointment, BP 1980

(typically 1 week) to reduce the risk of drug resistance Ointment , ichthammol 10%, yellow soft paraffin 45%, or skin sensitisation. Associated eczema is treated

wool fat 45%

simultaneously with a topical corticosteroid usually of

Zinc and Ichthammol Cream, BP

moderate or high potency. Cream , ichthammol 5%, cetostearyl alcohol 3%, wool Eczema involving widespread or recurrent infection

fat 10%, in zinc cream requires the use of a systemic antibacterial that is active

Zinc Paste and Ichthammol Bandage, BP 1993

against the infecting organism. Products that combine See Appendix 8 (section A8.2.9)

an antiseptic with an emollient application (section

13.2.1) and with a bath emollient (section 13.2.1.1)

Skin

can also be used; antiseptic shampoos (section 13.9)

Oral retinoid for eczema

can be used on the scalp. The retinoid, alitretinoin, is licensed for the treatment Intertriginous eczema commonly involves candida and

of severe chronic hand eczema refractory to potent bacteria; it is best treated with a mild or moderately

topical corticosteroids; patients with hyperkeratotic fea- potent topical corticosteroid and a suitable anti-

tures are more likely to respond to alitretinoin than microbial drug.

those with pompholyx. Widespread herpes simplex infection may complicate

Alitretinoin should be prescribed only by, or under the atopic eczema and treatment with a systemic antiviral

supervision of, a consultant dermatologist. drug (section 5.3.2.1) is indicated.

Alitretinoin is teratogenic and must not be given to The management of seborrhoeic dermatitis is described

women of child-bearing potential unless they practise below.

effective contraception and then only after detailed assessment and explanation by the physician. See also

Management of other features of eczema Liche- Pregnancy Prevention under Cautions, below. nification , which results from repeated scratching is treated initially with a potent corticosteroid. Bandages containing ichthammol paste (to reduce pruritus) and

ALITRETINOIN

other substances such as zinc oxide can be applied over Indications severe chronic hand eczema refractory to the corticosteroid or emollient. Coal tar (section 13.5.2)

potent topical corticosteroids and ichthammol can be useful in some cases of chronic

Cautions avoid blood donation during treatment and eczema .

for at least 1 month after stopping treatment; monitor

13.5.2 Preparations for psoriasis BNF 57 serum lipids (more frequently in those with risk fac-

Emollients (section 13.2.1), in addition to their effects tors for cardiovascular disease, diabetes, or history of

on dryness, scaling and cracking, may have an anti- hyperlipidaemia)—discontinue if uncontrolled hyper-

proliferative effect in psoriasis. They are particularly lipidaemia; history of depression; dry eye syndrome;

useful in inflammatory psoriasis and in plaque psoriasis interactions: Appendix 1 (retinoids)

of palms and soles , in which irritant factors can perpe- Pregnancy prevention In women of child-bearing poten-

tuate the condition. Emollients are useful adjuncts to tial, exclude pregnancy 1 month before treatment, up to 3 days before treatment, every month during treatment (unless

other more specific treatment. there are compelling reasons to indicate that there is no risk

More specific topical treatment for chronic stable plaque of pregnancy), and 5 weeks after stopping treatment—per-

psoriasis on extensor surfaces of trunk and limbs form pregnancy test in the first 3 days of the menstrual cycle. Women must practise effective contraception for at least 1

involves the use of vitamin D analogues, coal tar, month before starting treatment, during treatment, and for at

dithranol, and the retinoid tazarotene. However, they least 1 month after stopping treatment. Women should be

can irritate the skin and they are not suitable for the advised to use at least 1 method of contraception but ideally

more inflammatory forms of psoriasis; their use should they should use 2 methods of contraception. Oral proges- togen-only contraceptives are not considered effective.

be suspended during an inflammatory phase of psor- Barrier methods should not be used alone but can be used in

iasis. The efficacy and the irritancy of each substance conjunction with other contraceptive methods. Each pre-

varies between patients. If a substance irritates signifi- scription for alitretinoin should be limited to a supply of up to

cantly, it should be stopped or the concentration 30 days’ treatment and dispensed within 7 days of the date stated on the prescription. Women should be advised to

reduced; if it is tolerated, its effects should be assessed discontinue treatment and to seek prompt medical attention

after 4 to 6 weeks and treatment continued if it is if they become pregnant during treatment or within 1 month

effective.

of stopping treatment. Contra-indications

Widespread unstable psoriasis of erythrodermic or gen- hepatic impairment; severe renal

eralised pustular type requires urgent specialist assess- impairment (Appendix 3); uncontrolled hyperlipid-

ment. Initial topical treatment should be limited to using aemia; uncontrolled hypothyroidism; hypervitamino-

emollients frequently and generously; emollients should sis A; pregnancy (important teratogenic risk: see

be prescribed in quantities of 1 kg or more. More loca- Pregnancy Prevention, above); breast-feeding Side-effects

lised acute or subacute inflammatory psoriasis with hot, raised serum concentration of tri-

spreading or itchy lesions, should be treated topically glycerides and of cholesterol (risk of pancreatitis if

with emollients or with a corticosteroid of moderate triglycerides above 9 mmol/litre), flushing; headache;

potency.

changes in thyroid function tests; anaemia; myalgia, raised creatine kinase, arthralgia; conjunctivitis, dry

Calcipotriol and tacalcitol are analogues of vitamin D eyes (may respond to lubricating eye ointment or tear

that affect cell division and differentiation. Calcitriol is replacement therapy)—sometimes decreased toler-

an active form of vitamin D. Vitamin D and its analogues ance to contact lenses, eye irritation; dryness of skin

are used as first-line treatment for plaque psoriasis; they and lips, cheilitis, erythema, alopecia; less commonly

do not smell or stain and they may be more acceptable epistaxis, hyperostosis, ankylosing spondylitis,

than tar or dithranol products. Of the vitamin D analo- blurred vision, cataracts, pruritus, and asteototic

gues, tacalcitol and calcitriol are less likely to irritate. eczema; rarely benign intracranial hypertension (dis-

Coal tar has anti-inflammatory properties that are use- continue if severe headache, nausea, vomiting, papil-

ful in chronic plaque psoriasis; it also has antiscaling loedema, or visual disturbances occur) and vasculitis;

properties. Crude coal tar (coal tar, BP) is the most also reported keratitis and decreased night vision

effective form, typically in a concentration of 1 to 10% Dose

in a soft paraffin base, but few outpatients tolerate the . ADULT over 18 years, 30 mg once daily, reduced to

smell and mess. Cleaner extracts of coal tar included in Skin proprietary preparations, are more practicable for home 10 mg once daily if not tolerated; patients with dia-

betes, history of hyperlipidaemia, or risk factors for use but they are less effective and improvement takes

13 longer. Contact of coal tar products with normal skin is cardiovascular disease, initially 10 mg once daily, increased if necessary up to max. 30 mg daily

not normally harmful and they can be used for wide- Note Duration of treatment 12–24 weeks; discontinue if no

spread small lesions; however, irritation, contact allergy, response after 12 weeks. Course may be repeated in those

and sterile folliculitis can occur. The milder tar extracts who relapse. See also Pregnancy Prevention, above

can be used on the face and flexures. Tar baths and tar Toctino c (Basilea) TA

shampoos are also helpful. Capsules , alitretinoin 10 mg (brown), net price 30-cap

Dithranol is effective for chronic plaque psoriasis. Its pack = £411.43; 30 mg (red-brown), 30-cap pack =

major disadvantages are irritation (for which individual £411.43. Label: 10, patient information leaflet, 11, 21

susceptibility varies) and staining of skin and of clothing. It should be applied to chronic extensor plaques only, carefully avoiding normal skin. Dithranol is not gener-

13.5.2 ally suitable for widespread small lesions nor should it Preparations for psoriasis

be used in the flexures or on the face. Treatment should

be started with a low concentration such as dithranol Psoriasis is characterised by epidermal thickening and

0.1%, and the strength increased gradually every few scaling. It commonly affects extensor surfaces and the

days up to 3%, according to tolerance. Proprietary scalp. For mild psoriasis, reassurance and treatment

preparations are more suitable for home use; they are with an emollient may be all that is necessary.

usually washed off after 5 to 60 minutes (‘short con- Occasionally psoriasis is provoked or exacerbated by

tact’). Specialist nurses may apply intensive treatment drugs such as lithium, chloroquine and hydroxychloro-

with dithranol paste which is covered by stockinette quine, beta-blockers, non-steroidal anti-inflammatory

dressings and usually retained overnight. Dithranol drugs, and ACE inhibitors. Psoriasis may not be seen

should be discontinued if even a low concentration until the drug has been taken for weeks or months.

causes acute inflammation; continued use can result causes acute inflammation; continued use can result

Tazarotene, a retinoid, seems to be less effective than calcipotriol with a greater incidence of irritation. Although irritation is common, it is minimised by apply- ing tazarotene sparingly to the plaques and avoiding normal skin. Tazarotene is clean and odourless.

A topical corticosteroid (section 13.4) is not generally suitable as the sole treatment of extensive chronic plaque psoriasis; any early improvement is not usually maintained and there is a risk of the condition deterior- ating or of precipitating an unstable form of psoriasis (e.g. erythrodermic psoriasis or generalised pustular psoriasis). However, it may be appropriate to treat psor- iasis in specific sites, such as the face and flexures, usually with a mild corticosteroid, and psoriasis of the scalp, palms, and soles with a potent corticosteroid.

Combining the use of a corticosteroid with another specific topical treatment may be beneficial in chronic plaque psoriasis; the drugs may be used separately at different times of the day or used together in a single formulation. Eczema co-existing with psoriasis may be treated with a corticosteroid, or coal tar, or both.

Scalp psoriasis is usually scaly, and the scale may be thick and adherent. This requires softening with an emollient ointment, cream, or oil and usually combined with salicylic acid as a keratolytic.

Some preparations prescribed for psoriasis affecting the scalp combine salicylic acid with coal tar or sulphur. Preparations containing salicylic acid, sulphur, and coal tar are available as proprietary products. The product should be applied generously and an adequate quantity should be prescribed. It should be left on for at least an hour, often more conveniently overnight, before wash- ing it off. If a corticosteroid lotion or gel is required (e.g. for itch), it can be used in the morning.

Phototherapy Phototherapy is available in specialist centres under the supervision of a dermatologist. Ultra- violet B (UVB) radiation is usually effective for chronic stable psoriasis and for guttate psoriasis. It may be con- sidered for patients with moderately severe psoriasis in whom topical treatment has failed, but it may irritate inflammatory psoriasis.

Photochemotherapy combining long-wave ultraviolet

A radiation with a psoralen (PUVA) is available in specialist centres under the supervision of a dermatol- ogist. The psoralen, which enhances the effect of irra- diation, is administered either by mouth or topically. PUVA is effective in most forms of psoriasis, including localised palmoplantar pustular psoriasis . Early adverse effects include phototoxicity and pruritus. Higher cumu- lative doses exaggerate skin ageing, increase the risk of dysplastic and neoplastic skin lesions, especially squa- mous cancer, and pose a theoretical risk of cataracts.

Phototherapy combined with coal tar, dithranol, tazar- otene, topical vitamin D or vitamin D analogues, or oral acitretin, allows reduction of the cumulative dose of phototherapy required to treat psoriasis.

Systemic treatment Systemic treatment is required for severe, resistant, unstable or complicated forms of psoriasis, and it should be initiated only under specialist supervision. Systemic drugs for psoriasis include acitre- tin (see below) and drugs that affect the immune

response (such as ciclosporin and methotrexate, section 13.5.3).

Systemic corticosteroids should be used only rarely in psoriasis because rebound deterioration may occur on reducing the dose.

Acitretin, a metabolite of etretinate, is a retinoid (vit- amin A derivative); it is prescribed by specialists. The main indication for acitretin is psoriasis, but it is also used in disorders of keratinisation such as severe Darier’s disease (keratosis follicularis), and some forms of ichthyosis. Although a minority of cases of psoriasis respond well to acitretin alone, it is only moderately effective in many cases and it is combined with other treatments. A therapeutic effect occurs after 2 to 4 weeks and the maximum benefit after 4 to 6 weeks or longer. The manufacturers of acitretin do not recom- mend continuous treatment for longer than 6 months. However, some patients may benefit from longer treat- ment, provided that the lowest effective dose is used, patients are monitored carefully for adverse effects, and the need for treatment is reviewed regularly.

Apart from teratogenicity, which remains a risk for 3 years after stopping, acitretin is the least toxic systemic treatment for psoriasis; in women with a potential for child-bearing, the possibility of pregnancy must be excluded before treatment and effective contraception must be used during treatment and for at least 3 years afterwards (oral progestogen-only contraceptives not considered effective). Common side-effects derive from its widespread but reversible effects on epithelia, such as dry and cracking lips, dry skin and mucosal surfaces, hair thinning, paronychia, and soft and sticky palms and soles. Liver function and blood lipid concen- tration should be monitored.