Indications Section 8.1.3 (parenteral) and section 10.1.3 (oral) moderate to severe chronic plaque psor-
13 Indications Section 8.1.3 (parenteral) and section 10.1.3 (oral) moderate to severe chronic plaque psor-
iasis for those whose disease is unresponsive to, or who are intolerant of other systemic therapy or
PIMECROLIMUS
photochemotherapy Indications short-term treatment of mild to moderate Cautions low platelet count (monitor platelet count
atopic eczema (including flares) when topical corti- before treatment, monthly during initial therapy then
costeroids cannot be used; see also notes above every 3 months); monitor for neurological deficits—if
Cautions UV light (avoid excessive exposure to sun- progressive multifocal leucoencephalopathy sus-
light and sunlamps), avoid other topical treatments pected, suspend treatment until excluded; hepatic
except emollients at treatment site; alcohol con- impairment; renal impairment; interactions: Appen-
sumption (risk of facial flushing and skin irritation) dix 1 (efalizumab)
Contra-indications contact with eyes and mucous Contra-indications immunodeficiency, severe infec-
membranes, application under occlusion, infection at tion, active tuberculosis; history of malignancy;
treatment site; congenital epidermal barrier defects; pregnancy and breast-feeding (Appendix 5)
generalised erythroderma; immunodeficiency; con- Side-effects hypersensitivity reactions, asthenia,
comitant use with drugs that cause immunosuppres- influenza-like symptoms, leucocytosis, arthralgia,
sion (may be prescribed in exceptional circumstances exacerbation of psoriasis or development of variant
by specialists); application to malignant or potentially forms including psoriatic arthritis (discontinue treat-
malignant skin lesions ment); less commonly thrombocytopenia and injection-
Side-effects burning sensation, pruritus, erythema, site reactions; also reported progressive multifocal
skin infections (including folliculitis and less commonly leucoencephalopathy (see also under Cautions) and
impetigo, herpes simplex and zoster, molluscum inflammatory polyradiculoneuropathy
contagiosum); rarely papilloma, skin discoloration,
BNF 57
13.6 Acne and rosacea 637
local reactions including pain, paraesthesia, peeling, nate weeks starting 1 week after initial dose; dis- dryness, oedema, and worsening of eczema; skin
continue treatment if no response within 16 weeks malignancy reported Dose
Preparations
. Apply twice daily until symptoms resolve (stop
Section 10.1.3
treatment if eczema worsens or no response after 6 weeks); CHILD under 2 years not recommended
ETANERCEPT
Elidel c (Novartis) A Indications see notes above; ankylosing spondylitis, Cream , pimecrolimus 1%, net price 30 g = £19.69,
psoriatic arthritis, polyarticular course juvenile idio-
60 g = £37.41, 100 g = £59.07. Label: 4, 28 pathic arthritis, rheumatoid arthritis (section 10.1.3)
Excipients include benzyl alcohol, cetyl alcohol, propylene glycol,
Cautions
section 10.1.3 Contra-indications section 10.1.3
stearyl alcohol
Side-effects TACROLIMUS section 10.1.3
Dose
Indications short-term treatment of moderate to . By subcutaneous injection , plaque psoriasis, ADULT severe atopic eczema (including flares) either unre-
over 18 years, 25 mg twice weekly or 50 mg once sponsive to, or in patients intolerant of conventional
weekly; max. treatment duration 24 weeks; discon- therapy; see also notes above; other indications sec-
tinue if no response after 12 weeks tion 8.2.2 Cautions infection at treatment site, UV light (avoid
Preparations
excessive exposure to sunlight and sunlamps); alcohol
Section 10.1.3
consumption (risk of facial flushing and skin irrita- tion); pregnancy
INFLIXIMAB
Contra-indications congenital epidermal barrier Indications see notes above; inflammatory bowel defects; generalised erythroderma; immunodefi-
disease (section 1.5.3); ankylosing spondylitis, psor- ciency; concomitant use with drugs that cause
iatic arthritis, rheumatoid arthritis (section 10.1.3) immunosuppression (may be prescribed in excep-
Cautions section 10.1.3 tional circumstances by specialists); application to
malignant or potentially malignant skin lesions; avoid Contra-indications section 10.1.3 contact with eyes and mucous membranes; applica-
Side-effects section 10.1.3 tion under occlusion; breast-feeding (Appendix 5)
Dose
Side-effects application-site reactions including rash, . By intravenous infusion , plaque psoriasis, ADULT irritation, pain and paraesthesia; herpes simplex
over 18 years, 5 mg/kg, repeated 2 weeks and 6 infection, Kaposi’s varicelliform eruption; less com-
weeks after initial infusion, then every 8 weeks; monly acne; rosacea and skin malignancy also
discontinue if no response by 14 weeks of initial reported
. ADULT and CHILD over 16 years initially apply 0.1%
Section 10.1.3
ointment thinly twice daily until lesion clears (con- sider other treatment if eczema worsens or no improvement after 2 weeks); reduce to once daily or switch to 0.03% ointment if condition allows; CHILD 2–
Acne and rosacea
16 years, initially apply 0.03% ointment twice daily for
up to 3 weeks (consider other treatment if eczema worsens or if no improvement after 2 weeks) then
13.6.1 Topical preparations for acne
reduce to once daily until lesion clears
13.6.2 Oral preparations for acne
Protopic c (Astellas) A
Skin
Ointment , tacrolimus (as monohydrate) 0.03%, net Acne Treatment of acne should be commenced early price 30 g = £19.44, 60 g = £36.94; 0.1%, 30 g =
to prevent scarring. Patients should be counselled that £21.60, 60 g = £41.04. Label: 4, 11, 28
an improvement may not be seen for at least a couple of
Excipients include beeswax
months. The choice of treatment depends on whether the acne is predominantly inflammatory or comedonal
Cytokine modulators and its severity.
Mild to moderate acne is generally treated with topical preparations (section 13.6.1). Systemic treatment (sec-
tion 13.6.2) with oral antibacterials is generally used for Indications
ADALIMUMAB
moderate to severe acne or where topical preparations are see notes above; Crohn’s disease (section
not tolerated or are ineffective or where application to 1.5.3); ankylosing spondylitis, polyarticular juvenile
the site is difficult. Another oral preparation used for idiopathic arthritis, psoriatic arthritis, rheumatoid
acne is the hormone treatment co-cyprindiol (cypro- arthritis (section 10.1.3)
terone acetate with ethinylestradiol); it is for women Cautions section 10.1.3
only.
Contra-indications section 10.1.3 Side-effects
Severe acne , acne unresponsive to prolonged courses of section 10.1.3
oral antibacterials, scarring, or acne associated with Dose
psychological problems calls for early referral to a . By subcutaneous injection , plaque psoriasis, ADULT
consultant dermatologist who may prescribe isotretin- over 18 years, initially 80 mg, then 40 mg on alter-
oin for administration by mouth.
13.6.1 Topical preparations for acne BNF 57 Rosacea Rosacea is not comedonal (but may exist with Brevoxyl c (Stiefel)
acne which may be comedonal). The pustules and Cream , benzoyl peroxide 4% in an aqueous basis, net papules of rosacea respond to topical metronidazole
price 40 g = £3.30 (section 13.10.1.2) or to topical azelaic acid (section
Excipients include cetyl alcohol, fragrance, stearyl alcohol
13.6.1). Alternatively, oral administration of oxytetra- PanOxyl c cycline or tetracycline 500 mg twice daily (section 5.1.3) (Stiefel) (= aqueous gel), benzoyl peroxide 2.5%, net or of erythromycin 500 mg twice daily (section 5.1.5)
Aquagel price 40 g = £1.76; 5%, 40 g = £1.92; 10%, 40 g = £2.13
can be used; courses usually last 6–12 weeks and are
Excipients include propylene glycol
repeated intermittently. Doxycycline (section 5.1.3) Cream , benzoyl peroxide 5% in a non-greasy basis, 100 mg once daily can be used [unlicensed indication]
net price 40 g = £1.89 if oxytetracycline or tetracycline is inappropriate (e.g. in
Excipients include isopropyl palmitate, propylene glycol
renal impairment). Isotretinoin is occasionally given in Gel , benzoyl peroxide 5% in an aqueous alcoholic refractory cases [unlicensed indication]. Camouflagers
basis, net price 40 g = £1.51; 10%, 40 g = £1.69 (section 13.8.2) may be required for the redness.
Excipients include fragrance Wash , benzoyl peroxide 10% in a detergent basis, net price 150 mL = £4.00
Excipients include imidurea
13.6.1 Topical preparations for
With antimicrobials
Duac acne c Once Daily (Stiefel) A
Gel , benzoyl peroxide 5%, clindamycin 1% (as phos- phate) in an aqueous basis, net price 25 g = £9.95, 50 g
In mild to moderate acne, comedones and inflamed
lesions respond well to benzoyl peroxide (see below)
Excipients include disodium edetate
or to a topical retinoid (see p. 639). Alternatively, topical Dose apply once daily in the evening application of an antibacterial such as erythromycin or clindamycin may be effective for inflammatory acne. If
Quinoderm c (Ferndale) topical preparations prove inadequate, oral preparations
Cream , benzoyl peroxide 5%, potassium hydroxy- may be needed (section 13.6.2).
quinoline sulphate 0.5%, in an astringent vanishing- cream basis, net price 50 g = £2.21 Excipients include cetostearyl alcohol, edetic acid (EDTA)
Benzoyl peroxide and azelaic acid
Cream , benzoyl peroxide 10%, potassium hydroxy- quinoline sulphate 0.5%, in an astringent vanishing-
Benzoyl peroxide is effective in mild to moderate acne. cream basis, net price 25 g = £1.30, 50 g = £2.49 Both comedones and inflamed lesions respond well to
Excipients include cetostearyl alcohol, edetic acid (EDTA)
benzoyl peroxide. The lower concentrations seem to be as effective as higher concentrations in reducing inflam- mation. It is usual to start with a lower strength and to
AZELAIC ACID
increase the concentration of benzoyl peroxide gradu- Indications see preparations ally. Adverse effects include local skin irritation, parti-
Cautions avoid contact with eyes, mouth, and mucous cularly when therapy is initiated, but the scaling and
membranes
redness often subside with treatment continued at a Side-effects local irritation (reduce frequency or dis- reduced frequency of application. If the acne does not
continue temporarily); less commonly skin discolora- respond after 2 months then use of a topical anti-
tion; very rarely photosensitisation bacterial should be considered.
Finacea c (Valeant) Skin A
Azelaic acid has antimicrobial and anticomedonal , azelaic acid 15%, net price 30 g = £7.48 properties. It may be an alternative to benzoyl peroxide
Gel Excipients include disodium edetate, polysorbate 80, propylene glycol
13 or to a topical retinoid for treating mild to moderate
Dose facial acne vulgaris, ADULT and CHILD over 14 years, apply comedonal acne, particularly of the face. Some patients
twice daily; discontinue if no improvement after 1 month prefer azelaic acid because it is less likely to cause local
Papulopustular rosacea, ADULT over 18 years, apply twice daily irritation than benzoyl peroxide.
Skinoren c (Valeant) A Cream , azelaic acid 20%, net price 30 g = £3.74
BENZOYL PEROXIDE
Excipients include propylene glycol Dose acne vulgaris, apply twice daily (sensitive skin, once daily
Indications acne vulgaris for first week). Extended treatment may be required but manu- Cautions avoid contact with eyes, mouth, and mucous
facturer advises period of treatment should not exceed 6 months membranes; may bleach fabrics and hair; avoid
excessive exposure to sunlight Side-effects skin irritation (reduce frequency or sus-
Topical antibacterials for acne
pend use until irritation subsides and re-introduce at For many patients with mild to moderate inflammatory reduced frequency)
acne, topical antibacterials may be no more effective Dose
than topical benzoyl peroxide or tretinoin. Topical anti- . Apply 1–2 times daily preferably after washing with
bacterials are probably best reserved for patients who soap and water, start treatment with lower-strength
wish to avoid oral antibacterials or who cannot tolerate preparations
them. Topical preparations of erythromycin and Note May bleach clothing
clindamycin are effective for inflammatory acne. Topi- Acnecide c (Galderma)
cal antibacterials can produce mild irritation of the skin, Gel , benzoyl peroxide 5% in an aqueous gel basis, net
and on rare occasions cause sensitisation. price 60 g = £5.69
Antibacterial resistance of Propionibacterium acnes is
Excipients include propylene glycol
increasing; there is cross-resistance between erythro-
BNF 57
13.6.1 Topical preparations for acne 639
mycin and clindamycin. To avoid development of resis- mouth and mucous membranes, eczematous, broken or tance:
sunburned skin should be avoided. These drugs should .
when possible use non-antibiotic antimicrobials
be used with caution in sensitive areas such as the neck, (such as benzoyl peroxide or azelaic acid);
and accumulation in angles of the nose should be .
avoid concomitant treatment with different oral and avoided. Exposure to UV light (including sunlight, solar- topical antibacterials;
iums) should be avoided; if sun exposure is unavoidable, an appropriate sunscreen or protective clothing should
. if a particular antibacterial is effective, use it for
be used. Use of retinoids with abrasive cleaners, come- repeat courses if needed (short intervening courses
dogenic or astringent cosmetics should be avoided. of benzoyl peroxide or azelaic acid may eliminate
Allow peeling (e.g. resulting from use of benzoyl per- any resistant propionibacteria);
oxide) to subside before using a topical retinoid; alter- .
do not continue treatment for longer than necessary nating a preparation that causes peeling with a topical (however, treatment with a topical preparation
retinoid may give rise to contact dermatitis (reduce should be continued for at least 6 months).
frequency of retinoid application). Contra-indications Topical retinoids are contra-indi-
cated in pregnancy (Appendix 4); women of child-bear- Indications acne vulgaris
ANTIBACTERIALS
ing age must use effective contraception (oral progesto- Cautions some manufacturers advise preparations
gen-only contraceptives not considered effective). containing alcohol are not suitable for use with
Tretinoin is contra-indicated in personal or familial benzoyl peroxide
history of cutaneous epithelioma. Dalacin T c (Pharmacia) A
, clindamycin 1% (as phosphate), in Side-effects Local reactions include burning, erythe-
Topical solution ma, stinging, pruritus, dry or peeling skin (discontinue if an aqueous alcoholic basis, net price (both with
severe). Increased sensitivity to UVB light or sunlight applicator) 30 mL = £4.34, 50 mL = £7.23 Excipients include propylene glycol
occurs. Temporary changes of skin pigmentation have Dose apply twice daily
been reported. Eye irritation and oedema, and blistering Lotion , clindamycin 1% (as phosphate) in an aqueous
or crusting of skin have been reported rarely. basis, net price 30 mL = £5.08, 50 mL = £8.47
Excipients include cetostearyl alcohol, hydroxybenzoates (parabens) Dose apply twice daily
ADAPALENE
Stiemycin c (Stiefel) A Indications mild to moderate acne Solution , erythromycin 2% in an alcoholic basis, net
Cautions see notes above price 50 mL = £8.00
see notes above Dose apply twice daily
Contra-indications
Side-effects see notes above Zindaclin Dose c
Excipients include propylene glycol
. Apply thinly once daily before retiring £8.66
(Crawford) A Gel , clindamycin 1% (as phosphate), net price 30 g =
Differin (Galderma) A Dose apply once daily
Excipients include propylene glycol
Excipients Cream , adapalene 0.1%, net price 45 g = £11.40 include disodium edetate, hydroxybenzoates (parabens) Zineryt c (Astellas) A Gel , adapalene 0.1%, net price 45 g = £11.40
Topical solution , powder for reconstitution, erythro-
Excipients include disodium edetate, hydroxybenzoates (parabens),
mycin 40 mg, zinc acetate 12 mg/mL when reconsti-
propylene glycol
tuted with solvent containing ethanol, net price per
pack of powder and solvent to provide 30 mL = £7.71,
90 mL = £22.24
TRETINOIN
Skin
Excipients none as listed in section 13.1.3 Dose apply twice daily
Note Tretinoin is the acid form of vitamin A
Indications see preparations; malignant disease (sec-
tion 8.1.5)
Topical retinoids and related Cautions see notes above preparations for acne Contra-indications see notes above
Side-effects see notes above Topical tretinoin and its isomer isotretinoin are useful
Dose
for treating comedones and inflammatory lesions in mild to moderate acne. Patients should be warned that
. See preparations
some redness and skin peeling may occur initially but Retin-A c (Janssen-Cilag) A settles with time. Several months of treatment may be
Gel , tretinoin 0.01%, net price 60 g = £5.61; 0.025%, needed to achieve an optimal response and the treat-
60 g = £5.61
ment should be continued until no new lesions develop.
Excipients include butylated hydroxytoluene
Isotretinoin is given by mouth in severe acne; see Dose acne vulgaris, apply thinly 1–2 times daily section 13.6.2 for warnings relating to use by mouth.
With antibacterial Adapalene, a retinoid-like drug, is licensed for mild to
Aknemycin c Plus (Almirall) moderate acne. It is less irritant than topical retinoids.
A Solution , tretinoin 0.025%, erythromycin 4% in an