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