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 Formulary Chapter 13: Skin - Full Chapter
Notes:

Review date: September 2021

Non-formulary drugs - any drug or formulation not listed in the formulary is deemed to be non-formulary.

Off-label use: Drugs are included in the formulary for their licensed indications – where inclusion of off-label use is considered to be included in the formulary this is specifically stated in the formulary entry for the drug N.B. also see Paediatrics note below.

Paediatrics: Drugs are included in the formulary for paediatric use for their BNF for Children recommended indications (indicated by symbol View childrens BNF) which may be off-label, unless otherwise stated. All drugs are deemed to have the same RAG status as they have for adults unless stated otherwise.

NHS England Specialised Commissioning
Drugs carrying the NHS England logo are commissioned by them. Links to key documents, national programmes of care, and clinical reference groups are found below.

NHSE NHS England Specialised Commissioning: Key documents

NHSE NHS England Specialised Commissioning: National programmes of care and clinical reference groups





Chapter Links...
 Details...
13.05.02  Expand sub section  Preparations for psoriasis
 note 

Consult NICE CG 153 - Psoriasis: Assessment and management of psoriasis

Summary: Management of Psoriasis - taken from NICE CG 153:

  • First line – Topical therapy – e.g. corticosteroids, vitamin D, vitamin D analogues, dithranol and tar preparations
  • Second line – broad- or narrow-band UVB light and psoralen plus UVA light (PUVA) and systemic non-biologics e.g. ciclosporin, methotrexate or acitretin
  • Third line – systemic biologics; Anti-TNFs – adalimumab, etanercept and infliximab and mono-clonal antibody ustekinumab which targets IL-12 and IL-23.

Offer second and third line therapies if topical therapies unlikely to control psoriasis, such as extensive disease e.g. > 10% body surface area affected, or at least “moderate” on the static Physicians Global Assessment.
Calcipotriol and tacalcitol are analogues of vitamin D that affect cell division and differentiation. Calcitriol is an active form of vitamin D. Vitamin D and its analogues are used first-line for the long-term treatment of plaque psoriasis; they do not smell or stain and they may be more acceptable than tar or dithranol products. Of the vitamin D analogues, calcitriol is less likely to irritate.

Dimethyl fumarate
View adult BNF View SPC online
Formulary
Red

Tablets 30mg, 120mg

No BNFc entry; Paediatrics, seek specialist advice 

 
Link  NICE TA475: Dimethyl fumarate for treating moderate to severe plaque psoriasis
   
13.05.02  Expand sub section  Topical preparations for psoriasis
 note 

British Association of Dermatologists (BAD) preferred choice of products

Calcipotriol
View adult BNF View SPC online View childrens BNF
First Choice
Green

50 micrograms/g (Dovonex®) Ointment;
(not for face or flexures) 30 g

For chronic plaque psoriasis in adult and child 6-18 years
For Body

Amber Recommended Paediatrics < 6 years

 
Calcitriol
View adult BNF View SPC online View childrens BNF
First Choice
Green

3micrograms/g (Silkis®) Ointment; 100g

For chronic plaque psoriasis in adult and child over 12 years
For Body

 

Amber Recommended Paediatrics < 12 years

 
Betamethasone diproprionate 0.05%, calcipotriol 50 micrograms/g
View adult BNF View SPC online View childrens BNF
Second Choice
Green

(Dovobet®) Gel; 60g

(Enstilar®) Cutaneous Foam; 60g
 
For chronic plaque psoriasis
For body and scalp (Dovobet) or body (Enstilar)
Off label use in children 12-18 years (specialist use only)

Amber Recommended Paediatrics

 
Link  Pan Mersey APC (2019). CALCIPOTRIOL 50 micrograms and BETAMETHASONE 500 micrograms per 1 gram cutaneous foam (Enstilar®) for psoriasis vulgaris in adults
   
Dithranol
View adult BNF View SPC online View childrens BNF
Third Choice
Green

0.1%, 0.25%, 0.5%, 1%, 2% (Dithrocream®) Cream; 50 g

For chronic plaque psoriasis
For Body and Scalp

Consider short-contact dithranol only in treatment resistant trunk and limb psoriasis with educational support for self-use or ensure treatment is given in a specialist setting:

 
   
Coal Tar solution 12%, salicylic acid 2%, precipitated sulphur 4%
View adult BNF View SPC online View childrens BNF
Formulary
Green

in a coconut oil emollient basis (Sebco®); Ointment, 100 g

For scalp

Amber Recommended Paediatrics < 6 years

 
   
Coal tar solution 5% in emollient base
View adult BNF View SPC online View childrens BNF
Formulary
Green
(Exorex®) Lotion; 100 mL, 250 mL

For scalp 
   
Coal tar 5% solution in 0.025% strength betnovate ointment
View adult BNF View childrens BNF
Unlicensed Drug Unlicensed
Amber Initiated

Ointment; 100 g Topical steroid For psoriasis, this unlicensed special may be considered

 
   
Coal tar 6% solution with salicylic acid 2% in emulsifying ointment
View adult BNF View childrens BNF
Unlicensed Drug Unlicensed
Amber Initiated

Ointment; 100 g Tar For psoriasis, this unlicensed special may be considered

 
   
Salicylic acid 2% w/w in emulsifying ointment
View adult BNF View childrens BNF
Unlicensed Drug Unlicensed
Amber Initiated

Ointment; 100 g Keratolytic For psoriasis, this unlicensed special may be considered

 
   
Salicylic acid 5% w/w in emulsifying ointment
View adult BNF View childrens BNF
Unlicensed Drug Unlicensed
Amber Initiated

Ointment; 100 g Keratolytic For psoriasis, this unlicensed special may be considered

 
   
Salicylic acid 10% w/w in emulsifying ointment
View adult BNF View childrens BNF
Unlicensed Drug Unlicensed
Amber Initiated

Ointment; 100 g Keratolytic For psoriasis, this unlicensed special may be considered

 
   
Zinc and salicylic acid paste (Lassar’s Paste) half-strength
View adult BNF View childrens BNF
Unlicensed Drug Unlicensed
Amber Initiated

Paste; 100 g Keratolytic For psoriasis, this unlicensed special may be considered

 
   
13.05.02  Expand sub section  Oral retinoids for psoriasis
Acitretin
View adult BNF View SPC online View childrens BNF
Formulary
Red
Capsules; 10 mg, 25 mg

Pregnancy prevention
In women of child-bearing potential (including those with a history of infertility), exclude pregnancy up to 3 days before treatment, every month during treatment, and every 1–3 months for 3 years after stopping treatment. Treatment should be started on day 2 or 3 of menstrual cycle. Women must practise effective contraception for at least 1 month before starting treatment, during treatment, and for at least 3 years after stopping treatment. Women should be advised to use at least 1 method of contraception, but ideally they should use 2 methods of contraception. Oral progestogen-only contraceptives are not considered effective. Barrier methods should not be used alone but can be used in conjunction with other contraceptive methods. Each prescription for acitretin should be limited to a supply of up to 30 days' treatment and dispensed within 7 days of the date stated on the prescription. Women should be advised to seek medical attention immediately if they become pregnant during treatment or within 3 years of stopping treatment. They should also be advised to avoid alcohol during treatment and for 2 months after stopping treatment

Oral retinoids for psoriasis 
   
 ....
Key
note Notes
Section Title Section Title (top level)
Section Title Section Title (sub level)
First Choice Item First Choice item
Non Formulary Item Non Formulary section
Restricted Drug
Restricted Drug
Unlicensed Drug
Unlicensed
Track Changes
Display tracking information
click to search medicines.org.uk
Link to adult BNF
click to search medicines.org.uk
Link to children's BNF
click to search medicines.org.uk
Link to SPCs
SMC
Scottish Medicines Consortium
Cytotoxic Drug
Cytotoxic Drug
CD
Controlled Drug
High Cost Medicine
High Cost Medicine
Cancer Drugs Fund
Cancer Drugs Fund
NHSE
NHS England
Homecare
Homecare
CCG
CCG

Traffic Light Status Information

Status Description

Green

Medicines considered suitable for non-specialist prescribing in primary or secondary care.  

Amber Recommended

Requires specialist assessment to enable patient selection.  Amber Recommended medicines must meet criteria: (1) Requires specialist assessment to enable patient selection (2) Following specialist assessment, the medicine is suitable for prescribing in Primary Care.  

Amber Initiated

Amber Initiated. Requires specialist initiation of prescribing. Prescribing to be continued by the specialist until stabilisation of the dose is achieved and the patient has been reviewed. Amber Initiated medicines must meet criteria: (1) Requires specialist assessment to enable patient selection (2) Medicine is suitable for on-going prescribing in Primary Care (3) Requires short to medium term specialist prescribing and monitoring of efficacy or toxicity until the patient’s dose and condition is stable   

Amber Retained

Amber Patient Retained. Requires specialist initiation of prescribing. Prescribing to be continued by specialist until stabilisation of the dose is achieved and the patient had been reviewed. Patient remains under the care of specialist (ie not discharged) as occasional specialist input may be required. Amber Patient Retained medicines must meet criteria: (1)Requires specialist assessment to enable patient selection (2)Medicine is suitable for on-going prescribing in Primary Care (3) Requires short to medium term specialist prescribing and monitoring of efficacy or toxicity until the patient’s dose and condition is stable (4) May require occasional specialist input indefinitely and therefore the patient should not be discharged from specialist care   

Amber

Medicines recommended or initiated by specialists in primary or secondary care. Non-specialist prescribing in primary care may follow according the RAG criteria. In process of being superceded by Amber Recommended, Amber Initiated and Amber Patient Retained.  

Purple

Shared Care. Medicines are considered suitable for Primary Care prescribing and/or management, following specialist initiation of therapy, with on-going communication between the Primary Care prescriber and specialist, within the framework of a Shared Care Agreement. Medicines designated as requiring Shared Care require on-going input from both Specialist and Primary Care clinicians and patients should not be discharged from Specialist care. Where prescribing and monitoring are required under shared care, it is implicit that the responsibility for both of these tasks rests with the prescriber. A Shared Care Agreement will always be available for Shared Care medicines and this document will include a Shared Care Agreement pro-forma which will be completed by all involved clinicians. This pro-forma will record agreement to take on defined aspects of care e.g. monitoring and/or on-going prescribing for the individual patients. A policy detailing clinician responsibilities in Shared Care Agreements must be referred to in all cases of Shared Care. All drugs to be included in this category must meet Shared Care criteria 1 to 3: SC1 Requires specialist assessment to enable patient selection and also initiation, stabilisation and review of treatment and the patient`s condition. SC2 Prescribing and/or management of the drug in Primary Care with specialist support and input, within the framework of the Shared Care Agreement is safe and convenient and that there is an appropriate mechanism for individual patient access in Primary Care. SC3 Requires specific long-term monitoring (blood test or other measurement) for adverse effects and / or efficacy of the drug to be completed in Primary Care, and requires on-going specialist support for the dose changes or management of adverse effects. Monitoring is required on a regular basis (typically four times a year). Implicit in any shared care agreement is the understanding that participation is at the discretion of the Primary Care prescriber subject to their clinical confidence.   

Red

Primary care prescribing of these medicines is NOT recommended. These treatments should be initiated by specialists only; ongoing prescribing is retained within secondary care.   

Black

Not recommended for use. Deviation from the policy may be considered on an individual basis where exceptional circumstances exist.   

Grey

Not recommended for use at this time. Deviation from the policy may be considered on an individual basis where exceptional circumstances exist. Further guidance will be issued when more information or evidence is made available.  

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