Consider stopping tildrakizumab between 12 weeks and
28 weeks if there has not been at least a 50% reduction in
the PASI score from when treatment started.
Stop tildrakizumab at 28 weeks if the psoriasis has not
responded adequately. An adequate response is defined as:
. a 75% reduction in the PASI score (PASI 75) from when
. a 50% reduction in the PASI score (PASI 50) and a 5-
point reduction in DLQI from when treatment started.
Patients whose treatment was started within the NHS
before this guidance was published should have the option
to continue treatment, without change to their funding
arrangements, until they and their NHS clinician consider
www.nice.org.uk/guidance/ta575
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
EXCIPIENTS: May contain Polysorbates
Tildrakizumab 100 mg per 1 ml Ilumetri 100mg/1ml solution for
l DRUG ACTION Acitretin is a metabolite of etretinate.
Severe extensive psoriasis resistant to other forms of
therapy (under expert supervision)| Palmoplantar
pustular psoriasis (under expert supervision)| Severe
congenital ichthyosis (under expert supervision)
▶ Adult: Initially 25–30 mg daily for 2–4 weeks, then
adjusted according to response to 25–50 mg daily,
increased to up to 75 mg daily, dose only increased to
75 mg daily for short periods in psoriasis
Severe Darier’s disease (keratosis follicularis) (under
▶ Adult: Initially 10 mg daily for 2–4 weeks, then
adjusted according to response to 25–50 mg daily
l CONTRA-INDICATIONS Hyperlipidaemia
l CAUTIONS Avoid excessive exposure to sunlight and
unsupervised use of sunlamps . diabetes (can alter glucose
tolerance—initial frequent blood glucose checks). do not
donate blood during and for 2 years after stopping therapy
(teratogenic risk). in children use only in exceptional
circumstances and monitor growth parameters and bone
development (premature epiphyseal closure reported). investigate atypical musculoskeletal symptoms
l INTERACTIONS → Appendix 1: retinoids
abnormal . headache . increased risk of infection . mucosal
abnormalities . myalgia . nausea . oral disorders . peripheral
oedema . skin reactions .thirst. vomiting . xerophthalmia
▶ Uncommon Dizziness . hepatic disorders . photosensitivity
▶ Rare or very rare Bone pain . exostosis . idiopathic
intracranial hypertension . peripheral neuropathy
▶ Frequency not known Angioedema . capillary leak
syndrome . drowsiness . dysphonia . flushing . glucose
syndrome .taste altered .tinnitus
SIDE-EFFECTS, FURTHER INFORMATION Exostosis Skeletal
hyperostosis and extra-osseous calcification reported
following long-term treatment with etretinate (of which
acitretin is a metabolite) and premature epiphyseal closure
Benign intracranial hypertension Discontinue if
severe headache, nausea, vomiting, or visual disturbances
l CONCEPTION AND CONTRACEPTION Effective
Pregnancy prevention In females 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. Females of child-bearing age must
practise effective contraception for at least 1 month before
starting treatment, during treatment, and for at least
3 years after stopping treatment. Females 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. Females 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.
l PREGNANCY Avoid—teratogenic.
l HEPATIC IMPAIRMENT Manufacturer advises avoid in
l RENAL IMPAIRMENT Avoid in severe impairment;
▶ Monitor serum-triglyceride and serum-cholesterol
concentrations before treatment, 1 month after starting,
▶ Check liver function at start, then every 2–4 weeks for first
2 months and then every 3 months.
l PRESCRIBING AND DISPENSING INFORMATION
Prescribing for women of child-bearing potential 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.
l PATIENT AND CARER ADVICE Females of child-bearing
potential must be advised on pregnancy prevention.
A patient information leaflet should be provided.
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug. Forms available
from special-order manufacturers include: oral suspension, oral
CAUTIONARY AND ADVISORY LABELS 10, 11, 21
Acitretin 10 mg Acitretin 10mg capsules | 60 capsule P £23.80
Acitretin 25 mg Acitretin 25mg capsules | 60 capsule P £55.24
Acitretin 10 mg Neotigason 10mg capsules | 60 capsule P £17.30 DT = £23.80
Acitretin 25 mg Neotigason 25mg capsules | 60 capsule P £43.00 DT = £55.24
BNF 78 Eczema and psoriasis 1261
Severe chronic hand eczema refractory to potent topical
▶ Adult (prescribed by or under supervision of a consultant
dermatologist): 30 mg once daily; reduced if not
tolerated to 10 mg once daily for 12–24 weeks total
duration of treatment, discontinue if no response after
12 weeks, course may be repeated in those who relapse
Severe chronic hand eczema refractory to potent topical
corticosteroids in patients with diabetes, history of
hyperlipidaemia, or risk factors for cardiovascular
▶ Adult (prescribed by or under supervision of a consultant
dermatologist): Initially 10 mg once daily, increased if
necessary up to 30 mg once daily for 12–24 weeks total
duration of treatment, discontinue if no response after
12 weeks, course may be repeated in those who relapse
DOSE ADJUSTMENTS DUE TO INTERACTIONS
▶ Manufacturer advises reduce dose to 10 mg once daily
with concurrent use of potent inhibitors of CYP3A4,
CYP2C8 and moderate inhibitors of CYP2C9.
l CONTRA-INDICATIONS Hypervitaminosis A. uncontrolled
hyperlipidaemia . uncontrolled hypothyroidism
l CAUTIONS Avoid blood donation during treatment and for
at least 1 month after stopping treatment. dry eye
syndrome . history of depression
l INTERACTIONS → Appendix 1: retinoids
▶ Uncommon Bone disorders . cataract. dyspepsia . epistaxis . vision disorders
▶ Frequency not known Inflammatory bowel disease . mood
altered . peripheral oedema . suicidal ideation
SIDE-EFFECTS, FURTHER INFORMATION Dry eyes Dry eyes
may respond to lubricating eye ointment or tear
Benign intracranial hypertension Discontinue
treatment if headache, nausea, vomiting, papilloedema, or
l CONCEPTION AND CONTRACEPTION Effective
Pregnancy prevention In women of child-bearing potential,
exclude pregnancy 1 month before treatment, up to 3 days
before treatment, every month during treatment (unless
there are compelling reasons to indicate that there is no
risk of pregnancy), and 5 weeks after stopping treatment—
perform pregnancy test in the first 3 days of the menstrual
Women must practise effective contraception for at least
1 month before starting treatment, during treatment, and
for at least 1 month 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
Women should be advised to discontinue treatment and
to seek prompt medical attention if they become pregnant
during treatment or within 1 month of stopping treatment.
l PREGNANCY Avoid—teratogenic.
l BREAST FEEDING Manufacturer advises avoid.
l HEPATIC IMPAIRMENT Manufacturer advises avoid—
limited information available.
l RENAL IMPAIRMENT Manufacturer advises avoid in severe
impairment—no information available.
l MONITORING REQUIREMENTS Monitor serum lipids (more
frequently in those with diabetes, history of
hyperlipidaemia, or risk factors for cardiovascular
disease)—discontinue if uncontrolled hyperlipidaemia.
l PRESCRIBING AND DISPENSING INFORMATION
Prescribing for women of child-bearing potential Each
prescription for alitretinoin should be limited to a supply
of up to 30 days’ treatment and dispensed within 7 days of
the date stated on the prescription.
Alitretinoin is teratogenic and must not be given to
women of child-bearing potential unless they practise
effective contraception and then only after detailed
assessment and explanation by the physician.
l PATIENT AND CARER ADVICE A patient information leaflet
Conception and contraception Women of child-bearing
potential must be counselled on pregnancy prevention.
l NATIONAL FUNDING/ACCESS DECISIONS
▶ Alitretinoin for the treatment of severe chronic hand eczema
Alitretinoin (Toctino ®) is recommended for the treatment
of severe chronic hand eczema in adults that has not
responded to potent topical corticosteroids.
Treatment should be stopped as soon as an adequate
response has been achieved (hands clear or almost clear),
or if the eczema remains severe after 12 weeks, or if an
adequate response has not been achieved by 24 weeks.
www.nice.org.uk/guidance/ta177
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
CAUTIONARY AND ADVISORY LABELS 10, 11, 21
▶ Toctino (Stiefel Laboratories (UK) Ltd)
Alitretinoin 10 mg Toctino 10mg capsules | 30 capsule P £493.72 DT = £493.72
Alitretinoin 30 mg Toctino 30mg capsules | 30 capsule P £493.72 DT = £493.72
Mild to moderate plaque psoriasis affecting up to 10% of
▶ Adult: Apply once daily usually for up to 12 weeks,
l CAUTIONS Avoid contact with eczematous skin . avoid
contact with eyes . avoid contact with face . avoid contact
with hair-covered scalp . avoid contact with inflamed skin . avoid contact with intertriginous areas
l INTERACTIONS → Appendix 1: retinoids
▶ Common or very common Paraesthesia . skin reactions
SIDE-EFFECTS, FURTHER INFORMATION Local irritation is
more common with higher concentration and may require
1262 Inflammatory skin conditions BNF 78
l CONCEPTION AND CONTRACEPTION Effective
contraception required (oral progestogen-only
contraceptives not considered effective).
l BREAST FEEDING Manufacturer advises avoid—present in
l PATIENT AND CARER ADVICE Avoid excessive exposure to
UV light (including sunlight, solariums, PUVA or UVB
treatment). Do not apply emollients or cosmetics within
1 hour of application. Wash hands immediately after use.
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
EXCIPIENTS: May contain Benzyl alcohol, butylated hydroxyanisole,
butylated hydroxytoluene, disodium edetate, polysorbates
Tazarotene 500 microgram per 1 gram Zorac 0.05% gel |
Tazarotene 1 mg per 1 gram Zorac 0.1% gel | 30 gram P £14.80 DT = £14.80
SALICYLIC ACID AND DERIVATIVES
Salicylic acid with zinc oxide
l CAUTIONS Avoid broken skin . avoid inflamed skin
▶ Salicylate toxicity Salicylate toxicity may occur particularly
if applied on large areas of skin or neonatal skin.
l PRESCRIBING AND DISPENSING INFORMATION Zinc and
Salicylic Acid Paste BP is also referred to as Lassar’s Paste.
When prepared extemporaneously, the BP states Zinc and
Salicylic Acid Paste, BP (Lassar’s Paste) consists of zinc
oxide 24%, salicylic acid 2%, starch 24%, white soft
l MEDICINAL FORMS Forms available from special-order
VITAMINS AND TRACE ELEMENTS › VITAMIN D
▶ Adult: Apply 1–2 times a day, when preparations are
used together maximum total calcipotriol 5 mg in any
one week (e.g. scalp solution 60 mL with ointment 30 g
or scalp solution 30 mL with ointment 60 g); maximum
▶ TO THE SKIN USING SCALP LOTION
▶ Adult: Apply twice daily, when preparations are used
together maximum total calcipotriol 5 mg in any one
week (e.g. scalp solution 60 mL with ointment 30 g or
scalp solution 30 mL with ointment 60 g); maximum
l CONTRA-INDICATIONS Calcium metabolism disorders
l CAUTIONS Avoid excessive exposure to sunlight and
sunlamps . avoid use on face . erythrodermic exfoliative
psoriasis (enhanced risk of hypercalcaemia). generalised
pustular psoriasis (enhanced risk of hypercalcaemia)
l INTERACTIONS → Appendix 1: vitamin D substances
▶ Common or very common Skin reactions
▶ Uncommon Increased risk of infection
▶ Rare or very rare Hypercalcaemia . hypercalciuria . photosensitivity reaction
l PREGNANCY Manufacturers advise avoid unless essential.
l BREAST FEEDING No information available.
l HEPATIC IMPAIRMENT Manufacturers advise avoid in
severe impairment (no information available).
Advice on application Patient information leaflet for
Dovonex ® ointment advises liberal application. However,
patients should be advised of maximum recommended
Hands should be washed thoroughly after application to
avoid inadvertent transfer to other body areas.
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug. Forms available
from special-order manufacturers include: ointment
EXCIPIENTS: May contain Disodium edetate, propylene glycol
▶ Calcipotriol (Non-proprietary)
Calcipotriol 50 microgram per 1 gram Calcipotriol 50micrograms/g
ointment | 30 gram P £6.72 DT = £6.72 | 60 gram P £13.44–
£13.86 | 120 gram P £26.68–£27.72
Calcipotriol 50 microgram per 1 gram Dovonex 50micrograms/g
ointment | 30 gram P £5.78 DT = £6.72 | 60 gram P £11.56
▶ Calcipotriol (Non-proprietary)
Calcipotriol (as Calcipotriol hydrate) 50 microgram per
Combinations available: Calcipotriol with betamethasone,
(1,25-Dihydroxycholecalciferol)
Mild to moderate plaque psoriasis
▶ Adult: Apply twice daily, not more than 35% of body
surface to be treated daily; maximum 30 g per day
l CONTRA-INDICATIONS Do not apply under occlusion . patients with calcium metabolism disorders
l CAUTIONS Erythrodermic exfoliative psoriasis (enhanced
risk of hypercalcaemia). generalised pustular psoriasis
(enhanced risk of hypercalcaemia)
l INTERACTIONS → Appendix 1: vitamin D substances
l PREGNANCY Manufacturer advises use in restricted
amounts only if clearly necessary.
Monitoring Monitor urine- and serum-calcium
l BREAST FEEDING Manufacturer advises avoid.
l HEPATIC IMPAIRMENT Manufacturer advises avoid in liver
dysfunction—no information available.
l RENAL IMPAIRMENT Manufacturer advises avoid—no
l HANDLING AND STORAGE Hands should be washed
thoroughly after application to avoid inadvertent transfer
BNF 78 Eczema and psoriasis 1263
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
Calcitriol 3 microgram per 1 gram Silkis ointment | 100 gram P £18.06 DT = £18.06
▶ Adult: Apply once daily, preferably at bedtime,
maximum 10 g ointment or 10 mL lotion daily, when
lotion and ointment used together, maximum total
tacalcitol 280 micrograms in any one week (e.g. lotion
l CONTRA-INDICATIONS Calcium metabolism disorders
l CAUTIONS Avoid eyes . erythrodermic exfoliative psoriasis
(enhanced risk of hypercalcaemia). generalised pustular
psoriasis (enhanced risk of hypercalcaemia). if used in
▶ UV treatment If tacalcitol is used in conjunction with UV
treatment, UV radiation should be given in the morning
and tacalcitol applied at bedtime.
l INTERACTIONS → Appendix 1: vitamin D substances
▶ Frequency not known Hypercalcaemia
l PREGNANCY Manufacturer advises avoid unless no safer
alternative—no information available.
l BREAST FEEDING Manufacturer advises avoid application
to breast area; no information available on presence in
l MONITORING REQUIREMENTS Monitor serum calcium if
l PATIENT AND CARER ADVICE Hands should be washed
thoroughly after application to avoid inadvertent transfer
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
Tacalcitol (as Tacalcitol monohydrate) 4 microgram per
EXCIPIENTS: May contain Disodium edetate, propylene glycol
Tacalcitol (as Tacalcitol monohydrate) 4 microgram per
1 gram Curatoderm 4micrograms/g lotion | 30 ml P £12.73
Aluminium chloride hexahydrate below is a potent
antiperspirant used in the treatment of hyperhidrosis.
Aluminium salts are also incorporated in preparations used
for minor fungal skin infections associated with
Limited evidence suggests that oxybutynin hydrochloride
p. 778 [unlicensed indication] can be used to treat
hyperhidrosis in patients whose symptoms are not
adequately managed through lifestyle modifications and
In more severe cases specialists use glycopyrronium
bromide below as a 0.05% solution in the iontophoretic
treatment of hyperhidrosis of plantar and palmar areas.
Botox ® contains botulinum toxin type A complex p. 407 and
is licensed for use intradermally for severe hyperhidrosis of
the axillae unresponsive to topical antiperspirant or other
Glycopyrronium bromide 13-Sep-2017
Iontophoretic treatment of hyperhidrosis
▶ Adult: Only 1 site to be treated at a time, maximum 2
sites treated in any 24 hours, treatment not to be
repeated within 7 days (consult product literature)
l CONTRA-INDICATIONS Infections affecting the treatment
CONTRA-INDICATIONS, FURTHER INFORMATION Contraindications applicable to systemic use should be
considered; however, glycopyrronium is poorly absorbed
and systemic effects unlikely with topical use.
l CAUTIONS Cautions applicable to systemic use should be
considered; however, glycopyrronium is poorly absorbed
and systemic effects unlikely with topical use.
l INTERACTIONS → Appendix 1: glycopyrronium
l SIDE-EFFECTS Abdominal discomfort. eating disorder. pain . paraesthesia
SIDE-EFFECTS, FURTHER INFORMATION The possibility of
systemic side-effects should be considered; however,
glycopyrronium is poorly absorbed and systemic effects
are unlikely with topical use.
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
Powder for solution for iontophoresis
▶ Glycopyrronium bromide (Non-proprietary)
Glycopyrronium bromide 1 mg per 1 mg Glycopyrronium bromide
powder for solution for iontophoresis | 3 gram P £327.00 DT =
DERMATOLOGICAL DRUGS › ASTRINGENTS
Aluminium chloride hexahydrate
Hyperhidrosis affecting axillae, hands or feet
▶ Adult: Apply once daily, apply liquid formulation at
night to dry skin, wash off the following morning,
reduce frequency as condition improves—do not bathe
Hyperhidrosis | Bromidrosis | Intertrigo | Prevention of
tinea pedis and related conditions
▶ Adult: Apply powder to dry skin
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