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13.5 Preparations for eczema and psoriasis

13.5.1 Preparations for atopic eczema

NICE TA177 Eczema (chronic) - alitretinoin Aug 09 
NICE CG57 Atopic eczema in children: Management of atopic eczema in children from birth up to the age of 12 years Dec 07

Treatment of atopic eczema

1a  Leave on emollient (light cream) 500g 
  Apply frequently to all dry or inflamed areas during the day
   (Epaderm ointment or white soft paraffin 50% Liquid paraffin 50%)

AND/OR

1b Leave on emollient (heavy ointment) 500g 
  Apply all over after bathing and leave on overnight
  (Epaderm cream or Aveeno cream or Doublebase)
   
2 Wash product 500ml
  To be used instead of soap, rub onto skin and wash off
  (Dermol lotion or aqueous cream)
   
3 Bath emollient 250ml
  Add to bathwater, soak daily for 10-15 minutes
  (Dermol bath emollient or Aveeno bath oil)

*Oral immunosuppressants should only be prescribed on specialist advice.  See notes below*

Emollients with antiseptics should be used to reduce straphylococcal carriage in eczematous patients.

Weeping in eczema is due to an acute exacerbation which should be treated with an astringent such as potassium permanganate.

Exacerbation of eczema may represent secondary bacterial or viral infection.  Appropriate swabs should taken.  Systemic antibiotics (not topical) will be required in infected eczema, treat for 1 week only.  If the patient has not improved, refer to the Dermatologist.

Topical corticosteroids can be used twice weekly, or for 2 consecutive days per week to prevent flare ups.

Most eczema on the body will require a moderately potent topical steroid for control. 

Only 1% hydrocortisone should be used on the face.

Ciclosporin, azathioprine or systemic corticosteroids should be initiated on specialist advice only, with responsibility for monitoring agreed.

Sedating antihistamines should be used routinely at night if pruritus prevents sleeping (see section 3.4.1).

Non sedating antihistamines are generally ineffective in eczema.

13.5.2 Preparations for psoriasis

Vitamin D and analogues

1st        CALCIPOTRIOL 
      CALCITRIOL (Silkis) not for use on the face

Both preparations need to be used twice daily to be effective.  There is no need to change patients who are stable on topical calcipotriol (Dovonex) to calcitriol.

Other topical preparations for psoriasis used in combination

        COAL TAR lotion 5% (Exorex) 
      DITHRANOL (0.1%, 0.25%, 0.5%, 1.0%)
      DOVOBET ointment & gel

Dovobet is suitable for the initial topical treatment of stable plaque psoriasis.  Dovobet contains a potent steroid, the use of which carries risks of destabilising psoriasis and side effects from prolonged use.  Use twice daily for up to one month.  Not to be used on the face, but can be used on the scalp.

EMOLLIENTS (see section 13.2.1)

MILD/MODERATE TOPICAL CORTICOSTEROIDS (for face or flexures) see section 13.4

SALICYLIC ACID containing preps (for scaling) - Care when prescribing, many preparations are very expensive (specials) e.g 2% ointment = £222 for 100g.  Diprosalic (betamethasone 0.05% salicylic acid 3%) scalp application 100ml £10.10, ointment 30g £31.80 - Drug Tariff May 2015)

Treatment choice depends on site, extent of psoriasis and patient preference and tolerance.

Guttate psoriasis requires emollients and perhaps a mild tar preparation such as Exorex lotion; phototherapy may help.

Coal tar preparations are effective and may be used on the scalp (Sebco or Capasal (section 13.09) can be left on the scalp according to manufacturer's instructions), but may stain skin, hair, clothes.

Potent and very potent topical corticosteroids should be used on specialist advice only; they may precipitate unstable and pustular psoriasis after stopping.

Phototherapy, methotrexate, ciclosporin, acitretin, or biologics, should be initiated on specialist advice only, with responsibility for monitoring agreed.

13.5.3 Drugs affecting the immune response

NICE TA392 Adalimumab June 16
NICE TA350 Psoriasis - Secukinumab July 15
NICE TA180 Psoriasis - ustekinumab Sept 09
NICE TA134 Psoriasis - infliximab Jan 08
NICE TA146 Psoriasis - adalimumab Jun 08
NICE TA103 Psoriasis - etanercept and efalizumab July 06 

Pimecrolimus and/or tacrolimus ointment 0.03% or 0.1% should be initiated by a dermatologist or a doctor experienced in the management of skin disease.  It is usually appropriate for patients suffering moderate/severe eczema uncontrolled by topical steroids or those developing significant steroidal adverse effects.  Both products to be used within licence and in accordance with NICE TA82 Atopic dermatitis (eczema) - pimecrolimus and tacrolimus Aug 04

        TACROLIMUS (Protopic) for adults and children over 2 years 
      PIMECROLIMUS (Elidel)

 

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