Systemic biological agents for psoriasis

Systemic biological agents for psoriasis management, listed elsewhere in the formulary:

• Secukinumab, see section 8.2.1 Immunosuppressive agents
• Adalimumab, Etanercept, Infliximab, and Ustekinumab, see section 10.1.3 Drugs that suppress the rheumatic disease process
• Brodalumab, Guselkumab, Ixekizumab, Risankizumab and Tildrakizumab see section 13.5.3 Drugs affecting the immune response

Topical preparations for psoriasis

Topical preparations used for psoriasis management, listed elsewhere in the formulary:

• Emollients, see section 13.2.1 Emollients
• Topical corticosteroids, see section 13.4 Topical corticosteroids
• Shampoos, see section 13.9 Shampoos and other preparations for scalp and hair conditions

Vitamin D and analogues

Calcipotriol

(50micrograms/g and 50micrograms/ml)

• Ointment (£7.74 = 30g)
• Scalp solution (£94.31 = 60ml, £188.62 = 120ml)

Indications and dose

• Psoriasis
  • Ointment: Apply once or twice daily for 4 weeks
  • Adults: maximum 100g per week
  • Children aged 12 to 17 years: maximum 75g per week (unlicensed)
  • Children aged 6 to 11 years: maximum 50g per week (unlicensed)
• Scalp psoriasis
  • Scalp solution: Apply once or twice daily for 8 weeks
  • Adults: maximum 60ml per week
  • Children aged 12 to 17 years: maximum 45ml per week (unlicensed)
  • Children aged 6 to 11 years: maximum 30ml per week (unlicensed)

Notes

1. Treatment may be continued beyond 4 weeks or repeated, on the advice of a specialist
2. When preparations are used together, maximum total calcipotriol:
   1. Adults: 5mg in any one week (e.g. scalp solution 60ml with ointment 30g or scalp solution 30ml with ointment 60g)
   2. Children aged 12 to 17 years: 3.75mg in any one week (e.g. scalp solution 30ml with ointment 45g)
   3. Children aged 6 to 11 years: 2.5mg in any one week (e.g. scalp solution 20ml with ointment 30g)
3. The unlicensed use of calcipotriol in children is supported by BNFC, NICE CG153, and local specialists

Calcipotriol monohydrate / Betamethasone dipropionate

(50 micrograms/g / 500 micrograms/g)

• Ointment (£8.65 = 30g)
• Gel / Gel applicator (£25.87 = 60g)
• Foam (£39.68 = 60g, £79.36 = 120g)

Indications and dose

• Psoriasis
  • Ointment, Gel, or Foam: Apply once daily for 4 weeks; maximum 15g per day
• Scalp psoriasis
  • Gel or Foam: Apply once daily for 4 weeks

Notes

1. Treatment may be continued beyond 4 weeks or repeated, on the advice of a specialist
2. Apply to a maximum 30% of body surface
3. Maximum total calcipotriol 5mg in any one week
4. One 60g can of foam should last for at least 4 days; a two-second depression of the can actuator delivers approximately 0.5g. As a guide, 0.5g of foam should cover an area of skin roughly corresponding to the surface area of an adult hand
5. Calcipotriol monohydrate / betamethasone dipropionate foam is contraindicated in generalised pustular psoriasis

Calcitriol

(3 micrograms/g)

• Ointment (£18.06 = 100g)

Indications

• Psoriasis

Dose

• Apply once or twice daily for 4 weeks, maximum 30g daily

Notes

1. Calcitriol should be used for those patients not responding to calcipotriol
2. Not more than 35% of body surface to be treated daily

Tars

Psoriderm scalp lotion

(Coal tar distilled 25mg/ml)

• Scalp lotion (£4.74 = 250ml)

Indications

• Scalp psoriasis

Dose

• Apply to scalp as required to remove adherent scale

Notes

1. Useful in softening thick adherent scale on the surface of the psoriasis plaques

Exorex lotion

(Coal tar solution 50mg/g)

• Cutaneous emulsion (£8.11 = 100ml, £16.24 = 250ml)

Indications

• Psoriasis

Dose

• Apply to skin or scalp 2–3 times daily

Notes

1. Useful in softening thick adherent scale on the surface of the psoriasis plaques
2. Lotion can be diluted with a few drops of water before applying

Tar with lecithin

Psoriderm cream

(Coal tar distilled 60mg/g / Lecithin 4mg/g)

• Cream (£9.42 = 225ml)

Indications

• Psoriasis

Dose

• Apply to skin or scalp once or twice daily

Notes

1. Useful in softening thick adherent scale on the surface of the psoriasis plaques

Tar with salicylic acid

Sebco

(Coal tar solution 120mg/g / Salicylic acid 20mg/g / Sulfur precipitated 40mg/g)

• Ointment (£14.88 = 100g)

Indications

• Scalp psoriasis
• Eczema
• Seborrhoeic dermatitis
• Dandruff

Dose

• Adults and children ≥ 12 years: Apply as required (if severe use daily for first 3-7 days), shampoo off after 1 hour
• Children aged 6 to 11 years: Apply once weekly as required

Notes

1. Useful in softening thick adherent scale on the surface of the psoriasis plaques

Cocois

(Coal tar solution 120mg/g / Salicylic acid 20mg/g / Sulfur precipitated 40mg/g)

• Ointment (£14.50 = 100g)

Indications

• Scalp psoriasis
• Eczema
• Seborrhoeic dermatitis
• Dandruff

Dose

• Adults and children ≥ 12 years: Apply as required (if severe use daily for first 3-7 days), shampoo off after 1 hour
• Children aged 6 to 11 years: Apply once weekly as required

Notes

1. Useful in softening thick adherent scale on the surface of the psoriasis plaques

Oral preparations for psoriasis

Oral systemic non-biological agents for psoriasis management, listed elsewhere in the formulary:

• Methotrexate, see section 8.4.3 Antifolates
• Ciclosporin, see section 8.2.1 Immunosuppressive agents
• Dimethyl fumarate, see section 8.2.1 Immunosuppressive agents
• Apremilast, see section 10.1.3 Drugs that suppress the rheumatic disease process

Oral retinoids for psoriasis

Acitretin

• Capsules 10mg, 25mg

Notes

1. Specific information regarding oral acitretin and the use of remote consultations for monitoring safety requirements (from the Medicines and Healthcare products Regulatory Agency (MHRA)) during the Coronavirus (COVID-19) pandemic can be found here.
2. Due to a high risk of serious congenital malformations, acitretin must not be used in pregnancy, and any use in women and girls must be within the conditions of a Pregnancy Prevention Programme (PPP)
3. Acitretin has a substantially longer half-life and duration of effect than either isotretinoin or alitretinoin, and therefore the PPP measures must be undertaken for longer
4. Patients treated with an oral retinoid should be monitored or signs of depression or suicidal ideation and referred for appropriate treatment, if necessary; particular care needs to be taken in patients with history of depression
5. Advise patients taking an oral retinoid that they may experience changes in their mood or behaviour and that they should speak to their doctor if their mood is affected; they should be encouraged to let family and friends know they are taking an oral retinoid so they can look out for any change in mood
6. MHRA Drug Safety Update (June 2019): Oral retinoid medicines: revised and simplified pregnancy prevention educational materials for healthcare professionals and women, and advice about the risk of neuropsychiatric reactions
   1. See also resources for: contraception for drugs with teratogenic potential, and prescribing in pregnancy and lactation