Role of topical corticosteroids in the treatment of AD and psoriasis Zinc Code: UK/RET/0121/16b Date of Prep: November 2016  Role of topical corticosteroids in the treatment of AD and psoriasis

Zinc Code: UK/RET/0121/16b Date of Prep: November 2016 Daily skin care is the foundation of successful AD/psoriasis management Bathing1,2 Bath additives and shower products are an option for people with extensive areas of dry skin1,2 Bath emollient products should not replace standard emollients, but should be used in addition1 Long and very hot/cold baths exacerbate skin dryness so should be avoided3 Short baths (<5 mins) are recommended3,4 Washing1,2 Avoid use of soaps, detergents, and bubble bath when washing1 Use a suitable soap substitute (e.g. ointment dissolved in hot water or lotion in warm water)1,2 Gently dry skin after washing1 An emollient can then be applied while the skin is still moist1 Emollients1,2 Can be used liberally and frequently, even when skin appears improved or clear1 Use during or after bathing1,2 For very dry skin, applying every 2–3 hours should be considered normal1 Practical tip for patients: Emollients can be used liberally and freely in AD and psoriasis All image licenses obtained from dreamstime.com 1. NICE. Eczema – atopic. Clinical Knowledge Summaries 2015; http://cks.nice.org.uk/eczema-atopic. Accessed September 2016; 2. NICE. Psoriasis. Clinical Knowledge Summaries 2014; http://cks.nice.org.uk/psoriasis. Accessed September 2016; 3. Sanchez J, et al. Revista Alergia México 2014; 61:178–211; 4. Ring J, et al. J Eur Acad Dermatol Venereol. 2012; 26:1045–60 Medical approaches notwithstanding, basic management of both AD and psoriasis starts with the patient’s skin care regimen. A key element of this is the liberal use of emollients to help protect skin barrier function:1,2 NICE considers emollients the basis of management for AD.1 Gentle cleansing, avoiding soap, helps to limit further damage to the skin.1 References NICE. Eczema – atopic. Clinical Knowledge Summaries 2015; http://cks.nice.org.uk/eczema-atopic. Accessed September 2016. NICE. Psoriasis. Clinical Knowledge Summaries 2014; http://cks.nice.org.uk/psoriasis. Accessed September 2016.

Zinc Code: UK/RET/0121/16b Date of Prep: November 2016 Topical corticosteroids (TCS) are recommended for treatment of AD and psoriasis1,2 TCS are administered within a formulation to help delivery through the skin3 The formulation affects delivery of the steroid across the skin and therefore its effectiveness3,4 Ointments Spread easily; provide more lubrication than other formulations; suitable for dry or thick skin3,4 Creams Less potent than ointments; greater cosmetic appeal; suitable for weeping lesions and genital areas; can cause irritation3,4 Lotions Penetrate easily3,4 Gels Dry quickly4 Foams/shampoos For scalp; spread readily4 Useful for hairy areas Practical tip for patients: Multiple TCS may be prescribed in different formulations to use on different areas of the body* *Guidance regarding how TCS should be used will be provided by the prescribing physician, and patients should be reminded of these specific recommendations 1. NICE. Eczema – atopic. Clinical Knowledge Summaries 2015; http://cks.nice.org.uk/eczema-atopic. Accessed September 2016; 2. NICE. Psoriasis. Clinical Knowledge Summaries 2014; http://cks.nice.org.uk/psoriasis. Accessed September 2016; 3. Huang X, et al. J Am Acad Dermatol 2005; 53:S26–S38; 4. Ference JD, Last AR. Am Fam Physician 2009; 79:135–140. Topical corticosteroids are a recommended treatment option for both AD and psoriasis and are available in multiple formulations, which may be best suited to particular regions of the body, types of skin or needs for treatment.1-3 Each formulation of TCS is also available in a range of potencies: higher potency therapies are generally prescribed for more severe disease…1,2 References: NICE. Eczema – atopic. Clinical Knowledge Summaries 2015; http://cks.nice.org.uk/eczema-atopic. Accessed September 2016. NICE. Psoriasis. Clinical Knowledge Summaries 2014; http://cks.nice.org.uk/psoriasis. Accessed September 2016. Ference JD & Last AR. Am Fam Physician. 2009; 79:135–140.

Zinc Code: UK/RET/0121/16b Date of Prep: November 2016 Most key branded TCS are classed as potent (based on the UK classification)* Dermovate (Clobetasol propionate 0.05%) Nerisone Forte (Diflucortolone valerate)2 High Betnovate (Betamethasone valerate 0.1%) Locoid (Hydrocortisone butyrate 0.1%) IV Cutivate (Fluticasone propionate 0.05%) Metosyn (Fluocinonide 0.05%) Very potent/ super potent Diprosone (Betamethasone dipropionate 0.05%) Nerisone (Diflucortolone valerate 0.1%) Potency III Potent Elocon (Mometasone furoate 0.1%) Synalar (Fluocinolone acetonide 0.025%) II Moderate Eumovate (Clobetasone butyrate 0.05%) Modrasone (Alclometasone dipropionate 0.05%) I Mild Haelan (Fludroxycortide 0.0125%) Synalar 1 in 4 dilution (Fluocinolone acetonide 0.001%) Low (Hydrocortisone 0.1–2.5%) Ultralanum Plain (Fluocortolone 0.25%) Practical tip for patients: The potency of TCS prescribed will depend on the severity of disease and type of skin to be treated† …and there are multiple TCS options for each potency, though the majority are classed as potent. High-potency TCS are generally suitable only for short treatment durations, and can be used on the trunk, limbs, scalp, palms and soles1,2 The face, groin and underarms should be excluded other than in exceptional circumstances Moderate-potency TCS are suitable for severe disease and areas of thick skin, such as the palms1 Low-potency TCS can be used in the long term across broad regions of the body, on the face and on areas of the body with thin skin, such as the genital region1,2 They are also suitable for use on children1,2 References Ference JD, Last AR. Am Fam Physician. 2009;79:135−40. Uva L, et al. Int J Endocrinol 2012;2012:561018. *Includes representative preparations and brand names, and not all available agents; potency group may vary depending on the concentration and formulation †Guidance regarding how TCS should be used will be provided by the prescribing physician, and patients should be reminded of these specific recommendations NICE. Eczema – atopic. Clinical Knowledge Summaries 2015; http://cks.nice.org.uk/eczema-atopic. Accessed September 2016.

Guidelines recommend a stepwise approach to treating AD1,2 Zinc Code: UK/RET/0121/16b Date of Prep: November 2016 Guidelines recommend a stepwise approach to treating AD1,2 SEVERITY OF DISEASE Note: Where AD is not controlled satisfactorily or the diagnosis has become uncertain, the patient should be referred to their healthcare provider Potent TCS, systemic therapy, TCI, phototherapy, oral treatments, emollients Self-help advice Suggest: ✔ Avoid scratching ✔ Keep nails short ✔ Avoid known triggers (e.g. soaps, detergents) ✔ Use emollients ✔ Avoid complementary therapies Severe: Persistent AD Moderate: Recurrent AD Moderate TCS, sedating antihistamines, topical calcineurin inhibitors, phototherapy, emollients Cleansing, bathing and emollient Use is important with all steps Mild: Transient AD Mild TCS, antiseptics, non-sedating antihistamines, emollients Prevention of flares/maintenance Daily emollient use allergen avoidance/elimination diet if relevant Practical tip for patients: Shorten fingernails to reduce damage from scratching 1. NICE. Eczema – atopic. Clinical Knowledge Summaries 2015; http://cks.nice.org.uk/eczema-atopic. Accessed September 2016; 2. Luger TA. JEADV 2011; 25:251–258 A stepped approach to treatment of AD is recommended, with potent TCS only used for severe and persistent disease (along with additional therapies).1 Mild and transient AD can be managed over the counter using mild TCS (the basis of therapy),1 but in any situation where the disease does not seem properly controlled or there is uncertainty around the severity of the condition, it is important to refer the patient to their primary care physician. Reference NICE. Eczema – atopic. Clinical Knowledge Summaries 2015; http://cks.nice.org.uk/eczema-atopic. Accessed September 2016.

Guidelines recommend TCS as the foundation of psoriasis treatment Zinc Code: UK/RET/0121/16b Date of Prep: November 2016 Guidelines recommend TCS as the foundation of psoriasis treatment Systemic biological therapy Self-help advice Suggest: ✔ Using emollients as often as required to reduce scale and itch ✔ Using emollients as a soap substitute when bathing or washing ✔ Applying emollient before anti-psoriasis treatment ✔ Waiting 30 minutes after emollient use before using other treatment Third-line* Adalimumab, etanercept, ustekinumab and infliximab EMOLLIENT USE Second-line* Phototherapy Broad- or narrow-band ultraviolet B light & PUVA Systemic non-biological therapy Ciclosporin, methotrexate and acitretin First-line Corticosteroids, vitamin D analogues, dithranol and tar preparations Topical therapy Practical tip for patients: Use emollients as often as required to reduce scale and itch *Offer at the same time when topical therapy alone is unlikely to adequately control psoriasis NICE Clinical Guideline 153. 2012. Available at http://www.nice.org.uk/guidance/cg153. Accessed August 2016. NICE guidelines recommend several lines of therapy for psoriasis, with TCS a first-line therapy option along with vitamin D analogues and other topical preparations.1 If these therapeutic approaches are not successful, treatment may be escalated to phototherapy and/or systemic treatment options.1 Maintaining appropriate skincare regimens is always essential, regardless of the medication approach undertaken. Reference NICE Clinical Guideline 153. 2012. Available at http://www.nice.org.uk/guidance/cg153. Accessed August 2016.

Zinc Code: UK/RET/0121/16b Date of Prep: November 2016 A range of TCS potencies and formulations is available to treat AD and psoriasis TCS are recommended for first-line treatment of psoriasis, with systemic and phototherapies available in later lines3 1 Topical corticosteroids are available in a range of potencies and formulations for treatment of AD and psoriasis1,2 Daily skin care is the foundation of therapy, and liberal emollient use is advised – even when skin appears clear1 A stepwise approach to treatment of AD is recommended, with higher potency TCS only being used for more severe forms of the disease1 In addition to advice on using emollients, pharmacists can provide key practical support and guidance on TCS use, including how and where to apply the formulations. It is common for patients to be prescribed a selection of TCS with different potencies; therefore, it is important that they understand which therapy should be used where, and for how long. In case of any doubt, the patient should return to their HCP for further assessment and guidance. 1. NICE. Eczema – atopic. Clinical Knowledge Summaries 2015; http://cks.nice.org.uk/eczema-atopic. Accessed September 2016; 2. NICE. Psoriasis. Clinical Knowledge Summaries 2014; http://cks.nice.org.uk/psoriasis. Accessed September 2016; 3. NICE Clinical Guideline 153 Psoriasis Assessment and Management. 2012. Available at http://www.nice.org.uk/guidance/cg153. Accessed August 2016.