The pharmacist’s role: The rational use of topical steroids Zinc Code: UK/RET/0102/16b Date of Prep: November 2016 The pharmacist’s role: The rational use of topical steroids

Zinc Code: UK/RET/0120/16b Date of Prep: November 2016 Christine Eksteen Global Scientific Director for Dermatology at Stiefel, a GSK company Pharmacist by training, working in the pharmaceutical industry for the last 15 years and in Global Medical Affairs for dermatology over the last 3 years In Stiefel, she has been leading the Global Medical Affairs activities for acne, superficial skin infections, psoriasis, atopic dermatitis and androgenic alopecia

Webinar overview Introduction to atopic dermatitis (AD) and psoriasis Zinc Code: UK/RET/0120/16b Date of Prep: November 2016 Webinar overview Introduction to atopic dermatitis (AD) and psoriasis Role of topical corticosteroids (TCS) in the treatment of AD and psoriasis Appropriate use and potential side effects of TCS Role of pharmacists in patient education Live Q&A

Introduction to atopic dermatitis (AD) and psoriasis Zinc Code: UK/RET/0120/16b Date of Prep: November 2016  Introduction to atopic dermatitis (AD) and psoriasis There is a range of skin disorders that are responsive to topical corticosteroid therapy; for the purposes of this presentation, we will focus specifically on atopic dermatitis and psoriasis

About atopic dermatitis (AD) Zinc Code: UK/RET/0120/16b Date of Prep: November 2016 About atopic dermatitis (AD) Causes1 Common symptoms1 Impacts2 No known single cause Dry skin Itching Redness Reduced quality of life Genetic link Prevalence3 Emotional distress Affects at least 15% of children Affects 2–10% of adults Environmental factors Disturbed sleep AD can be mild, moderate or severe1 AD is a common condition, seen in up to 10% of adults,1 and can have a broad impact on patients’ quality of life beyond the symptoms themselves.2 The itching associated with AD can disturb patients’ sleep, and emotional impact can include embarrassment and loss of social confidence, as well as frustration and anger.2 References Kabashima K. J Dermatol Sci 2013; 70:3–11. Basra MK, et al. Expert Rev Pharmacoecon Outcomes Res 2009; 9(3):271-283. 1. NICE. Eczema – atopic. Clinical Knowledge Summaries 2015; http://cks.nice.org.uk/eczema-atopic. Accessed September 2016; 2. Basra MK, et al. Expert Rev Pharmacoecon Outcomes Res 2009; 9(3):271–283; 3. Kabashima K. J Dermatol Sci 2013; 70:3–11.

Assessing severity of AD Zinc Code: UK/RET/0120/16b Date of Prep: November 2016 Assessing severity of AD Clear Mild Moderate* Severe** Dry skin None Some Widespread Itching Infrequent Frequent Incessant Redness Possibly small areas Some areas For moderate-to-severe cases, advise the patient to consult their doctor For mild cases, patients may be able to be treated with over-the-counter treatment options The severity of AD is assessed based on the patient’s symptoms.1 Within the pharmacy, you should only expect to deal with mild cases of AD, which can be treated with options that are available without prescription. If patients appear to have moderate or severe AD, they should consult their primary care physician for advice and treatment options. Reference NICE. Eczema – atopic. Clinical Knowledge Summaries 2015. Available at http://cks.nice.org.uk/eczema-atopic. Accessed September 2016. *May include excoriation and localised skin thickening **May include picked skin, extensive thickening, bleeding, oozing, cracking, or colour alterations NICE. Eczema – atopic. Clinical Knowledge Summaries 2015; http://cks.nice.org.uk/eczema-atopic. Accessed September 2016.

Patches, papules or plaques Reduced quality of life Zinc Code: UK/RET/0120/16b Date of Prep: November 2016 About psoriasis Causes Common symptoms2 Impacts2,3 Scaly skin lesions Itching Patches, papules or plaques Reduced quality of life Inappropriate immune response1 Flare triggers include: Psychological effects Prevalence Affects approximately 2% of the world’s population:4 nearly 150 million people worldwide5 Stress, trauma2 There are several forms of psoriasis, including plaque, pustular, nail, guttate, and erythrodermic2 Physical effects Environmental factors2 Psoriasis should normally be managed by a primary or secondary care physician, following appropriate referral2 Psoriasis is an autoimmune condition affecting tens of millions of people worldwide.1,2 Psychological and social effects of psoriasis may include:3 Anxiety and depression Negative body image and self image Shame, guilt, embarrassment, and fear of being considered dirty or infectious Limitation of activities, including those requiring skin exposure (such as swimming) and work Negative effect on social, professional, and personal relationships References Lowes MA, et al. Nature 2007; 445(7130):866-873 Bhosle MJ, et al. Health Qual Life Out 2006. NICE. Psoriasis. Clinical Knowledge Summaries 2014; http://cks.nice.org.uk/psoriasis. Accessed September 2016; 1. Lowes MA, et al. Nature 2007; 445(7130):866–873; 2. NICE. Psoriasis. Clinical Knowledge Summaries 2014; http://cks.nice.org.uk/psoriasis. Accessed September 2016; 3. Basra MK, et al. Expert Rev Pharmacoecon Outcomes Res 2009; 9(3):271–283; 4. Bhosle MJ, et al. Health Qual Life Out 2006; 4:35; 5. World population estimate: 7,450,000,000 (http://www.worldometers.info/world-population/, accessed 23 September 2016).

Assessing severity of plaque psoriasis Zinc Code: UK/RET/0120/16b Date of Prep: November 2016 Assessing severity of plaque psoriasis Plaque psoriasis accounts for 80–90% of all psoriasis cases and the Physician’s Global Assessment (PGA) is used for assessing severity of disease on a 7-point scale1 1 2 3 4 5 6 Clear Nearly clear Mild Moderate Severe Very severe The Psoriasis Area and Severity Index (PASI) is another commonly used tool to quantify disease severity. Scores range from 0–72 with higher scores indicating more severe disease2 Those patients with severe or very severe PGA scores should be referred to a specialist dermatologist1 By far the most common type of psoriasis is plaque psoriasis, which can present with varying levels of severity – this assessment is performed by the primary care physician, generally using either the PGA or the PASI scale.1 All patients with psoriasis should consult their primary care physician and manage the condition with therapies that are prescribed to them. Reference: NICE. Psoriasis. Clinical Knowledge Summaries 2014; http://cks.nice.org.uk/psoriasis. Accessed September 2016. 1. NICE. Psoriasis. Clinical Knowledge Summaries 2014; http://cks.nice.org.uk/psoriasis. Accessed September 2016; 2. Fredriksson T, Pettersson U. Dermatologica 1978; 157:238–44.

Zinc Code: UK/RET/0120/16b Date of Prep: November 2016 Psoriasis and AD are common disorders that impact patients’ quality of life AD is a common condition featuring dry, itchy and red skin1 Only mild AD can be treated over the counter – patients with more severe forms of the condition should be referred to their primary care physician1 Psoriasis is a debilitating disease with psychological and physical consequences;2,3 plaque psoriasis is by far the most common form2 Patients with psoriasis should be managed collaboratively by both their primary care physician and dermatologist with regard to assessing the impact of psoriasis and disease severity2 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. Doctor by ProSymbols, Noun Project 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. Basra MK, et al. Expert Rev Pharmacoecon Outcomes Res 2009; 9(3):271-283.