Prescribing advice for the management and treatment of psoriasis

Transcription

1 Prescribing advice for the management and treatment of psoriasis This guidance contains suggested advice for the management and treatment of patients presenting with psoriasis. This guidance applies to Camden primary care practitioners (GPs, practice nurses, community nursing). It will also be relevant to community pharmacists both as assisting with patient education and suitable treatments. Start date: 11 th December 2006 Reviewed & updated: January 2013 Next Review Date: January 2015 Original agreed by: Camden PCT Dermatology Group on 7 th November 2006 & by Medicines Management, Interventional Procedures and Medical Devices Committee on 30 th November Updates approved by: NHS Camden Medicines Management Committee on 25/11/10, 08/07/11 and 27/02/13 Comments on this guidance should be directed to the Medicines Management Team, Camden Clinical Commissioning Group (CCG) by to mmt.camdenccg@nhs.net This document is for use by Camden Prescribers and primary care practitioner only the information contained in it is not suitable to be shared with patients / public or non NHS Organisations. Produced to inform and review local decision making using the best available evidence at the time of publication. The information in this document may be superseded in due course. Not to be used or reproduced for commercial or marketing purposes. Every care has been taken in the compilation and publication of this document, however, neither the Medicines Management Team nor Camden CCG will be held responsible for any loss, damage or inconvenience caused as a result of any inaccuracy or error within these pages. Please also note that Camden CCG is not responsible for the content or availability of any external sites to which it may include links. Please be aware that this information is correct at the time of the search and Camden CCG is under no obligation to inform you if the situation changes in the future. The information provided is the property of Camden CCG and is subject to Intellectual Property and Database Rights. Camden CCG does not restrict assessment, treatment, therapy or care on the basis of age, gender, ethnic group, sexual orientation or any other irrelevant consideration. Prescribing Advice for Psoriasis v 3 Page 1 of 10

2 1 SUMMARY Prescribing advice for the management and treatment of psoriasis 2 RESPONSIBLE PERSON: Neeshma Shah 3 ACCOUNTABLE DIRECTOR: David Cryer 4 APPLIES TO: NHS Camden Clinical Commissioning Group (CCG) primary care practitioners. 5 GROUPS/ INDIVIDUALS WHO HAVE OVERSEEN THE DEVELOPMENT OF THIS GUIDANCE 6 GROUPS WHICH WERE CONSULTED AND HAVE GIVEN APPROVAL: 7 EQUALITY IMPACT ANALYSIS COMPLETED: NHS Camden Clinical Commissioning Group (CCG) Medicines Management Team Camden Medicines Management Committee Guidance Screened 05 July 2013 Template completed 8 RATIFYING COMMITTEE(S) & DATE OF FINAL APPROVAL: Camden Medicines Management Committee 27 th February VERSION: V3 10 AVAILABLE ON: Intranet Camden GPs Website 11 RELATED DOCUMENTS: 12 DISSEMINATED TO: To be placed on intranet and disseminated via Prescribing Matters. 13 DATE OF IMPLEMENTATION: July DATE OF NEXT FORMAL REVIEW: January 2015 Prescribing Advice for Psoriasis v 3 Page 2 of 10

3 DOCUMENT CONTROL Date Version Action Amendments November Guidance first implemented March Guidance reviewed N/A November Guidance amended Addition of information and on Finger Tip Units including diagram. Addition of appendix on Drug Tariff topical treatments for psoriasis. July Guidance amended A cautionary note added to advise that aqueous cream should be used as a soap substitute only. Nail psoriasis advice re treatment has been expanded. July Guidance amended Bath emollients removed February Guidance amended Guidance updated following publication of NICE CG153 (The assessment and management of psoriasis). NICE general recommendations regarding treatment and assessment added. Advice updates to flexure and genital psoriasis, scalp psoriasis and facial psoriasis. Advice re topical calcineurin inhibitors added. Appendix on drug tariff topical treatments removed. Prescribing Advice for Psoriasis v 3 Page 3 of 10

4 Prescribing Advice for the management and treatment of psoriasis Initial assessment 1-8 There is no cure for psoriasis, although there are effective suppressive treatments aimed at inducing a remission or making the amount of psoriasis tolerable to the patient The clinician should make the patient aware of the possible therapeutic options, including the simplest available therapies and the option that treatment may not be necessary. The patient s perception of his or her disability will often dictate the need for treatment. Assess the impact of disease on physical, psychological and social wellbeing. To be able to advise the patient on suitable therapies, the clinician needs to know the sites, extent and severity of the psoriasis Assess the severity and impact of any type of psoriasis before referral. If referral is considered necessary, treatment should be initiated while awaiting a clinic appointment. Drugs thought to precipitate or worsen psoriasis include beta-adrenoceptor blocking drugs, NSAIDs, lithium, chloroquine, mepacrine and alcohol Discuss risk factors for cardiovascular co-morbidities with patients who have any type of psoriasis. Offer preventative advice, healthy lifestyle information and support for behavioural change to meet the needs of the individual where risk factors are identified. 8 Points to discuss/consider at initial presentation: o Explanation of psoriasis, including reassurance that it is neither infectious nor malignant o May need to prescribe a variety of emollients e.g. ointment + cream (see emollient recommendations below) or prescribe just one emollient depending on skin texture and extent of psoriasis. o Treatment options (including no active treatment) o The probable benefit the patient can expect from treatment. o Techniques of application of any topical treatment (especially important with dithranol and scalp preparations) o An introduction to patient support groups may be helpful e.g. The Psoriasis Association o Arrange a review appointment 4 weeks after starting new topical therapy in adults, and 2 weeks in children, to evaluate treatment response, adherence and tolerability 8 General recommendations for treatment 8 Offer topical therapy as first line treatment. If phototherapy or systemic therapy is required, refer the patient. When offering topical treatment take into account patient preference, cosmetic acceptability and practical aspects of application and the site(s) and extent of psoriasis to be treated. Lotion or solution formulations may be more suitable for the scalp or hair-bearing areas, ointments may be more suitable for areas with thick adherent scale. Where psoriasis has responded to topical treatment, discuss the importance of continuing treatment with the patient or in the case of topical corticosteroids, how long they should be used for. Where topical treatment has not been effective or only partly effective, consider possible nonadherence to treatment and reasons for this before considering an alternative treatment. This may include difficulties with application, cosmetic acceptability or tolerability. Patients should be supported to adhere to treatment 9. Treatment of chronic plaque psoriasis Emollients should be used regularly for all types of psoriasis to soften scaling, reduce any irritation 6 and help relieve other symptoms such as itch. 7 The NHS Camden prescribing recommendations for these are shown in the table below: Prescribing Advice for Psoriasis v 3 Page 4 of 10

5 Emollient Creams Step one Hydrous ointment (oily cream) Emollient Ointments Step one Emulsifying ointment White soft paraffin 50% liquid paraffin 50% (50/50) Step 2 Diprobase cream Cetraben cream Double base gel Oilatum cream Step 2 Hydromol ointment Epaderm ointment Soap substitutes All creams and ointments may be used as soap substitutes except 50/50. Aqueous cream- Should be used as a soap substitute only. Aqueous cream and emulsifying ointment are the most cost effective options for the cream and ointment respectively. Note there are significantly more skin reactions to the cream preserved with phenoxyethanol than to chlorocresol.(check with your local pharmacist) Bath additives Bath additives are not recommended as they are not cost-effective compared to soap substitutes and may be wasteful as a large proportion will be washed away during use, with bath/shower water. Patients should be warned that these are not a replacement for emollient creams and ointments and if purchased should be advised to take care to avoid slipping when stepping in and out of the bath. Routine use of antiseptic/ emollient combinations is not routinely recommended Recommended suitable quantities for prescribing The following is intended as a guide to help determine appropriate quantities of dermatological preparations to prescribe for adult patients. Children will require less. Emollients and non-steroid preparations 1 The following quantities are usually suitable for an adult for twice daily application for one week. Area of body Creams and ointments Lotions Face 15-30g 100ml Both hands 25-50g 200ml Scalp g 200ml Both arms or both legs g 200ml Trunk 400g 500ml Groin and genitalia 15-25g 100ml Corticosteroid preparations 1,2 The quantities below are the recommendation for adult patients where the preparation is used ONCE daily for two weeks. Children require less, for example, a child of 4 years will require one third of the adult quantity. Area of body Quantity for once daily application for 2 weeks Face and neck 15-30g Both hands 15-30g Scalp 15-30g Both arms 30-60g Both legs 100g Trunk 100g Groin and genitalia 15-30g Prescribing Advice for Psoriasis v 3 Page 5 of 10

6 Be aware that continuous use of potent or very potent corticosteroids may cause the following: Irreversible skin atrophy Psoriasis to become unstable Systemic side-effects when applied continuously to extensive psoriasis (more than 10% of the body surface area is affected) Aim for a four week break between courses of potent or very potent corticosteroids. Consider topical treatments that are not steroid-based (such as coal tar or vitamin D or vitamin D analogues) during this period 8. Offer a review at least annually to those using steroids to assess presence of steroid atrophy and other effects 8 Finger Tip Units When counselling patients on the appropriate doses and use of corticosteroid preparations, applying the Finger Tip Unit (FTU) measurement is a useful method of counselling patients on the appropriate quantities of cream or ointment to use. One FTU is equivalent to about 500 mg and is sufficient to treat a skin area about twice that of the flat of the hand with the fingers together. 1 The approximate amount that should be applied for each area of the body is shown below Prescribing Advice for Psoriasis v 3 Page 6 of 10

7 NHS Camden Prescribing Recommendations BEFORE USING THIS GUIDANCE ALWAYS ENSURE YOU ARE USING THE MOST UP TO DATE VERSION Condition Drug choice Special considerations Chronic plaque psoriasis Flexure and genital psoriasis e.g. breasts, groin For all patients: Simple emollients should be used regularly for all patients (if patient untroubled by the condition) or treat with coal tar cream/lotion Short term treatment (to gain rapid improvement): Calcipotriol and potent topical steroid e.g. betamethasone valerate 0.1% or mometasone furoate 0.1% (as separate products) 12 hours apart (one in the morning, one in the evening) on the plaques OR Calcitrol ointment ONCE daily If patient has responded to calcipotriol and steroid, the combination product Dovobet (calcipotriol and betamethasone) may be used Steroids to be used short-term: usually 3-7 days duration (but no more than 4 weeks), and intermittently. Not suitable for widespread psoriasis. For long term treatment or if steroid not effective/partly effective after a maximum of 8 weeks treatment with choices above: Calcitrol ointment applied TWICE daily If calcitrol alone is not effective or not tolerated then consider: Coal tar cream, lotion or ointment OD or BD (see notes opposite) If treatment ineffective consider referral for treatment with short contact dithranol, very potent corticosteroids or tazarotene. Emollients should be offered to all patients and regular use encouraged 1 st line: Mild to moderate potency steroid e.g. hydrocortisone 1% (mild) or clobetasone butyrate 0.05% (moderate) or betamethasone valerate 0.025% (moderate) once or twice daily, for a maximum of 2-4 weeks. For longer term use or if moderate potency steroids are ineffective or corticosteroids cannot be used: Calcitrol ointment OD or BD OR Consider topical tacrolimus ointment BD for up to 4 weeks where there has been a poor response to steroids or steroid treatment is required for longer than 2 weeks. Topical tacrolimus can be considered but should be initiated by a specialist or on the recommendation of a specialist.. Topical tacrolimus or pimecrolimus for the management of psoriasis is not licensed. Calcitrol is less likely to cause irritation than calcipotriol 2,6. Calcipotriol ointment is more effective than the cream but patients may find that it preferable to use the cream version in the morning. Avoid using Calcipotriol on the face and flexures. Monitor for irritant effects when used on the limbs and body. Do not exceed max recommended weekly dose-see BNF or BNF-C (children s dosage). Treatment needs to be used for at least 6-8 weeks to see improvement. Palms and soles may need trial of potent steroids for 4 weeks. People with more extensive severe disease may require referral to secondary care for phototherapy or systemic biological treatments Coal tar- a wide variety of proprietary preparations are available (see BNF) Exorex lotion (coal tar 5%) Psoriderm Cream (coal tar 6%) Carbo-Dome cream (coal tar 10%) Sebco scalp ointment (Coal tar 12%, salicyclic acid 2%, precipited sulphur 4%) Note BP preparations of coal tar are likely to be available as specials ONLY and therefore of high cost Treatment duration with topical steroids usually limited to 2-4 weeks, or 1-2 weeks per month. Vitamin D derivatives can be irritant in the flexural areas, and this can limit their use, especially calcipotriol Calcitrol is less likely to cause irritation than calcipotriol Prescribing Advice for Psoriasis v 3 Page 7 of 10

8 Condition Drug choice Special considerations Coal tar products can be considered for intermittent use for flexural psoriasis. Use with caution in genital psoriasis Antifungal treatment should not be used unless there are signs of fungal infection (red to red-brown, sometimes itchy, flat or slightly raised plaques with active borders [pustules or vesicles]). Dithranol and topical retinoids are NOT recommended for flexural sites. Scalp psoriasis Potent or very potent steroids are NOT recommended for flexures and genitals as these areas are particularly vulnerable to steroid atrophy. Emollients should be offered to all patients to soften scale If scale is thick and adherent: Olive oil, coconut oil, or arachis oil, to soften scale. A keratolytic, such as salicylic acid combined with coal tar and coconut oil (Cocois, Sebco ). These may be rubbed into scalp at night and should be used prior to application of a topical steroid if this is also prescribed. For treatment of plaques: 1st line A potent topical steroid e.g. Betamethasone valerate 0.1% scalp application (such as Betacap ) applied to plaques by parting hair and rubbed in up to 4 weeks. OR Topical corticosteroid scalp preparation is licensed for use for up to 4 weeks only. Vitamin D scalp preparation may be more likely than a topical corticosteroid to cause local irritation. Use of this product alone can be considered for mild to moderate scalp psoriasis or where patients are intolerant or cannot use topical corticosteroids. Calcipotriol scalp application once daily for up to 8 weeks OR A combination steroid and calcipotriol product (Xamiol betamethasone 0.05% and calcipotriol 50mcg/g) can be considered once daily, for up to 4 weeks 2 nd line Consider very potent corticosteroid e.g. clobetasol propionate 0.05% shampoo BD for 2 weeks if 1 st line treatment not effective or unsatisfactory response. Coal tar preparations OD or BD (Polytar Liquid, Alphosyl 2 in 1, Capasal ). The use of coal tar preparations has a poor evidence base Coal tar based shampoos should not be used alone in severe psoriasis but may have a role in reducing itch in scalp psoriasis based on expert opinion Prescribing Advice for Psoriasis v 3 Page 8 of 10

9 Condition Drug choice Special considerations Facial psoriasis Guttate psoriasis Emollients should be offered to all patients and regular use encouraged 1 st line A mild or moderate topical steroid (e.g hydrocortisone 1%,(mild) or Clobetasone butyrate 0.05% (moderate), Betamethasone valerate 0.025%) (moderate) once or twice daily for a maximum of 2 weeks 2 nd line (if topical mild to moderate corticosteroid is not effective) consider: Calcitriol ointment OD or BD Treatment with a topical calcineurin inhibitor e.g. tacrolimus ointment can be considered but should be initiated by a specialist or on the recommendation of a specialist. Topical tacrolimus or pimecrolimus for the management of psoriasis is not licensed. In treating facial psoriasis, topical calcineurin inhibitors should be used for a maximum of 4 weeks. Potent or very potent steroids are NOT recommended for face 1 st line Emollients should be offered to all patients and regular use encouraged 2 nd line A moderate potency topical steroid e.g Clobetasone butyrate 0.05% (moderate), Betamethasone valerate 0.025%) (moderate) Calcipotriol or calcitriol cream/ointment Coal tar cream/ointment/lotion Topical steroids should be used for a maximum 2 weeks, or 1-2 weeks per month Calcipotriol may be considered if only applied to hair margins/ears but not to the face due to irritation, and not licenced for use on the face. No value of oral antibiotics Consider early referral for phototherapy Calcipotriol cream may be very difficult to apply to the very small plaques and therefore cause irritation to surrounding skin. Calcitriol could then be considered. Nail psoriasis For mild disease: Advise to keep nails short and conceal with nail vanish if required. Advise avoiding manicuring the cuticle and prosthetic nails For moderate to severe disease: As above Evidence to support the effectiveness of topical treatment is limited. Nail disease responds poorly to topical treatment. Topical corticosteroids, salicylic acid, calcipotriol or tazarotene used alone or in combination can be considered but preferably/only after specialist advice has been sought Refer to podiatry as appropriate if nails distorted/painful Check to see if there is a coexistent fungal infection as this may worsen the appearance. Topical treatments such as topical steroids, vitamin D analogues etc are not licensed for this indication and have very limited evidence base Notes Some products are formulated as combinations. These are usually more expensive than their separate constituents, but they may be useful where compliance is a problem. Some BP preparations may be difficult to obtain and if made as a special are likely to cost considerably more than a proprietary preparation. Advice on current costs can be obtained from a local community pharmacist. Prescribing Advice for Psoriasis v 3 Page 9 of 10

10 References and further reading 1. BNF 64 (September 2012) British National Formulary. 64th edn. London: British Medical Association and Royal Pharmaceutical Society of Great Britain. 2. NHS Clinical Knowledge Summaries ; 3. Smith CH, Barker JNWN (2006) Psoriasis and its management. British Medical J 333, British Association of Dermatologists. Psoriasis guideline British Association of Dermatologists and Primary Care Dermatology Society. Recommendations for the initial management of psoriasis (Reviewed Jan 2010) 6. SIGN. Diagnosis and management of psoriasis and psoriatic arthritis in adults. A national clinical guideline. October MeReC (1999) Using topical corticosteroids in general practice. MeReC Bulletin 10(6), NICE Clinical Guideline 153. The assessment and management of psoriasis. October NICE Clinical Guideline 76. Medicines Adherence: Involving patients in decisions about prescribed medicines and supporting adherence. January 2009 Comments on this guidance should be sent to the Medicines Management Team by to mmt.camdenccg@nhs.net Prescribing Advice for Psoriasis v 3 Page 10 of 10