13.5 Preparations for eczema and psoriasis

13.5.1 Preparations for atopic eczema

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

Step 1:
emollients ± antiseptic (see section 13.2.1)
topical corticosteroid (see section 13.4)
Step 2:
ichthammol 1% + zinc oxide 15%
made to 100% with yellow soft paraffin[unlicensed preparation]
Formulations/Dose
  • ichthammol 1% + zinc oxide 15% in yellow soft paraffin[unlicensed preparation] : apply 1–3 times daily. Available from Specials manufacturers.
Prescribing Notes
  • All patients with eczema should use emollients, soap substitutes and/or bath oil.
  • Emollients with antiseptics should be used in patients with infected eczema.
  • Exacerbation of eczema may represent secondary bacterial or viral infection. Appropriate swabs should be taken, and topical antibacterials applied. Systemic antibiotics may be required in widespread infected eczema.
  • Preparations containing coal tar with hydrocortisone may be useful in eczema.
  • Tacrolimus ointment 0.03% or 0.1%, is appropriate for shared care arrangements to facilitate the seamless transfer of individual care from secondary care to general practice. It can also be initiated by GPs with specialist interest in, and experience of, treating atopic dermatitis using immunomodulatory therapy.  Tacrolimus ointment is usually recommended second-line for patients suffering moderate eczema uncontrolled by topical steroids or those at risk of significant steroid-induced adverse effects.
  • Pimecrolimus cream 1% is appropriate for shared care arrangements to facilitate the seamless transfer of individual care from secondary care to general practice.  It is used second-line for patients suffering moderate eczema uncontrolled by topical steroids or those at risk of significant steroid-induced adverse affects.
  • Tacrolimus ointment can also be used for maintenance treatment for the prevention of flares and the prolongation of flare-free intervals in patients experiencing a high frequency of disease exacerbations (i.e. occurring 4 or more times per year) who have had an initial response to a maximum of 6 weeks treatment of twice daily tacrolimus ointment (lesions cleared, almost cleared or mildly affected).
  • Tacrolimus may be prescribed for patients aged over 2 years while pimecrolimus is recommended for moderate atopic eczema on the face and neck in children aged 2-16 years. The long-term safety of these products is unknown.
  • Ciclosporin, azathioprine or systemic corticosteroids should be initiated on specialist advice only, with responsibility for monitoring agreed.
13.5.2 preparations for psoriasis

First Choice
calcitriol
Second Choice:
calcipotriol

Other topical preparations for psoriasis often used in combination
 
coal tar (see below for suitable preparations)
dithranol
emollients (see section 13.2.1)
salicylic acid containing preps (for scaling)
For face or flexures
First Choice:
mild/moderate topical corticosteroids (see section 13.4)
For trunk, limbs, scalp
First Choice:
topical vitamin D analgue +/- potent topical corticosteroids (see prescribing notes below)
Formulations/Dose
  • calcitriol 3micrograms/g ointment (100g): apply twice daily; max 30g daily.
  • calcipotriol 50micrograms/g cream or ointment (120g): apply once or twice daily; max 100g weekly.
  • coal tar: apply 1–2 times daily starting with low–strength preparations.
    • Mild - moderate psoriasis
    • First choice: Psoriderm® cream (225ml) (distilled coal tar 6% and lecithin 0.4%)
    • Second choice: Exorex® lotion (100ml, 250ml) (coal tar 5% in an emollient basis)
    • Moderate psoriasis
    • Coal Tar (crude) in yellow soft paraffin 2%, 5% (100g)[unlicensed preparation];available from Tayside Pharmaceuticals
    • Coal Tar (crude) in yellow soft paraffin 10%, 20%, 40% (100g)[unlicensed preparation]; under supervised use in Dermatology Treatment Centres only.
  • dithranol cream: apply carefully to lesions at concentrations of 0.1%–2%, usually for short contact periods of 30–60 minutes. It stains skin, clothing, baths and floors.
  • salicylic acid and coal tar containing preparations: Sebco® scalp ointment (coal tar solution 12%, salicylic acid 2%, precipitated sulphur 4% in coconut oil emollient basis), applied overnight and washed off in the morning, is useful for scaling scalp.
Prescribing Notes
  • Calcitriol may be less irritant than calcipotriol and therefore better tolerated.
  • Treatment choice depends on site, extent of psoriasis and patient preference and tolerance.
  • To gain rapid improvement in plaque psoriasis, short term (4 weeks) and intermittent use of a potent topical corticosteroid or a potent topical corticosteroid plus a topical vitamin D analogue is recommended.  (Individual preparations should be used in the first instance, however a combination product can be used where adherence is an issue e.g Dovobet® and Entislar®.)
  • For the long term topical treatment of plaque psoriasis a vitamin D analogue is recommended.
  • Potent to very potent topical corticosteroids are not recommended for regular use over prolonged periods because of concern over long term adverse effects.
  • Guttate psoriasis requires emollients and perhaps a mild tar preparation such as Exorex® lotion; phototherapy may help.
  • “Lotion” should be specified when prescribing Exorex® since the cream is “pay and report”.
  • Coal tar solution 10% in yellow soft paraffin[unlicensed preparation] (100g) is an alternate preparation for mild-moderate psoriasis. It is available from Tayside Pharmaceuticals.
  • Salicylic acid 2% or 3% may enhance loss of scale.
  • Coal tar preparations are effective but may stain skin, hair and clothes.
  • Phototherapy, methotrexate, ciclosporin, acitretin should be initiated on specialist advice only, with responsibility for monitoring agreed.
  • Emulsifying ointment BP 25% in Coconut Oil BP is approved for use in scalp dermatitis, psoriasis and keratosis.  It should be applied to the scalp for 12 hours and then washed out.  It is a special and is available from Tayside Pharmaceuticals, tel: 01382 632052.