Back to Section 13 Selection Page

13.5.3 Drugs affecting the immune response 

Topical treatments

 Tacrolimus ointment is used for atopic dermatitis in patients who are not adequately responsive to or are intolerant of conventional therapies including topical corticosteroids. Tacrolimus is a calcineurin inhibitor, which acts as an immunosuppressant mainly reducing inflammation by suppressing the T-cell response. See section 13.5.1 – Eczema and Tacrolimus Ointment Shared Care Agreement (Staffnet intranet link only).

Systemic treatments

Systemic drugs acting on the immune system are used under specialist supervision. Refer to BSR guideline for disease-modifying anti-rheumatic drug (DMARD) therapy in consultation with the British Association of Dermatologists.

 Azathioprine (typical dose range 25-200mg daily) is used in systemic lupus erythematosus, dermatomyositis and polymyositis, pemphigus vulgaris, autoimmune bullous disorders [unlicensed use ‘off-label’], and severe refractory eczema [unlicensed use ‘off-label’]. See BNF for dose in severe refractory eczema. Refer to the British Association of Dermatologists (BAD) website for guidance on safe and effective prescribing of azathioprine.

  Chloroquine phosphate tablets (chloroquine phosphate tablets 250mg are equivalent to 155mg chloroquine base) may be used at a low dose in the treatment of Porphyria Cutanea Tarda [unlicensed use ‘off-label’]. Typical dose range is chloroquine phosphate 250mg weekly or chloroquine base 150-200mg per week. For further information see the BAD Porphyria Cutanea Tarda PIL.

 Ciclosporin (specify brand name on prescription) is licensed for severe psoriasis and may be used in autoimmune bullous disorders [unlicensed use ‘off-label’]. It is also licensed for short-term treatment of severe atopic dermatitis where conventional therapy ineffective or inappropriate. See BNF for dose (typical initial dose 2.5mg/kg daily in 2 divided doses).

 Dapsone is licensed for dermatitis herpetiformis and other dermatoses, and is used in autoimmune bullous disorders [unlicensed use ‘off-label’], hidradenitis suppurativa [unlicensed use ‘off-label’], and neutrophilic vasculitides [unlicensed use ‘off-label’]. Refer to Dapsone Shared Care Agreement for further information including dose range and other indications.

 Hydroxychloroquine sulphate tablets 200mg (typical dose range 200-400mg daily) are licensed for systemic and discoid lupus erythematosus and dermatological conditions caused or aggravated by sunlight. They may also be used for other cutaneous lupus erythematosus [unlicensed use ‘off-label’] and skin manifestations of dermatomyositis [unlicensed use ‘off-label’]. Refer to Hydroxychloroquine and Ocular Toxicity Recommendations on Screening 2009 for information on ocular toxicity with hydroxychloroquine.

 Lymecycline (typical dose range 1-2 of the 408mg capsules daily) is used in autoimmune bullous disorders [unlicensed use ‘off-label’], pyoderma gangrenosum [unlicensed use ‘off-label’], hidradenitis suppurativa [unlicensed use ‘off-label’], severe atopic eczema [unlicensed use ‘off-label’] and is licensed for, but rarely used for acne. See section 13.6.

 Mepacrine hydrochloride tablets 100mg [unlicensed] may be used in discoid lupus erythematosus (second line to hydroxychloroquine or in combination with hydroxychloroquine).

 Mycophenolate mofetil tablets (typical dose range 500mg-2g daily) are used in autoimmune bullous disorders [unlicensed use ‘off-label’], severe refractory eczema in those unresponsive to or intolerant of other immunosuppressants [unlicensed use ‘off-label’], systemic lupus erythematosus (unlicensed use ‘off-label’) and dermatomyositis and polymyositis (unlicensed use ‘off-label’).  See MHRA Drug Safety Update – mycophenolate mofetil and mycophenolic acid: risk of hypogammaglobulinaemia and risk of bronchiectasis, Jan 2015.

Methotrexate can be used for severe psoriasis , severe psoriatic arthritis [licensed indications] and for severe atopic eczema [unlicensed use ‘off-label’].

 Methotrexate 2.5mg tablets
Dose: 2.5-10mg ONCE WEEKLY, increased according to response in steps of 2.5-5mg at intervals of at least 1 week; usual dose 7.5-15mg once weekly; max. weekly dose 25mg. If the oral dose is not effective or not tolerated, consider subcutaneous administration before discontinuation (differences in bioavailability between routes of administration should also be considered).

Oral methotrexate is restricted to use under specialist advice from a dermatologist, gastroenterologist or rheumatologist.  Guidelines on the use of oral methotrexate have been produced by the National Patient Safety Agency (NPSA). In Tayside, the majority of patients should be prescribed and dispensed the 2.5mg strength tablets.

 Methotrexate injection 50mg/mL (Metoject^®) 
Dose: Severe psoriasis, severe psoriatic arthritis, by subcutaneous injection, 2.5-10mg ONCE WEEKLY, increased according to response in steps of 2.5-5mg at intervals of at least 1 week; usual dose 7.5-15mg once weekly; max. weekly dose 25mg (in general doses should not exceed 25mg).

 Methotrexate injection 50mg/mL (Metoject^®) Note: May be administered in primary care.
Dose: Severe atopic eczema by subcutaneous injection, 2.5-10mg ONCE WEEKLY, increased according to response in steps of 2.5-5mg at intervals of at least 1 week; usual dose 7.5-15mg once weekly; max. weekly dose 25mg (in general doses should not exceed 25mg).

Folic acid 5mg usually once a week (not on day of methotrexate) is given after the weekly methotrexate dose. See section 9.1.

Apremilast (Otezla^®▼) is an oral phosphodiesterase-4 (PDE-4) inhibitor, a new class of treatment for psoriasis. It is indicated for the treatment of moderate to severe chronic plaque psoriasis in adult patients who have failed to respond to or who have a contraindication to, or are intolerant to other systemic therapy including narrowband ultraviolet B, psoralen and ultraviolet-A (PUVA), acitretin, methotrexate and ciclosporin. Prescribing and monitoring is undertaken by the secondary care Dermatology clinic. A local protocol is in development.

Biologic therapies (Cytokine modulators)

The TNF-alpha inhibitors (antagonists)  adalimumab (Humira^®▼) (by subcutaneous injection every 2 weeks),  etanercept (Enbrel^®▼) (by subcutaneous injection once or twice weekly), and  infliximab (Remicade^®) (by intravenous infusion every 8 weeks) may be used in severe psoriasis in accordance with local guidance (Staffnet intranet link only).

 Ustekinumab (Stelara^®▼) (by subcutaneous injection every 12 weeks) is a monoclonal antibody that inhibits interleukins 12 and 23. It can be used for severe psoriasis as a second line agent in accordance with local guidance (Staffnet intranet link only). See MHRA Drug Safety Update – ustekinumab: risk of exfoliative dermatitis, Jan 2015.

Secukinumab (Cosentyx^®▼) (by subcutaneous injection every 4 weeks) is an IgG1 monoclonal antibody that binds to and neutralises interleukin-17A. It is also a second line agent for severe psoriasis.  

Back to top

© 2010 NHS Tayside