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13.5.3 Drugs affecting the immune response

Azathioprine tablets
Ciclosporin capsules - click here for shared care guidelines
Methotrexate tablets - click here for shared care guidelines
Tacrolimus ointment - consultant dermatologist initiation only (to be used according to individual patient specific treatment plan)
Pimecrolimus cream - consultant dermatologist initiation only

Cytokine modulators

NICE guidance on biologic drugs for the treatment of psoriasis (October 2012); psoriatic arthritis(April 2011)

Biologic algorithms for use in Dermatology are listed here

Apremilast tablets - severe plaque psoriasis: see NICE TA419psoriatic arthritis: see NICE TA433; see Note
- severe plaque psoriasis: see NICE TA 146 
- psoriatic arthritis: see NICE TA 199
- Hidradenitis Suppurativa: see NICE TA 392  
Brodalumab –  See NICE TA 511 
Dimethyl Fumarate (Skilarance) – see NICE TA 475 
Dupilumab – see NICE TA 534
Guselkumab - see NICE TA 521 
- very severe plaque psoriasis: see NICE TA 134
- psoriatic arthritis: see NICE TA 199
Etanercept injection (Adults)
- severe plaque psoriasis: see NICE TA 103
- psoriatic arthritis: see NICE TA 199
Ixekizumab – for moderate to severe psoriasis see NICE TA 442
Secukinumab injection – severe psoriasis NICE TA 350
Ustekinumab injection - moderate to severe psoriasis - as per NICE guidance available here 


1. Ustekinumab has been associated with reports of exfoliative dermatitis. See DSU January 2015.

 2. Tacrolimus should be initiated by a consultant dermatologist. It is reserved for the second line trearment of moderate to severe atopic eczema where there has been an inadequate response to topical corticosteroidsor where there is a serious risk of important adverse effects from further topical corticosteroid use e.g. skin atrophy.

 3. Pimecrolimusis reserved for 2nd line treatment of mild to moderate atopic eczema in patients aged 2 to 16 years. It is licensed for short term treatment and intermittant long term flare prevention. Pimecrolimus use should be for patients with eczema of the face, neck, genitals and flexures who:

a) require long-term daily application of a mild/moderate topical steriods.

b) require regular use of a moderate topical steroid intermittantly, for more than one week. 

c) Does not tolerate tacrolimus.

Topical tacrolimus and pimecrolimus:

  • they should only be initiated by physicians with experience of the diagnosis and treatment of atopic dermatitis.

  • they should not be given to patients with congenital or acquired immunodeficiences, or to patients on therapy causing immunosuppression.

  • they should not be applied to malignant or potentially malignant skin lesions.

  • the medicines should be applied thinly and to the affected skin surfaces only.

  • treatment should be short-term: continuous long-term use should be avoided.

  • if no improvement occurs (after 6 weeks for Elidel or 2 weeks for Protopic), or the disease worsens, the diagnosis of atopic dermatitis should be re-evaluated and other therapeutic options considered.

(Current Problems in Pharmacovigilance. July 2006)

In addition:

Pimecrolimus cream1% and tacrolimus ointment 0.03% are not recommended for use in children aged 2 years or below. Tacrolimus ointment 0.1% should not be used in children under 16 years of age.

See NICE TA 82. 

4. Apremilast is associated with an increased risk of psychiatric symptoms, including depression, suicidal thoughts, and suicidal behaviours – see MHRA DSU.

For the link to the BNF section: 13.5.3 Drugs affecting the immune response