Antibiotics - Topical

Drug	Available Strength	Dosage	Remarks
Fusidic acid	2% cream, ointment, gel	Apply 6-8 hourly	Adverse Reactions Rarely hypersensitivity reactions
Gentamicin	0.1% cream, ointment	Apply 6-8 hourly	Adverse Reactions Pruritus and erythema
Mupirocin	2% cream, ointment	Apply 6-8 hourly	Adverse Reactions Burning sensation, stinging, pain, itching, swelling, redness, rash

Anti-infectives with Corticosteroids - Topical

Drug	Available Strength	Dosage	Remarks
Flumetasone pivalate/Salicylic acid	0.02%/3% ointment	Apply 12-24 hourly	Adverse Reactions Dermatologic effects (rashes, irritation, burning sensation, itching, dryness, folliculitis, hypertrichosis, acneiform eruption, hypopigmentation, maceration of skin, secondary infection, skin atrophy, striae and miliaria) Local skin irritation eg burning sensation, itching. May adversely affect adrenocortical function. Mild skin atrophy, changes in skin pigmentation, telangiectasia, purpura, steroid acne on prolonged use Special Instructions Avoid contact with eyes Contraindicated in patients with viral skin infection, TB, acne, rosacea, fungal infections perioral dermatitis, ulcerative condition
Fusidic acid/Betamethasone dipropionate	2%/0.064% cream, ointment 2%/0.05% cream, ointment	Apply 12 hourly
Fusidic acid/Betamethasone valerate	2%/0.1% cream	Apply 8-12 hourly
Gentamicin/Betamethasone dipropionate	0.1%/0.05% cream, ointment	Apply 12 hourly
Gentamicin/Fluocinolone acetonide	0.1%/0.025% cream	Apply 8-12 hourly
Neomycin/Betamethasone valerate	0.5%/0.1% cream, ointment	Apply 12-24 hourly	Adverse Reactions Dermatologic effects (pruritus, local skin burning/pain) Special Instructions Avoid contact with eyes, prolonged application to face, and long-term therapy especially in infants and children Contraindicated in patients with viral skin infection, TB, acne, rosacea, fungal infections perioral dermatitis, ulcerative condition, otitis externa
Neomycin/Fluocinolone acetonide	0.35%/0.025% cream	Apply 8-12 hourly	Special Instructions Discontinue use in case of hypersensitivity Long-term use may cause systemic effects
Neomycin/Nystatin/Clobetasol propionate	Neomycin 5 mg/Nystatin 100,000 IU/Clobetasol propionate 500 mcg cream, ointment	Apply 12-24 hourly	Adverse Reactions Dermatologic effects (atrophic skin changes, pigmentation changes and hypertrichosis); Other effects (hypersensitivity, features of hypercorticism, exacerbation of symptoms) Special Instructions Use with caution in patients with discoid lupus erythematosus, severe eczema, renal impairment Face may exhibit atrophic changes on prolonged treatment Contraindicated in patients with rosacea, acne vulgaris and perioral dermatitis; perianal or genital pruritus; viral skin infections; primary infected skin lesions caused by infection with fungi, bacteria, yeast or secondary infections due to Pseudomonas or Proteus sp
Neomycin/Nystatin/Gramicidin/Triamcinolone acetonide	Neomycin 2.5 mg/Nystatin 100,000 IU/Gramicidin 0.25 mg/Triamcinolone acetonide 1 mg cream	Apply 8-12 hourly	Special Instructions Contraindicated in patients with viral skin infection, TB, fungal lesions not susceptible to Nystatin
Salicylic acid/Betamethasone dipropionate	2%/0.064% lotion 3%/0.064% ointment	Apply 12 hourly	Adverse Reactions Dermatologic effects (irritation, burning, itching, dryness, folliculitis, hypertrichosis, acneiform eruption, hypopigmentation, maceration of skin, secondary infection, skin atrophy, striae and miliaria) Special Instructions Contraindicated in patients with viral skin infection, TB, acne, rosacea

Calcineurin Inhibitors

Drug

Available Strength

Dosage

Remarks

Pimecrolimus

1% cream

Apply thinly to affected skin 12 hourly

Adverse Reactions

Local effects: Burning, sensation of warmth which usually decreases with continued use, application site reactions (eg irritation, erythema, itching)
Less common: Bacterial and viral infections
If lymphadenopathy occurs, the cause should be investigated and if no clear cause, Pimecrolimus should be discontinued

Special Instructions

Contraindicated in patients with malignant or premalignant skin lesions and areas affected by acute cutaneous viral infections or in immunocompromised patients
- Clinical cutaneous infections should be cleared before application of Pimecrolimus
Use is not recommended in patients with Netherton’s syndrome or skin conditions which may increase the potential for systemic absorption
Avoid excessive or unnecessary exposure to UV light and sunlight during treatment
- Higher dose than used in humans shortened time to skin tumor formation in an animal photocarcinogenicity study
Should not be used with occlusive dressing
Patients should minimize or avoid natural or artificial sunlight

Tacrolimus

0.03% ointment
0.1% ointment

Apply thinly to affected skin 12 hourly

Corticosteroids - Systemic

Drug	Dosage	Remarks
Betamethasone	Severe psoriasis: 0.6-7.2 mg/day PO as a single dose or in divided doses	Adverse Reactions Ophthalmologic effects (increased intraocular pressure, visual disturbances); GI effects (acute pancreatitis, peptic ulcer with possible perforation and hemorrhage); Other effects (fluid and electrolyte disturbance, muscle weakness, osteoporosis, cushingoid state, growth retardation, menstrual irregularities, manifestations of latent DM, impaired wound healing, convulsion and increased intracranial pressure with papilledema) Special Instructions Contraindicated in patients with systemic fungal infection Use with caution in patients with CHF, DM, chronic renal failure, hypertension, GI diseases, recent intestinal anastomoses, osteoporosis, infectious diseases, myasthenia gravis, ocular herpes simplex, quiescent TB Risk of posterior subcapsular cataracts, glaucoma with possible damage to optic nerves and enhanced establishment of secondary ocular infections due to fungi or viruses upon prolonged use
Dexamethasone	Severe psoriasis: 0.75-9 mg/day PO in 2-4 divided doses
Methylprednisolone	Severe psoriasis: 4-48 mg/day PO as a single dose or in 4 divided doses or 10-40 mg IM/IV of Methylprednisolone Na succinate Subsequent doses are determined by response and condition
Prednisolone	Severe psoriasis: 5-60 mg/day PO in divided doses, as a single dose after breakfast or as a double dose on alternate days
Triamcinolone	Severe psoriasis: 4-48 mg/day PO Isolated foci of psoriasis: Single intralesional injection of Triamcinolone hexacetonide not exceeding 0.1 mg/cm² of the skin surface area Should be generally diluted at a ratio of at least 1:1

Corticosteroids - Topical*

Drug	Available Strength	Dosage	Remarks
Very Potent			Adverse Reactions The more potent the agent, the more chance of adverse reactions Local effects: Reversible thinning of skin, worsening of underlying infection, contact dermatitis, acne at site of application, hypopigmentation, dryness, reversible irritation, irreversible telangiectasia and striae atrophicae Systemic effects: Absorption through the skin can cause pituitary-adrenal-axis suppression, growth retardation, hypertension and Cushing’s syndrome Absorption is increased by thin and/or raw skin, intertriginous areas or occlusion Absorption is more likely when used over very large areas and in children Special Instructions Once-twice daily applications are recommended for most agents. More frequent administration may be necessary for palms or soles of feet Every other day or weekend application has been used to treat chronic conditions Length of cream/ointment squeezed from tube can be measured by finger tip unit (FTU) which is tip of adult index finger to first crease 1 FTU (approximately 500 mg) is sufficient to cover 2x the size of flat adult hand Recommended use of very potent agents is for 1-2 weeks (max 3 weeks) following with weaker potency preparations as the condition improves Mildly potent preparations are preferred for face and intertriginous areas Very potent agents should not be used in infants <1 year Moderately potent and potent agents will rarely cause side effects if used for <3 months (except if used on face or intertriginous areas) Intermittent therapy is usually preferable to long-term continuous therapy Mildly potent agents will rarely cause side effects Intermittent therapy is usually preferable to long-term continuous therapy especially if large areas are treated Contraindicated in patients with viral, fungal or tubercular skin infections Should not be applied to large areas of the body with an occlusive dressing
Clobetasol propionate	0.05% cream, gel, ointment, scalp application, shampoo 0.5% ointment	Apply 12-24 hourly Max dose (cream, ointment): 50 g/week Max dose (shampoo): 50 mL/week
Potent
Amcinonide	0.1% cream, lotion, ointment	Apply 8-12 hourly
Beclometasone dipropionate	0.025% cream	Apply 8-24 hourly
Betamethasone dipropionate	0.05% cream, lotion, ointment, solution 0.064% cream, lotion, ointment, solution	Apply 12-24 hourly
Betamethasone valerate	0.01% cream 0.0125% cream 0.025% cream 0.05% cream 0.1% cream, lotion, ointment, scalp application, solution	Apply 8-24 hourly
Betamethasone valerate	0.06% cream	Apply 24 hourly
Desoximetasone (Desoxymetasone)	0.05% gel 0.25% cream, ointment	Apply 8-24 hourly
Diflucortolone valerate	0.1% cream, fatty ointment, ointment	Apply 8-24 hourly
Fluclorolone acetonide	0.2% cream, ointment	Apply 12-24 hourly
Fluocinolone acetonide	0.01% cream, ointment 0.025% cream, gel, ointment 0.2% cream	Apply 8-12 hourly
Fluocinonide	0.05% cream, gel, ointment, solution	Apply 6-12 hourly
Fluocinonide	0.1% cream	Apply 12-24 hourly
Fluocortolone/Fluocortolone caproate	0.25%/0.25% ointment	Apply 12-24 hourly
Fluticasone propionate	0.005% ointment 0.05% cream	Apply 12-24 hourly
Halometasone	0.05% cream	Apply 12-24 hourly
Hydrocortisone aceponate	0.127% cream	Apply 12-24 hourly
Methylprednisolone aceponate	0.1% cream, ointment	Apply 24 hourly
Mometasone furoate	0.1% cream, fatty ointment, gel, lotion, ointment	Apply 12-24 hourly Max dose: 15 g
Prednicarbate	0.25% cream	Apply 12-24 hourly
Moderately Potent
Alclometasone dipropionate	0.05% cream	Apply 8-12 hourly
Clobetasone butyrate	0.05% cream, ointment	Apply up to 6 hourly
Desonide	0.05% cream, lotion, ointment	Apply 6-12 hourly
Flumetasone	0.02% ointment	Apply 12-24 hourly
Fluprednidene acetate	0.1% cream	Apply 12-24 hourly
Hydrocortisone butyrate	0.1% cream, ointment, solution	Apply 6-12 hourly
Triamcinolone acetonide	0.02% cream 0.1% cream, lotion, ointment, scalp lotion 0.2% cream 0.5% cream	Apply 6-12 hourly
Mildly Potent
Hydrocortisone	0.5% cream 1% lotion, cream, ointment 2.5% cream, lotion	Apply 6-24 hourly
Prednisolone	0.5% cream	Apply 8-24 hourly
*Various corticosteroid combination preparations are available. Please see the latest MIMS for specific formulations and prescribing information.

Cytotoxic Chemotherapy

Drug

Dosage

Remarks

Hydroxycarbamide
(Hydroxyurea)

500 mg PO 8-24 hourly

Adverse Reactions

Hematologic effect (bone marrow suppression); GI effects (nausea/vomiting); Hepatic effect (mild hepatitis which is not permanent); CNS effects (dizziness, drowsiness, disorientation, hallucinations, convulsions, headache); Dermatologic effects (hyperpigmentation, transient alopecia, cutaneous vasculitic toxicities); Other effects (renal function impairment, dyspnea, hyperuricemia)

Special Instructions

Contraindicated in patients with severe bone marrow depression, severe anemia, pregnancy and lactation
Use with caution in patients with renal impairment
Vaccination with live-virus vaccines not recommended
Monitor CBC with platelets, uric acid, hepatic and renal function regularly prior to and during treatment
- Toxic range: Hb <4.5 g/dL, neutrophils <2,000 cells/mm³, platelet count <80,000 mm³
Discontinue therapy if there is infection and if no response after 8 weeks of treatment

Methotrexate

7.5-25 mg PO/IV/IM once weekly
Max dose: 30 mg/wk or
2.5 mg PO 12 hourly x 3 doses or 8 hourly x 4 doses given weekly
May increase dosage gradually by 2.5 mg/week
Max dose: 30 mg/week or
2.5 mg PO 24 hourly for 5 days followed by rest period for ≥2 days
Max dose: 6.25 mg/day or
10-25 mg SC once weekly
Max dose: 25-30 mg/week

Adverse Reactions

Hematologic effects (bone marrow depression which can occur abruptly, leukopenia, thrombocytopenia, anemia); GI effects (nausea/vomiting, loss of appetite, abdominal pain, diarrhea); Hepatic effect (acute and chronic liver damage); CNS effects (dizziness, fever, seizure); Other effects (renal failure, renal tubular necrosis, interstitial lung disease, potentially fatal dermatologic reactions eg toxic epidermal necrolysis and Stevens-Johnson syndrome, ocular irritation, alopecia, osteoporosis, neurotoxicity, impaired fertility, arthralgia, soft tissue and bone necrosis)
Low-dose Methotrexate has been associated with development of malignant lymphomas
Use may predispose patients to opportunistic infection
Early signs of toxicity: Mouth ulcers, stomatitis, diarrhea. If these occur, therapy may need to be interrupted

Special Instructions

Avoid in patients with alcoholic liver disease or abnormal LFT or in those with significant renal impairment, blood disorders or immunodeficiency
Contraindicated in pregnancy and lactation
Use with caution in patients with peptic ulcer disease, ulcerative colitis, hepatic or renal impairment
Monitor CBC with platelets, LFT and renal function prior to and regularly during therapy
Baseline liver biopsy should be performed before Methotrexate institution in patients with risk factors for hepatotoxicity
Medication should be interrupted if diarrhea, myelosuppression, stomatitis or signs of liver dysfunction occur
Signs of infection (eg fever, sore throat) should be reported to physician immediately
May cause folic acid deficiency, consider giving folate supplement

Immunosuppressants - Oral

Drug	Dosage	Remarks
Apremilast	Titrate to recommended dose Initial dose: Day 1: 10 mg PO 24 hourly in the morning Day 2: 10 mg PO 12 hourly (morning and evening) Day 3: 10 mg PO in the morning and 20 mg PO in the evening Day 4: 20 mg PO 12 hourly (morning and evening) Day 5: 20 mg PO in the morning and 30 mg PO in the evening Maintenance dose (day 6 onwards): 30 mg PO 12 hourly (morning and evening)	Adverse Reactions GI effects (gastroenteritis, nausea); CNS effects (headache, migraine headache, tension headache, insomnia, depression, suicidal ideation); Respiratory effects (cough, upper respiratory tract infection [URTI], nasopharyngitis, sinusitis); Musculoskeletal effects (arthralgia, back pain); Other effects (fatigue, hypertension, decreased appetite, weight loss, hypersensitivity, rashes) Special Instructions Use with caution in patients with moderate-severe renal impairment, depression, history of suicidal thoughts/behavior, galactose intolerance, Lapp lactase deficiency, glucose-galactose malabsorption Obtain baseline renal function and monitor body weight, signs of emergence/worsening depression, suicidal thoughts, mood changes
Ciclosporin (Cyclosporin A, Cyclosporine)	Initial dose: 2.5 mg/kg/day PO divided 12 hourly for 1 month May increase by 0.5 mg/kg/day every 2 weeks Max dose: 4-5 mg/kg/day	Adverse Reactions CNS effects (headache, tremor); CV effects (hypertension, edema); GI effects (abdominal pain, diarrhea, nausea, dyspepsia, gingival hyperplasia); Metabolic/endocrine effects (hyperlipidemia, hyperkalemia); Hepatic effect (hepatotoxicity); Renal effect (reversible elevation of serum creatinine and BUN); Other effects (hirsutism, hypertrichosis, burning sensation of the extremities, infection) Less common: Rashes, anemia, pancreatitis, neuropathy, hyperuricemia, paresthesia Special Instructions Avoid in patients with renal dysfunction, uncontrolled hypertension, uncontrolled infections, persistently raised creatinine, malignancy, porphyria Monitor renal and hepatic function, BP and serum electrolytes and lipids regularly Should not be combined with UV irradiation and avoid exposure to excessive sunlight or UV radiation May increase the risk of malignancies Discontinue use if insufficient response after 6 weeks of max dose Vaccination with live-virus vaccines while on therapy is not recommended Commercially available oral products differ in their bioavailability; use caution when switching from one product to another
Deucravacitinib	6 mg PO 24 hourly	Adverse Reactions Dermatologic effects (folliculitis, acne); Other effects (URTI, increased blood creatine phosphokinase, rhabdomyolysis, herpes simplex, mouth ulcers) Hypersensitivity reactions (eg angioedema) and malignancies have been reported; may increase risk of infection Special Instructions Contraindicated in patients with known hypersensitivity to Deucravacitinib Avoid use with live vaccines and in patients with active or serious infection Evaluate for: TB prior to initiation of treatment, serum triglycerides periodically, liver enzymes at baseline and thereafter in patients with known or suspected liver disease
Dimethyl fumarate	Week 1: 30 mg PO 24 hourly Week 2: 30 mg PO 12 hourly Week 3: 30 mg PO 8 hourly Week 4: 120 mg PO 24 hourly Week 5: 120 mg PO 12 hourly Week 6: 120 mg PO 8 hourly Week 7: 120 mg PO in AM and midday, 240 mg PO in PM Week 8: 240 mg PO in AM, 120 mg PO in midday, 240 mg PO in PM Week 9 onwards: 240 mg PO 8 hourly Max dose: 720 mg/day	Adverse Reactions Hematologic effects (leukopenia, lymphopenia); GI effects (diarrhea, abdominal distention, abdominal pain, nausea/vomiting, dyspepsia, constipation, abdominal discomfort, flatulence); Renal effects (proteinuria, ketonuria, albuminuria); Other effects (angioedema, anaphylaxis, opportunistic infections, hepatic injury) Special Instructions Avoid use in patients with severe renal and hepatic impairment Use with caution in patients with severe GI disorders, serious infections, during pregnancy and lactation Monitor CBC including lymphocytes, renal and hepatic function prior to initiation and periodically during treatment Monitor for signs and symptoms of infection and hypersensitivity May impair ability to drive or operate machinery
Mycophenolic acid (Mycophenolate mofetil)	2-3 g PO 24 hourly	Adverse Reactions CV effects (hypertension, electrolyte imbalances, blood lipid disturbances); GI effects (nausea/vomiting, diarrhea, GI hemorrhage); Hepatic effects (pancreatitis, hepatitis); Hematologic effects (leukopenia, anemia, thrombocytopenia); CNS effects (fever, pain, headache, dizziness, insomnia, tremor); Other effects (asthenia, renal tubular necrosis, hematuria, cough, hyperglycemia, dyspnea, acne, rashes, alopecia, hypersensitivity) Increased risk of the following has been reported: Infection, including activation of latent viral infections, development of lymphoma and skin malignancy Special Instructions Contraindicated in pregnancy, lactation, and in patients with Kelley-Seegmiller or Lesch-Nyhan syndrome Use with caution in patients with renal impairment or active peptic ulcer disease Monitor CBC, renal and liver function Avoid inhalation or direct contact with skin or mucous membranes Avoid exposure to excessive sunlight or UV radiation May increase risk of malignancies Vaccination with live-virus vaccines while on therapy is not recommended

Immunosuppressants - Parenteral

Drug	Dosage	Remarks
Adalimumab (Adalimumab-adbm, Adalimumab-afzb, Adalimumab-atto)	80 mg SC initially, followed by 40 mg SC given every other week starting 1 week after initial dose	Adverse Reactions CNS effects (headache, dizziness); GI effects (nausea, diarrhea, abdominal pain, esophagitis); Respiratory effects (URTI, sinusitis, cough, pharyngitis); CV effects (hypertension, chest pain); Metabolic/endocrine effects (hyperlipidemia, hypercholesterolemia, increase in alkaline phosphatase, menorrhagia); Other effects (increased hepatic enzyme, positive ANA and anti-double stranded DNA antibodies, local injection site reactions, proteinuria, hematuria, rash) Serious and potentially fatal infections (eg bacterial, mycobacterial, viral, fungal infections) have been reported. Reports of reactivation of latent TB infection and new infection have been noted Special Instructions Contraindicated in patients with active TB or other severe infections (eg sepsis, opportunistic infections), moderate to severe heart failure Use with caution in patients with blood dyscrasias, heart failure, history of new/recurrent infections, conditions that predispose to infection, demyelinating CNS disorders Monitor for signs and symptoms of malignancy (eg splenomegaly, hepatomegaly, abdominal pain, persistent fever, night sweats, weight loss) Hepatitis B and TB screening is recommended prior to treatment Carefully reconsider continuing therapy beyond 16 weeks in a patient not responding during this time period
Bimekizumab (Bimekizumab-bkzx)	320 mg SC (given as 2 SC injection of 160 mg) at week 0, 4, 8, 12 and 16, then every 8 weeks thereafter ≥120 kg: Consider a dose of 320 mg every 4 weeks after week 16	Adverse Reactions Dermatologic effects (tinea infections, acne, folliculitis); Other effects (headache, URTI, gastroenteritis, fatigue, injection site reactions, herpes simplex infections, oral candidiasis, other candida infections) May increase risk of infections and suicidal ideation and behavior Special Instructions Avoid use in patients with active TB or IBD Initiate latent TB treatment before Bimekizumab therapy Test liver enzymes, alkaline phosphatase and bilirubin at baseline and according to routine patient management Complete all recommended age-appropriate vaccinations Monitor for signs and symptoms of infection and worsening of depression, suicidal ideation or other mood changes
Brodalumab	210 mg SC at week 0, 1, and 2 followed by 210 mg SC every 2 weeks	Adverse Reactions Respiratory effects (URTI, nasopharyngitis); Other effects (headache, arthralgia, pruritus, fatigue, oral candidiasis, neutropenia) Special Instructions Contraindicated in patients with severe infection and active TB Use with caution in patients with active Crohn's disease, depression, in a state of depression, or with history of suicidal ideation or suicidal attempt, elderly patients Avoid concomitant use with live vaccines, another biologic, immunosuppressant or phototherapy Monitor for signs and symptoms of infection and malignancy
Certolizumab pegol	400 mg SC (given as 2 SC injection of 200 mg each) every 2 weeks ≤90 kg: Initial dose of 400 mg SC (given as 2 SC injection of 200 mg each) on treatment week 0, 2 and 4 then reduce to 200 mg every 2 weeks starting on treatment week 6 Maintenance dose: 200 mg SC every 2 weeks or 400 mg SC every 2 weeks in patients with insufficient response	Adverse Reactions GI effect (nausea); Immunologic effect (antinuclear antibody development); Respiratory effect (URTI, nasopharyngitis); Other effects (serious infections, heart failure, malignancies) Special Instructions Contraindicated in pediatric patients, patients with severe infection, active TB, moderate-severe heart failure (NYHA Class III/IV) Use with caution in patients with history of neoplastic disease, current or past history of significant hematologic disorders, preexisting or recent-onset central or peripheral nervous system demyelinating disorders, elderly Avoid concomitant use with live vaccines Hepatitis and TB screening is recommended prior to treatment Monitor for signs and symptoms of infection and malignancy; discontinue Certolizumab if patient develops serious infection or sepsis
Efalizumab	0.7 mg/kg SC as a single dose Followed by 1 mg/kg SC weekly for 12 weeks Max dose: 200 mg/dose	Adverse Reactions Mild constitutional symptoms that follow first 1-2 injections (headache, chills, nausea, fever, myalgia); Hematologic effect (thrombocytopenia); Other effects (acne, back pain, increase in alkaline phosphatase concentration and LFT) Worsening of psoriasis during and after treatment has been reported Serious acute infections have been reported and there is the possibility of a risk of malignancies Special Instructions Avoid in patients with clinically important infection Use with caution in patients with high risk for malignancy or with history of malignancy, patients with chronic infection or history of recurrent infection Platelet counts should be measured prior to and periodically during treatment
Etanercept (Etanercept-szzs)	Initial dose: 25 mg SC 2x/week or 50 mg SC weekly or 50 mg SC 2x/week at intervals of 3-4 days for 3 months then reduce to 25 mg SC 2x/week or 50 mg SC weekly Continue treatment until remission is achieved for up to 24 weeks, discontinue if no response after 12 weeks	Adverse Reactions Associated with increased risk of hepatosplenic T-cell lymphoma in adolescents and young adults, and increased risk of leukemia in all patient age groups CNS effects (headache, dizziness); Respiratory effects (URTI, rhinitis); GI effects (abdominal pain, nausea/vomiting); Other effects (local site reaction, erythema, swelling) Allergic reactions may occur; rare cases of autoimmune disorder have been reported Serious and potentially fatal infections (eg bacterial, mycobacterial, viral, fungal infections) have been reported Reactivation of latent TB infection and new infection have been noted Special Instructions Contraindicated in patients with or at risk of sepsis Use with caution in patients with hematologic conditions, heart failure, history of recurrent infections, or diseases predisposing the patient to infection, with alcoholic hepatitis, demyelinating CNS disorders All immunizations should be updated prior to initiating therapy No dose adjustment is required in patients with hepatic and renal impairment Monitor for signs and symptoms of malignancy Discontinue treatment after 12 weeks in unresponsive patients
Guselkumab	100 mg SC at week 0 & 4, followed by maintenance dose every 8 weeks	Adverse Reactions GI effects (gastroenteritis, diarrhea); Respiratory effect (URTI); Other effects (herpes simplex and tinea infections, headache, urticaria, arthralgia, injection site erythema) Special Instructions Contraindicated in patients with clinically active infection (eg active TB) Use with caution in elderly ≥65 years old, children and adolescents ≤18 years old, during pregnancy and lactation Avoid concomitant use with live vaccines, biologics, other immunosuppressants or phototherapy Screen for TB prior to treatment initiation; monitor for signs and symptoms of active TB All immunizations should be updated prior to initiating therapy
Infliximab (Infliximab-abda, Infliximab-dyyb)	5 mg/kg IV infusion over 2 hours at week 0, 2 and 6 then every 8 weeks thereafter	Adverse Reactions Associated with increased risk of hepatosplenic T-cell lymphoma in adolescents and young adults, and increased risk of leukemia in all patient age groups CNS effects (headache, dizziness); GI effects (nausea, diarrhea, abdominal pain, esophagitis); Respiratory effects (URTI, sinusitis, cough, pharyngitis); CV effects (hypertension, chest pain); Other effects (hyperlipidemia, hypercholesterolemia, increased hepatic enzyme, positive ANA and anti-double stranded DNA antibodies, local site reaction, proteinuria, hematuria, increased alkaline phosphatase, menorrhagia) Serious and potentially fatal infections (eg bacterial, mycobacterial, viral, fungal), reactivation of latent TB infection, and new infection have been reported Special Instructions Consider premedication with antihistamine and/or corticosteroids to avoid reactions related to infusion of the drug Contraindicated in patients with severe infection (sepsis, TB, opportunistic infection), heart failure NYHA class III/IV Use with caution in patients with blood dyscrasias, heart failure, history of new/recurrent infections, with conditions that predispose to infection, demyelinating CNS disorders Monitor for signs and symptoms of malignancy Hepatitis and TB screening is recommended prior to treatment
Itolizumab	1.6 mg/kg IV infusion once every 2 weeks for 12 weeks followed by 1.6 mg/kg IV infusion every 4 weeks up to 24 weeks	Adverse Reactions GI effects (diarrhea, vomiting, toothache, gastritis); CNS effects (headache, peripheral neuropathy, cerebrovascular accident); Dermatologic effects (pruritus, erythrodermic psoriasis, exfoliative dermatitis); Musculoskeletal effects (arthralgia, musculoskeletal pain); Other effects (infusion-related reactions, pyrexia, URTI, UTI, bacterial lymphadenitis, lymph node TB, oral herpes, peripheral edema, chest pain, hypertriglyceridemia) Special Instructions Contraindicated in patients with active serious infection Should not be used with other biologic agents for psoriasis treatment Use with caution in patients with HIV or hepatitis B or C infection; patients receiving or previously on chronic steroid therapy Monitor for signs and symptoms of infection (eg latent TB) during and after treatment TB screening is recommended prior to treatment Should not be given concurrently with live or attenuated vaccines
Ixekizumab	160 mg SC injection (2 SC injections of 80 mg) at week 0, then 80 mg SC injection at weeks 2, 4, 6, 8, 10 and 12, followed by maintenance dose of 80 mg SC every 4 weeks	Adverse Reactions Infections (URTI, tinea infections, oral candidiasis, conjunctivitis); GI effects (Crohn’s disease, ulcerative colitis, nausea); Other effects (angioedema, urticaria, injection site reactions, neutropenia, thrombocytopenia) Special Instructions Contraindicated in patients with active infections Use with caution in patients with infections, hypersensitivity, IBD Should not be used with live vaccines
Risankizumab (Risankizumab-rzaa)	150 mg SC injection (2 SC injections of 75 mg) at week 0 and 4 then every 12 weeks thereafter	Adverse Reactions CNS effect (headache); Dermatologic effects (folliculitis, injection site reactions); Other effects (URTIs, urticaria, fatigue, asthenia, tinea infections) Special Instructions Screen for TB prior to treatment initiation Avoid in patients with clinically active infection All immunizations should be updated prior to initiating therapy
Secukinumab	300 mg SC injection (2 SC injections of 150 mg) at weeks 0, 1, 2, 3 and 4, followed by monthly maintenance dosing starting at week 4	Adverse Reactions GI effects (oral herpes, diarrhea, IBD); Respiratory effects (URTIs, rhinorrhea); Other effects (urticaria, mucocutaneous candida infection, neutropenia) Special Instructions Avoid in patients with clinically active infection Use with caution in patients with mild or moderate URTIs, non-serious mucocutaneous candida infections, chronic infection or a history of recurrent infection, Crohn’s disease, in latex-sensitive individuals, in women of childbearing potential Avoid administration of live vaccines
Spesolimab (Spesolimab-sbzo)	900 mg IV infusion over 90 minutes single dose May administer second 900 mg IV infusion 1 week after the initial dose if flare symptoms persist	Adverse Reactions CNS effects (asthenia, fatigue, headache); Other effects (nausea/vomiting, pruritus, prurigo, infusion site hematoma and bruising, UTI) Special Instructions Contraindicated in patients with severe or life-threatening hypersensitivity to Spesolimab or to any of the excipients, clinically active infection (eg TB) Avoid concurrent vaccination with live vaccines Evaluate for TB prior to initiating therapy Monitor for signs and symptoms of clinically important infection after treatment; discontinue use if a serious hypersensitivity reaction occurs
Tildrakizumab	100 mg SC at week 0 and 4, followed by maintenance dose every 12 weeks	Adverse Reactions Respiratory effect (URTI); GI effect (diarrhea); Immunologic effect (antibody development); Other effects (infection, injection site reaction) Special Instructions Contraindicated in patients with clinically active infection (eg TB) Avoid concurrent vaccination with live vaccines All immunization should be updated prior to initiating therapy Screen for latent TB prior to initiating therapy Monitor for signs and symptoms of infection including active TB; discontinue use if serious infection or sepsis occurs
Ustekinumab	45 mg SC at week 0 and 4, then every 12 weeks thereafter >100 kg: 90 mg may be used	Adverse Reactions Infrequent but serious infections (eg bacterial, fungal, viral); CNS effects (headache, dizziness, fatigue); Other effects (back pain, rash, urticaria, antibody formation, local site reaction) Special Instructions Avoid in patients with clinically important active infection Use with caution in patients with high risk for malignancy or with history of malignancy, patients with chronic infection or history of recurrent infection, patients with renal or hepatic impairment All immunizations should be updated prior to initiating therapy TB screening is recommended prior to treatment Consideration should be given to discontinuing treatment in patients who have shown no response up to 28 weeks of treatment

Psoriasis, Seborrhea & Ichthyosis Preparations - Oral

Psoralen
Drug	Dosage	Remarks
Methoxsalen	10-70 mg PO given 1.5-2 hours prior to UVA exposure Usually given twice 2-3x weekly (with ≥48 hours between treatments) depending on UVA schedule	Adverse Reactions GI effect (nausea); CNS effects (insomnia, nervousness, depression) When combined with UVA: Dermatologic effects (pruritus, mild transient erythema, acne, severe skin pain, premature aging, hypertrichosis and pigmentation alteration); CNS effects (headache, dizziness); Other effects (edema, onycholysis) Severe burns may result from inadvertent sunlight/UV light exposure post-treatment Increased risk of malignant neoplasms Special Instructions Contraindicated in patients with aphakia, melanoma, invasive squamous cell carcinoma and diseases associated with light sensitivity (eg porphyria) Use with caution in patients with hepatic insufficiency, CV disease Protect genitalia and eyes during therapy Avoid sunlight for >8 hours after Methoxsalen ingestion and should wear wrap-around UVA absorbing glasses for 24 hours after administration Avoid excessive sunlight for 24 hours before and 48 hours after PUVA treatment Patients should undergo ophthalmologic exams (prior to treatment and annually) and regular exams to look for signs of malignant or premalignant skin lesions
Systemic Retinoid
Acitretin	Initial dose: 25-30 mg/day PO for 2-4 weeks Adjust dose based on patient response and adverse reactions Maintenance dose: 25-50 mg/day PO for 6-8 weeks Max dose: 50 mg/day	Adverse Reactions Usually dose-related and reversible upon discontinuation: Dermatologic effects (cheilitis, dry mucous membranes and skin, scaling, erythematous rash, skin atrophy, pruritus, alopecia, photosensitivity); Ophthalmologic effect (visual disturbances); GI effect (xerostomia); Hepatic effects (increased LFT, pancreatitis); CNS effects (hyperesthesia, headache, depression, suicidal tendencies); Metabolic/endocrine effects (hypertriglyceridemia, hypercholesterolemia, elevated blood glucose, hyperuricemia); Musculoskeletal effects (arthralgia, spinal hyperostosis progression); Other effects (epistaxis, rhinitis, hematuria) Special Instructions Contraindicated in patients with severe hepatic or renal dysfunction, chronically elevated blood lipid levels; pregnancy is contraindicated for 3 years after treatment discontinuation Patients should not donate blood during therapy or for 3 years after treatment discontinuation; should also abstain from ethanol or ethanol-containing products during therapy and for 2 months after discontinuation Avoid exposure to excessive sunlight or UV radiation Monitor CBC, BUN, creatinine, LFT, lipids, prior to therapy, after the first month and as required thereafter Monitor blood glucose throughout treatment

Psoriasis, Seborrhea & Ichthyosis Preparations - Topical

Drug	Available Strength	Dosage	Remarks
Coal tar¹	0.5%, 1.5% lotion 0.5%, 2% gel 2% ointment, aerosol foam 2.3% solution 5% emulsion 6% cream	Apply 6-24 hourly (for gel, ointment, aerosol foam, lotion, emulsion) Apply 12-24 hourly (for cream, solution)	Adverse Reactions Skin irritation and acne-like skin eruption, photosensitivity Special Instructions Do not apply to inflamed or broken skin, genital or rectal areas Avoid in patients with psoriasis exacerbation Use with caution on the face, near eyes and mucous membranes If undergoing Goeckerman treatment, all coal tar preparation should be removed from skin before exposure to radiation
Other Antipsoriatics for Topical Use
Calcipotriol (Calcipotriene)	50 mcg/g cream, gel, ointment 50 mcg/mL scalp solution	Apply 12-24 hourly (for ointment and gel) Apply 12 hourly (for cream and scalp solution) Max dose for cream, gel and ointment: 15 g/day or 100 g/week Max dose for scalp solution: 60 mL/week Max treated area: 30% BSA Recommended treatment period: 4 weeks	Adverse Reactions Transient local irritation, erythema, scaling and rarely facial dermatitis Potential for hypercalcemia if max dose is exceeded Special Instructions Contraindicated in patients with viral, fungal or bacterial infections of the skin Apply 2 hours before or after UV treatment Maintenance therapy may be achieved with less frequent application Should not be used on the face
Calcipotriol/ Betamethasone dipropionate	50 mcg/500 mcg ointment, gel, foam	Apply 24 hourly Max dose: 15 g/day or 100 g/week Max treated area: 30% BSA Recommended treatment period: Ointment: 4 weeks; gel: 8 weeks	Adverse Reactions Pruritus, dermatitis, erythema, exacerbation of psoriasis Ointment: Local transient irritation Gel: Burning sensation of skin, skin pain or irritation, folliculitis, acne, dry skin, rash, and eye irritation Special Instructions Avoid application on the face, mouth, eyes and genital area, large areas of skin or on mucous membranes Avoid concomitant use with other steroids Hypercalcemia may occur in overdose Discontinue use if infections worsen
Calcitriol	3 mcg/g ointment	Apply 12 hourly Max dose:30 g/day up to 35% BSA	Adverse Reactions Skin sensitivity or irritation Hypercalcemia can occur Special Instructions Avoid in patients with hypercalcemia or Ca metabolism problems, kidney or liver/biliary impairment, or on systemic therapy for Ca deficiency Not evaluated for use in patients with erythrodermic, exfoliative, or pustular psoriasis
Roflumilast	0.3% cream	Apply 24 hourly	Adverse Reactions CNS effects (headache, insomnia): Other effects (application site pain, URTI, UTI, diarrhea) Special Instructions Contraindicated in patients with moderate to severe liver impairment
Tapinarof	1% cream	Apply thinly 24 hourly	Adverse Reactions Dermatologic effects (folliculitis, contact dermatitis, pruritus); Other effects (headache, influenza, nasopharyngitis) Special Instructions Not for oral, ophthalmic or intravaginal use
Tazarotene²	0.05%, 0.1% cream, gel	Apply thinly to the lesions 24 hourly in the evening	Adverse Reactions Pruritus, burning, stinging, peeling, skin redness, edema, discoloration, fissuring, rash, contact dermatitis, dryness, photosensitivity, bleeding Special Instructions Avoid exposure to excessive sunlight or UV radiation Contraindicated in pregnancy, lactation, women of childbearing potential who are unable to comply with birth control requirements Avoid contact with eyes, mouth, mucous membranes; broken, eczematous or sunburned skin Safety and efficacy of gel applied over >20% BSA have not been established
Topical Antracen Derivative Agent
Dithranol³ (Anthralin)	0.02% cream	Apply to lesions 24 hourly	Adverse Reactions Burning sensation, skin irritation especially on non-affected skin; staining of skin and hair Special Instructions Contraindicated in patients with inflamed skin or hypersensitivity Use with caution in patients with renal disease and during extensive and prolonged applications Short-contact therapy is recommended to limit adverse effects Avoid use on face, skin flexures, inner thighs, upper arms, breasts and genitals Avoid contact with eyes and mucous membranes Recommend that patients apply cream/ointment using cotton-tipped applicator or a gloved hand

¹Combinations with a number of different agents are available. Please see the latest MIMS for specific formulations and prescribing information.
²Tazarotene combined with corticosteroid is available. Please see the latest MIMS for specific formulations and prescribing information.
³Dithranol combined with keratolytics are available. Please see the latest MIMS for specific formulations and prescribing information.

Warts & Calluses Preparations*

Drug	Available Strength	Dosage	Remarks
Salicylic acid	2-11.8% cream, lotion, ointment, shampoo	Apply 6-24 hourly	Adverse Reactions Prolonged use over large BSA may result in salicylate toxicity Local irritation when in contact with normal skin, sensitivity, excessive drying Special Instructions Avoid use on broken skin, mouth, eyes, mucous membranes and anogenital regions
Sulfur	10% ointment	Apply 12-24 hourly	Adverse Reactions Skin irritation and dermatitis Special Instructions Avoid contact with eyes, mouth and other mucous membranes
Urea	10% cream, lotion 20% cream	Apply 8-12 hourly	Adverse Reactions May be irritating to sensitive skin Special Instructions Avoid contact with eyes Contraindicated in patients with viral skin infection

*Warts and calluses preparations combined with a number of different agents are available. Please see the latest MIMS for specific formulations and prescribing information.

Disclaimer

All dosage recommendations are for non-pregnant and non-breastfeeding women and non-elderly adults with normal renal and hepatic function unless otherwise stated.
Not all products are available or approved for above use in all countries.
Products listed in the Drug Summary are based on indications stated in the locally approved product monographs.
Please refer to local product monographs in Related MIMS Drugs for country-specific prescribing information.

Psoriasis Drug Summary

Antibiotics - Topical

Anti-infectives with Corticosteroids - Topical

Calcineurin Inhibitors

Corticosteroids - Systemic

Corticosteroids - Topical*

Cytotoxic Chemotherapy

Immunosuppressants - Oral

Immunosuppressants - Parenteral

Psoriasis, Seborrhea & Ichthyosis Preparations - Oral

Psoriasis, Seborrhea & Ichthyosis Preparations - Topical

Warts & Calluses Preparations*

Disclaimer

Related MIMS Drugs