Appropriate use and potential side effects of TCS Zinc Code: UK/RET/0122/16b Date of Prep: November 2016   Appropriate use and potential side effects of TCS As pharmacists, you can support the patient with advice on how to best use the TCS they have been prescribed, as well as information on the side effect profile of these therapies.

The fingertip unit is a well-established measure for TCS application Zinc Code: UK/RET/0122/16b Date of Prep: November 2016 The fingertip unit is a well-established measure for TCS application One adult fingertip unit (FTU) Amount of ointment or cream expressed from a tube with a standard 5mm diameter nozzle Age Face and neck Arm and hand Leg and foot Trunk (front) Trunk (back including buttocks) Adults 2.5 4 8 7 Children 3–6 months 1 1.5 1–2 years 2 3 3–5 years 3.5 6–10 years 4.5 5 One fingertip unit Ensure patient is aware of the different FTUs required based on age and location of disease* TCS quantities are generally measured in fingertip units – this is a simple and relatively consistent way to measure the amount of TCS being used on a particular area The age of the patient and location on the body affects the number of FTUs needed – it’s important that the patient uses the correct amount to address the symptoms while limiting the potential for adverse effects Reference NICE. Eczema – atopic. Clinical Knowledge Summaries 2015; http://cks.nice.org.uk/eczema-atopic. Accessed September 2016 *Guidance regarding how TCS should be used will be provided by the prescribing physician, and patients should be reminded of these specific recommendations NICE. Eczema – atopic. Clinical Knowledge Summaries 2015; http://cks.nice.org.uk/eczema-atopic. Accessed September 2016.

Systemic side effects with TCS are rare Zinc Code: UK/RET/0122/16b Date of Prep: November 2016 Systemic side effects with TCS are rare TCS can cause local and systemic side effects; local side effects are more common1 Fear of side effects can lead to undertreatment2 Factors affecting the risk of systemic side effects include:3–6 Potency and formulation, occlusive dressings, duration of exposure, surface area of application, location (e.g. thin skin areas, broken skin), and age as children are at higher risk Should be used with caution in patients with a history of hypersensitivity to other corticosteroids3–6 Local side effects3–6 Skin thinning Wrinkling Dryness Atrophy Stretch marks Visible blood vessels,* Rash Hives Redness Pigmentation changes Excessive hair growth Allergic contact dermatitis Pustular psoriasis Systemic side effects3–6 HPA axis suppression Cushing’s syndrome Hypersensitivity Opportunistic infection Most patients are prescribed TCS with mild potency, which carry a minimal risk of harm2 TCS use can be associated with both local and systemic effects,1 but mild-potency TCS are generally considered to be low risk2 TCS should be used with caution in:2-4 Selected locations on the body, including the scrotum and groin, face, underarms and eye area Children and older adults Different TCS vehicles may have a varying ability to penetrate the skin, and different potencies will influence the likelihood of side effects4 TCS use over time should be monitored References NICE. Psoriasis. Clinical Knowledge Summaries 2014; http://cks.nice.org.uk/psoriasis. Accessed September 2016. Rubel D, et al. J Dermatol 2013; 40:160–171. Eichenfield LF, et al. J Am Acad Dermatol 2014; 71:116–132. Ference JD, et al. Am Fam Physician 2009; 79:135–140. 1. NICE. Psoriasis. Clinical Knowledge Summaries 2014; http://cks.nice.org.uk/psoriasis. Accessed September 2016; 2. Bewley A, et al. Br J Dermatol 2008; 158:917–920; 3. Cutivate cream. UK Summary of Product Characteristics, February 2014; 4. Betnovate cream. UK Summary of Product Characteristics, Sept 2013; 5. Dermovate cream. UK Summary of Product Characteristics, Nov 2014; 6. Eumovate cream. UK Summary of Product Characteristics, March 2014.

Zinc Code: UK/RET/0122/16b Date of Prep: November 2016 A range of TCS potencies and formulations is available to treat AD and psoriasis The amount of TCS to use is measured in fingertip units (FTU)1 Different numbers of fingertip units are appropriate for different ages and areas of the body1 TCS can cause both local and systemic side effects, but TCS are generally well tolerated2–5 1 It is important to be aware of the risk factors predisposing patients to side effects and to support them to use their treatment appropriately In addition to advice on using emollients, pharmacists can provide key practical support and guidance on TCS use, including how and where to apply the formulations. It is common for patients to be prescribed a selection of TCS with different potencies; therefore, it is important that they understand which therapy should be used where, and for how long. In case of any doubt, the patient should return to their HCP for further assessment and guidance. 1. NICE. Eczema – atopic. Clinical Knowledge Summaries 2015; http://cks.nice.org.uk/eczema-atopic. Accessed September 2016; 2. Cutivate cream. UK Summary of Product Characteristics, February 2014; 3. Betnovate cream. UK Summary of Product Characteristics, Sept 2013; 4. Dermovate cream. UK Summary of Product Characteristics, Nov 2014; 5. Eumovate cream. UK Summary of Product Characteristics, March 2014.