Drugs List

Therapeutic Indications

Uses

Chronic psoriasis
Psoriasis - scalp
Subacute psoriasis

Dosage

A small amount should be used and this should be rubbed in gently and thoroughly until it no longer smears. A bath or shower should be taken after each treatment to remove dithranol residue. Rinse the bath or shower immediately after washing/showering to avoid discolouration.

Brands differ in formulation. Advice patients to follow the detailed instructions from the manufacturer.

Initiate treatment with a cream containing a low concentration of dithranol, then increase according to tolerance and response. The aim should be to build up gradually over approximately 4 weeks to the highest tolerated strength to produce the optimum therapeutic effect. The optimum concentration will depend on a number of factors including thickness and location of psoriatic plaques, and variation between patients in their to reaction to dithranol.

For scalp use, first comb the hair to remove scalar debris and rub cream well into the affected areas.

Short contact therapy:
Apply once every 24 hours (day or evening). Remove by washing off the skin or scalp, usually no more than one hour after application.

Alternative use (0.1%, 0.25% and 0.5% concentrations only):
Apply at night before bed and wash off in the morning.

Continue treatment until skin is entirely clear, i.e. texture is normal. Gradual titration should clear patches of psoriasis within 4 to 6 weeks.

Contraindications

Exfoliative dermatitis
Folliculitis

Precautions and Warnings

Children under 18 years
Recent potent topical steroids use
Breastfeeding
Pregnancy

Unsuitable for widespread small lesions, pustular or acute psoriasis
Allow 1 week between discontinuation of steroid cream & starting dithranol
Not all available brands/formulations are licensed for use in children
Advise patient to wash hands after use
Avoid contact with eyes
Avoid contact with mucous membranes
Avoid excessive use
Breastfeeding: Wash product off breasts prior to breastfeeding infant
Do not apply to blistered skin
Do not apply to genitalia
Do not apply to intertriginous skin
Do not apply to raw or oozing areas of skin
If accidental contact with the eyes occurs, rinse thoroughly with water
Not to be applied to the face
Discontinue if burning sensation occurs
Discontinue if sensitisation occurs
Reduce or discontinue treatment if excessive soreness, or lesions spread
Avoid use on normal skin
May stain the bath or fabrics
Stains clothes and skin
Stains hair

Only titrate to higher treatment strength (dithranol 0.5%, dithranol 1% and dithranol 2%) aqueous creams in patients who have failed to respond to the lowest strength. If adverse reactions occur, reduce to the highest strength tolerated.

Long term use of topical corticosteroids may destabilise psoriasis, and withdrawal of the steroid therapy may cause a rebound phenomenon. Allow an interval of at least 1 to 2 weeks between discontinuation of steroid cream and starting dithranol. A bland emollient may be used during this interval.

Pregnancy and Lactation

Pregnancy

Use dithranol with caution during pregnancy.

Briggs suggests the embryo-foetal risk is probably nil. High systemic absorption of dithranol from topical application is not considered likely (Schaefer 2007). The manufacturer's suggest there is no experimental evidence to support the safe use of dithranol during pregnancy, however no adverse effects have been reported.

At the time of writing, there have been no studies on humans or animals, concerning exposed pregnancies and their outcomes. If dithranol is systemically absorbed, its low molecular weight (about 226) would suggest that transfer to the embryo or foetus is possible.

If dithranol is required during pregnancy, the lowest effective concentration on small areas, for short durations should be used.

The use of all medication in pregnancy should be avoided whenever possible; particularly in the first trimester. Non-drug treatments should also be considered. When essential, a medication with the best safety record over time should be chosen, employing the lowest effective dose for the shortest possible time. Polypharmacy should be avoided. Teratogens taken in the pre-embryonic period, often quoted as lasting until 14 to 17 days post-conception, are believed to have an all-or-nothing effect. Where drugs have a short half-life, and when the date of conception is certain, this may allow women to be reassured where drug exposure has occurred within this time frame. Further advice may be available from the UK National Teratology Information Service (NTIS) and through ToxBase, available via password on the internet ( www.toxbase.org ) or if this is unavailable at the backup site ( www.toxbasebackup.org ).

Lactation

Use dithranol with caution in breastfeeding.

Briggs suggests exposure of the breastfed infant to clinically significant amounts of dithranol appears to be nil. Hale suggests that dithranol may cause diarrhoea, nausea and vomiting, if ingested by an infant. The manufacturer's suggest there is no experimental evidence to support the safe use of dithranol in breastfeeding, however no adverse effects have been reported. Breastfeeding mothers are advised not to use dithranol on the breast area. Care should be taken to avoid contact between dithranol treated areas, and the infant's mouth or skin.

The systemic absorption of dithranol has not been studied, and therefore the passage of dithranol into breast milk is unknown. The molecular weight (about 226) is low enough for excretion into breast milk.

Neonates, infants born prematurely, those with low birth weight, those with an unstable gastrointestinal function or who have serious illnesses may require special consideration. For any infant, if a drug is prescribed to the nursing mother, it should be at the lowest practical dose and for the shortest time. When drug administration is unavoidable and breastfeeding is to continue, minimisation of exposure of the infant to the drug may sometimes be achieved by timing the maternal doses to just after a feeding episode. Infants exposed to drugs via breast milk should be monitored for unusual signs or symptoms. Interactions between the drug received by the infant from the mother's milk and medication prescribed for the infant should also be considered, for example, when the drug given to the infant may prevent metabolism of the drug received via breast milk.
Specialist advice is available from the UK Drugs in Lactation Advisory Service at https://www.midlandsmedicines.nhs.uk/content.asp?section=6&subsection=17&pageIdx=1

Side Effects

Burning sensation (local)
Discolouration of nails (temporary)
Erythema
Hypersensitivity reactions
Irritation (localised)
Rash
Sensation of warmth
Stained hair
Stained skin and clothing

Presentation

Creams containing dithranol

Drugs List

Therapeutic Indications

Uses

Chronic psoriasis
Psoriasis - scalp
Subacute psoriasis

Dosage

A small amount should be used and this should be rubbed in gently and thoroughly until it no longer smears. A bath or shower should be taken after each treatment to remove dithranol residue. Rinse the bath or shower immediately after washing/showering to avoid discolouration.

Brands differ in formulation. Advice patients to follow the detailed instructions from the manufacturer.

Initiate treatment with a cream containing a low concentration of dithranol, then increase according to tolerance and response. The aim should be to build up gradually over approximately 4 weeks to the highest tolerated strength to produce the optimum therapeutic effect. The optimum concentration will depend on a number of factors including thickness and location of psoriatic plaques, and variation between patients in their to reaction to dithranol.

For scalp use, first comb the hair to remove scalar debris and rub cream well into the affected areas.

Short contact therapy:
Apply once every 24 hours (day or evening). Remove by washing off the skin or scalp, usually no more than one hour after application.

Alternative use (0.1%, 0.25% and 0.5% concentrations only):
Apply at night before bed and wash off in the morning.

Continue treatment until skin is entirely clear, i.e. texture is normal. Gradual titration should clear patches of psoriasis within 4 to 6 weeks.

Contraindications

Exfoliative dermatitis
Folliculitis

Precautions and Warnings

Children under 18 years
Recent potent topical steroids use
Breastfeeding
Pregnancy

Unsuitable for widespread small lesions, pustular or acute psoriasis
Allow 1 week between discontinuation of steroid cream & starting dithranol
Not all available brands/formulations are licensed for use in children
Advise patient to wash hands after use
Avoid contact with eyes
Avoid contact with mucous membranes
Avoid excessive use
Breastfeeding: Wash product off breasts prior to breastfeeding infant
Do not apply to blistered skin
Do not apply to genitalia
Do not apply to intertriginous skin
Do not apply to raw or oozing areas of skin
If accidental contact with the eyes occurs, rinse thoroughly with water
Not to be applied to the face
Discontinue if burning sensation occurs
Discontinue if sensitisation occurs
Reduce or discontinue treatment if excessive soreness, or lesions spread
Avoid use on normal skin
May stain the bath or fabrics
Stains clothes and skin
Stains hair

Only titrate to higher treatment strength (dithranol 0.5%, dithranol 1% and dithranol 2%) aqueous creams in patients who have failed to respond to the lowest strength. If adverse reactions occur, reduce to the highest strength tolerated.

Long term use of topical corticosteroids may destabilise psoriasis, and withdrawal of the steroid therapy may cause a rebound phenomenon. Allow an interval of at least 1 to 2 weeks between discontinuation of steroid cream and starting dithranol. A bland emollient may be used during this interval.

Pregnancy and Lactation

Pregnancy

Use dithranol with caution during pregnancy.

Briggs suggests the embryo-foetal risk is probably nil. High systemic absorption of dithranol from topical application is not considered likely (Schaefer 2007). The manufacturer's suggest there is no experimental evidence to support the safe use of dithranol during pregnancy, however no adverse effects have been reported.

At the time of writing, there have been no studies on humans or animals, concerning exposed pregnancies and their outcomes. If dithranol is systemically absorbed, its low molecular weight (about 226) would suggest that transfer to the embryo or foetus is possible.

If dithranol is required during pregnancy, the lowest effective concentration on small areas, for short durations should be used.

The use of all medication in pregnancy should be avoided whenever possible; particularly in the first trimester. Non-drug treatments should also be considered. When essential, a medication with the best safety record over time should be chosen, employing the lowest effective dose for the shortest possible time. Polypharmacy should be avoided. Teratogens taken in the pre-embryonic period, often quoted as lasting until 14 to 17 days post-conception, are believed to have an all-or-nothing effect. Where drugs have a short half-life, and when the date of conception is certain, this may allow women to be reassured where drug exposure has occurred within this time frame. Further advice may be available from the UK National Teratology Information Service (NTIS) and through ToxBase, available via password on the internet ( www.toxbase.org ) or if this is unavailable at the backup site ( www.toxbasebackup.org ).

Lactation

Use dithranol with caution in breastfeeding.

Briggs suggests exposure of the breastfed infant to clinically significant amounts of dithranol appears to be nil. Hale suggests that dithranol may cause diarrhoea, nausea and vomiting, if ingested by an infant. The manufacturer's suggest there is no experimental evidence to support the safe use of dithranol in breastfeeding, however no adverse effects have been reported. Breastfeeding mothers are advised not to use dithranol on the breast area. Care should be taken to avoid contact between dithranol treated areas, and the infant's mouth or skin.

The systemic absorption of dithranol has not been studied, and therefore the passage of dithranol into breast milk is unknown. The molecular weight (about 226) is low enough for excretion into breast milk.

Neonates, infants born prematurely, those with low birth weight, those with an unstable gastrointestinal function or who have serious illnesses may require special consideration. For any infant, if a drug is prescribed to the nursing mother, it should be at the lowest practical dose and for the shortest time. When drug administration is unavoidable and breastfeeding is to continue, minimisation of exposure of the infant to the drug may sometimes be achieved by timing the maternal doses to just after a feeding episode. Infants exposed to drugs via breast milk should be monitored for unusual signs or symptoms. Interactions between the drug received by the infant from the mother's milk and medication prescribed for the infant should also be considered, for example, when the drug given to the infant may prevent metabolism of the drug received via breast milk.
Specialist advice is available from the UK Drugs in Lactation Advisory Service at https://www.midlandsmedicines.nhs.uk/content.asp?section=6&subsection=17&pageIdx=1

Counselling

Advice patients to follow the detailed instructions from the manufacturer.

Advise patient to always wash hands after use.

Advise patient to avoid contact of cream with eyes and/or mucous membranes especially when removing the cream from the scalp.

Advise patient to avoid application to surrounding normal skin.

Advise patient not to use soap and/or hot water (above 30 degrees C) to wash of these preparations as this can cause increased staining of the skin. Clothing and bed linen may be stained by the lipid stabilised base creams. To remove this staining, rinse in lukewarm water only (not more than 30 degrees C). Possible discolouration of the bath or shower should be avoided by rinsing surfaces with lukewarm water. A suitable cleanser may be used if any cream remains on the surface.

Advise patient to stop treatment and contact their physician if a burning sensation occurs at application site or the lesions spread.

Advise patient dithranol cream may cause staining of skin, hair, clothing and bedding.

Side Effects

Burning sensation (local)
Discolouration of nails (temporary)
Erythema
Hypersensitivity reactions
Irritation (localised)
Rash
Sensation of warmth
Stained hair
Stained skin and clothing

Overdosage

It is strongly recommended that the UK National Poisons Information Service be consulted on cases of suspected or actual overdose where there is doubt over the degree of risk or about appropriate management.

The following number will direct the caller to the relevant local centre (0844) 892 0111

Information may be obtained if you have access to ToxBase the primary clinical toxicology database of the National Poisons Information Service. This is available via password on the internet ( www.toxbase.org ) or if this is unavailable at the backup site ( www.toxbasebackup.org ).

Further Information

Last Full Review Date: October 2013

Reference Sources

Drugs During Pregnancy and Lactation: Treatment Options and Risk Assessment, 2nd edition (2007) ed. Schaefer, C., Peters, P. and Miller, R. Elsevier, London.

Drugs in Pregnancy and Lactation: A Reference Guide to Fetal and Neonatal Risk, 9th edition (2011) ed. Briggs, G., Freeman, R. and Yaffe, S. Lippincott Williams & Wilkins, Philadelphia.

Joint Formulary Committee. British National Formulary (online) London: BMJ Group and Pharmaceutical Press [Accessed on 09 October 2013].

Medications and Mothers' Milk, 14th Edition (2010) Hale, T. Hale Publishing, Amarillo, Texas.

Paediatric Formulary Committee. BNF for Children (online) London: BMJ Group, Pharmaceutical Press, and RCPCH Publications [Accessed on 09 October 2013].

Summary of Product Characteristics: Dithrocream. Dermal Laboratories. Revised October 2006
Summary of Product Characteristics: Micanol cream 1%. GP Pharma. Revised April 2003.
Summary of Product Characteristics: Micanol cream 3%. GP Pharma. Revised April 2003.

Therapeutics in Pregnancy and Lactation (2000) Lee, A., Inch, S. and Finnigan, D. Radcliffe Medical Press, Abingdon.