Synopsis
Select targeted dermatology treatment through disease-specific NICE pathways, screen infection, vaccination, cardiovascular, malignancy and reproductive risk, match mechanism to comorbidity, and apply agent-specific response, laboratory and adverse-event monitoring.
- A marketing authorisation does not equal NHS eligibility: verify the current disease-specific NICE technology appraisal, severity threshold, previous-treatment requirement and local pathway before offering a drug.
- Biologics are antibodies or receptor proteins targeting cytokines or cells; small molecules enter cells and inhibit signalling enzymes such as JAK, TYK2 or PDE4 and often need more laboratory and interaction surveillance.
- Baseline review includes infection history, TB, hepatitis B and C, HIV by risk, vaccination, FBC, renal and liver function, pregnancy plans, malignancy, cardiovascular and thrombotic risk and disease-specific comorbidity.
- Complete needed live vaccines before immunosuppression using Green Book timing; live vaccines are generally avoided during biologic or JAK treatment, while non-live vaccines remain important.
- Choose by phenotype and comorbidity: inflammatory bowel disease discourages some IL-17 choices, demyelination or severe heart failure affects TNF selection, and recurrent eye disease matters with dupilumab.
- JAK inhibitors have serious infection, zoster, MACE, malignancy, thrombosis and mortality warnings; in people aged 65 or over, smokers or those with cardiovascular or cancer risk, use only when no suitable alternative exists.
- Do not combine two biologics or a biologic with a JAK inhibitor; additive immune suppression lacks routine benefit and increases serious infection risk.
- Record generic and brand or biosimilar name, batch where available and exact dosing interval so adverse events and switching remain traceable.
- Assess response at the appraisal-specified time using an objective disease measure and quality-of-life outcome; stop or switch when the required response is not achieved.
- A long biologic half-life means risk persists after withholding; serious infection treatment, pregnancy planning and surgery cannot be managed by simply skipping one dose without specialist timing.
Key red flags
Fever or systemic infection, shingles near the eye, persistent cough or weight loss, new neurological deficit, severe abdominal pain or bloody diarrhoea, chest pain, breathlessness, limb swelling, jaundice, marked cytopenia, anaphylaxis, pregnancy or new malignancy requires prompt treatment interruption and specialist assessment.
Hypotension, hypoxia, confusion, disseminated vesicles or rapidly spreading painful skin infection is an emergency even when inflammatory markers are blunted.
Investigation priorities
Demonstrate that the current NICE and local initiation criteria are met.
Management branches
Severe skin disease remains uncontrolled and targeted treatment is being considered.
- Confirm the live NICE indication, required severity and previous-treatment sequence and document an objective baseline outcome and goals important to the patient.
- Screen infection, vaccination, pregnancy, malignancy, cardiovascular, thrombotic, neurological, bowel and eye risks and map them against candidate mechanisms.
- Agree agent, brand, route, loading and maintenance schedule, laboratory plan, infection and vaccine actions, response deadline and stopping rule.