Looking after yourself whilst on biologics or biosimilars for skin conditions (self care)

This information describes some of the things you can do to keep yourself healthy, plan your family, and travel, whilst taking biologics or biosimilars for skin conditions.

There are also some things that you can do to keep yourself as healthy as possible if you have a skin condition. This depends on the skin condition and is not discussed in this leaflet. Please talk to your skin doctor (Dermatologist) or skin nurse (Dermatology clinical nurse specialist/CNS) if you have any questions about this or see the websites at the end of this leaflet.

It is thought you could be more likely to catch infection (food poisoning) from your food if you are on biologics or biosimilars. This is because biologics or biosimilars affect part of your body’s defence (immune) system. We would suggest you don’t eat the following foods to cut down the risk of food poisoning.

• Unpasteurised milk and dairy products, e.g. cheese made from unpasteurised milk.
• Mould ripened soft cheeses (e.g. Brie and Camembert) and blue cheeses (whether pasteurised or not), feta and goats cheeses.
• Raw eggs, or foods with this in, e.g. home-made mayonnaise.
• Raw or undercooked meat and fish.
• Cooked rice over 24 hours old and not stored in a fridge. (always reheat cooked rice fully).
• All types of paté.

Continue to cook using ‘common good sense’, for example:

Washing your hands and surfaces before cooking; washing your fruit and vegetables in clean water before using; reheating cooked dishes thoroughly.

Being on a biologic means you could be more likely to pick up infections. This includes ‘winter flu’. We would recommend that you have a ‘winter influenza vaccination’ (often called a ‘winter flu’ jab) every year. Your GP (Doctor) may ask you to come to the GP surgery for the vaccine around September/October time.

You should contact your GP surgery if they have not called you for the vaccine. Remind the GP surgery that you are on biologics and have been advised to have the winter flu vaccine. The flu vaccine in an injection form for adults is not what is called a ‘live vaccine’. You should also have the “pneumococcal vaccine’ (also called ‘pneumovax’). This protects you against a few types of pneumonia. Pneumonia is a severe type of chest infection. Your GP surgery may offer this to you. You should contact your GP surgery if they have not called you for this vaccine. It is not a live vaccine. The pneumonia vaccine is usually administered every 5 years. You may need to check with your GP surgery, if, and when, you had the pneumonia vaccine. Contact your dermatology nurse if you are unsure, worried, or have any questions about this.

It is unsafe to have some types of vaccines called ‘live’ vaccines whilst on biologics. This is because you may not respond well (not have a good immune/body-defence reaction), and you may be more likely to have ‘complications’ (more health problems). Examples of live vaccines are polio, yellow fever, rubella (German measles), MMR (measles, mumps and rubella), BCG (tuberculosis), and typhoid. Some of these vaccines can also be given as an ‘inactivated form’; this means they are not ‘live’. It is safe to have inactivated vaccines whilst on biologics.

Always check with the person giving you a vaccine if it is ‘live’. Explain you are on biologics or biosimilars and cannot have live vaccines, if it is ‘live’. Ask if it comes in an inactivated form. Contact your dermatology nurse if you are unsure, worried, or have any questions.

Before you start biologic or biosimilar treatment you may be recommended by the dermatologist or dermatology nurse to have a live vaccine such as a chicken pox vaccine You can have a live vaccine four weeks or more, before starting biologics or biosimilars.

You can have a live vaccine 6 months (or 12 months if it is the shingles vaccine) after stopping biologics or biosimilars, or any other drug that can affect your immune system, such as methotrexate, prednisolone, or ciclosporin.

You can find further information about vaccinations from The British Association of Dermatologists (BAD) in a leaflet called Immunisation recommendations for children and adult patients treated with immune-suppressing medicines.

Biologics can affect your body’s immune (defence) system. This means you might not be able to fight infections so well. It also means that some infections could become severe or very severe. It could also take longer to get better from infection.

It is probably best not to meet with people if you know they have a serious ‘catching’ infection whilst you are on biologics. For example a ‘diarrhoea and vomiting bug’.

For mild or moderate infections that you may ‘catch’ or develop (e.g. coughs, colds, ‘thrush’, ‘athletes foot’, tooth abscess), you should continue to take your biologic or biosimilar as normal.

You should not take your biologic or biosimilar injection or dose, if you have a severe infection. A severe infection may make you feel very unwell, usually for more than a day, and often with a high temperature. A severe infection may also make you feel you need to stay in bed, see your GP, or go to hospital. The biologic or biosimilar may stop or slow your recovery from severe infection, and should be stopped whilst you feel unwell. You can restart your biologic or biosimilar after stopping it for a severe infection, if the infection has got better. All biologics or biosimilars are taken at different time gaps, depending on what biologic or biosimilar it is. Do not shorten the amount of time between doses because you have taken a dose later than you expected because of severe infection. For example, you may normally take your injection once a week on a Tuesday (every biologic or biosimilar has a different time gap between doses). You may have delayed your injection on Tuesday, due to severe infection, and then felt well enough to take it on the Friday. After the injection on Friday, don’t take the following injection on a Tuesday, as there still needs to be a week between injections. In this example, the following injection would be on a Friday. The day of the weekly injections would have moved to a Friday.

Let your dermatologist or dermatology nurse know if you have had a severe infection.

Contact the dermatology nurse (or dermatologist) if you are unsure what to do. It is not always easy to decide when an infection is severe enough to stop taking your biologic. The nurse (or doctor) is there to help you decide if you are unsure.

It is thought that one biologic called Dupilumab (also called Dupixent) may not work so well if it is stopped and re-started.

There may be all sorts of reasons why your health may change. You should see your GP if you have a change in health, for example, a change in bowel habit, a persistent cough, unexplained weight loss, or new pain. Some changes in health could be due to side effects from biologics or biosimilars so it is also important to mention them to your dermatology nurse or dermatologist. It is not always possible to be sure if something is due to a side effect. Should you have a side effect from the biologic or biosimilar, it is important to decide with your dermatology nurse or dermatologist to continue with the biologic or biosimilar or not.

Some changes in health may mean that all or some biologics or biosimilars are not suitable for you. You should tell your dermatology nurse or dermatologist if you have a change in health, become pregnant, or are given a new diagnosis. For example, if you notice an unexplained change in your eyesight and strength, if any heart failure gets worse, or if you are diagnosed with cancer or psoriatic arthritis.

You may be offered routine cancer screening by the NHS depending on your age and gender. We would advise people on biologics or biosimilars to accept cancer screening invitations. For example people may be offered a cervical cancer screening (smear test) or bowel cancer screening.

Before you start your biologic you will have been tested for infections which include:- TB, HIV, Hepatitis B, and Hepatitis C. You might not be prescribed biologics or biosimilars if you have these infections. Normally, if tests show you have these conditions, we will arrange for advice on treatment for these conditions and if/when it might be possible to prescribe biologics or biosimilars. Often people are not aware that they are infected, which is why blood tests and x-rays are used to check for these before starting a biologic or biosimilar. Being on biologics or biosimilars whilst having an untreated infection such as TB may mean the infection becomes active and severe.

You can also ‘contract’ (catch) one of these infections after you have started biologics or biosimilars. This is more likely if some of your behaviour, social, family, and work life put you more at risk.

The following may put you more at risk of ‘contracting’ (catching) TB.

• Living or staying in a country with a high amount of TB for more than 2 months.
• Living with, or having lots of close contact, with someone who has TB.
• Working, or living, with groups of people who are more likely to have TB such as new immigrants from certain countries, homeless people, prison population.

The following may put you more at risk of ‘contracting’ (catching) HIV, Hepatitis B & C.

Having ‘unprotected’ (without a condom/barrier method of contraception) sex with someone with HIV or hepatitis B or C.

• Having unprotected sex with someone from Asia or Africa.
• Women having unprotected sex with a bisexual partner.
• Men having unprotected sex with another man.
• Sharing injection equipment (needles).
• Having a blood transfusion in some countries.
• Should you feel you are more at risk, talk to your dermatologist or dermatology nurse. You will probably have a more regular blood or chest x-ray for these infections, if your doctor or nurse thinks you are more at risk.

It is important that you tell your dermatologist or dermatology nurse if you have any new illness, or unexplained symptoms, or if you are worried.

There may be an unlikely event, where you need an emergency operation. This might be not long after your last dose of biologic or biosimilar. After the emergency operation you can restart your biologic once your medical/surgical team are happy for you to do so, and they feel that any wound is healing and free of infection. Your medical/ surgical team can contact your dermatologist or dermatology nurse specialist for advice on this.

Ideally, and usually, you should stop your biologic or biosimilar before any planned operation. This is because biologics and biosimilars can effect healing and increase the risk for infection in the operation wound. Different biologic or biosimilars should be stopped at different times before operations. For example:- the biologic and its biosimilar Etanercept (Enbrel, Benepali), will need to be stopped 2 weeks before an operation. You can restart your biologic once your surgeon can see healing has taken place and that there is no infection, and your surgical/medical team are happy for you to do so. Some conditions, for example Hidradenitis Suppurativa, mean that for some operations, you don’t need to stop your biologic or biosimilar. Whatever operation has been planned, you should ask your dermatologist or dermatology nurse for advice about stopping your biologic or biosimilar.