Looking after yourself while you are on biologics or biosimilars or skin conditions (self-care)

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Why have I been given this leaflet?

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

We don’t want you to worry, but to stay fit and healthy, and to enjoy your improved skin condition.

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.

Do I need to follow a special diet when I am on biologics or biosimilars?

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.

To cut down the risk of food poisoning, avoid the following foods:

• Unpasteurised milk and dairy products, for example, cheese made from unpasteurised milk
• Mould ripened soft cheeses (for example, Brie and Camembert) and blue cheeses (whether pasteurised or not), feta and goat’s cheese
• Raw eggs, or foods with this in, for example, 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 good common sense. For example: washing your hands and surfaces before cooking; washing your fruit and vegetables in clean water before using; reheating cooked dishes thoroughly.

What happens if I miss a dose of my biologic?

Take your biologic at soon as you remember, if you have forgotten or have been unable to take it at the right time. Your next dose of biologic will need to be taken with the usual time gap between injections for your type of biologic. This will mean the day of the week you normally take your drug will change.

For example:

• for people on weekly Etanercept, you might normally have your injection on Mondays. You might forget to take your weekly injection on a Monday, but then remember on Tuesday and take it then; you would then need to change your injection day to Tuesdays for all the following weeks
• for people on fortnightly Adalimumab, you might normally have your injection on Wednesdays. You might forget to take your injection on a Wednesday, but then remember on Friday and take it then; you would then need to change your injection day to Fridays for all the following fortnights.

Forgetting to take your biologic may mean you end up with less control of your disease. Should you find it difficult to keep injecting on the right days, you can discuss this with your dermatology nurse as there may be techniques or a different treatment plan which may help you remember or manage.

Should I still get vaccinated?

Yes. Being on a biologic means you could be more likely to pick up infections. This includes winter flu, pneumonia, and COVID-19. You are safe to have these vaccines.

We 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 or biosimilars and have been advised to have the winter flu vaccine. The flu vaccine 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 given every five 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

You will be asked to have the COVID-19 Vaccine and boosters by your dermatology clinical nurse specialist or dermatologist. COVID-19 vaccines/boosters reduce the likelihood of getting COVID-19 infections or mean you are less likely to get a severe COVID-19 infection.

People who are on biologic or biosimilar treatment are thought to have a weakened immune system due to the treatment and are at more risk of COVID-19. The NHS advises that people aged between 16-64 years on biologic or biosimilar treatment have a seasonal booster vaccine. This advice may change with time as more is learnt about COVID-19 and vaccines.

Information on COVID-19 vaccines can be found on the NHS website or from your GP surgery or local vaccination centre.

Can I have live vaccines?

No. It is unsafe to have some types of vaccines called live vaccines while 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)
• Zostavax (‘live’ shingles)
• 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, such as Shingrix (inactivated or non-live shingles).

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

Can I have a live vaccine before I start biologic or biosimilar treatment?

Yes. 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.

Can I have a live vaccine when I finish the treatment?

You can have a live vaccine 6 to 12 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.

Where can I find more information about vaccinations?

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 on their web site.

What happens if I am unwell with an infection?

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.

Being on a biologic or biosimilar means you may be more likely to catch an infection. Ideally, you should not meet with people if you know they have a serious ‘catching’ infection whilst you are on biologics, for example a diarrhoea and vomiting bug.

If you catch a mild or moderate infection (for example, coughs colds, thrush, athletes foot, tooth abscess), you should continue to take your biologic or biosimilar as normal.

If you have a severe infection, you should not take your biologic or biosimilar injection or dose.

What is 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 while you feel unwell. You can restart your biologic or biosimilar once the infection has got better.

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.

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

Should I change the amount of time between doses if I have stopped taking them while I have a severe infection?

No. Do not shorten the amount of time between doses because you have taken a dose later than you expected because of severe infection.

All biologics or biosimilars are taken at different time gaps, depending on what biologic or biosimilar it is.

For example, you may normally take your injection once a week on a Tuesday.

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.

What happens if I have a change in health?

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, you may be offered a cervical cancer screening (smear test) or bowel cancer screening.

What happens if I have an infection that I do not know about?

Before you started your biologic you will have been tested for infections which include TB (tuberculosis), HIV, Hepatitis B, and Hepatitis C. Some people may not be 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.

You might not be prescribed biologics or biosimilars when planned if you have these infections.

Normally, if tests show you have these conditions, we will arrange for advice on treatment for these infections and if/when it might be possible to prescribe biologics or biosimilars. Being on biologics or biosimilars whilst having an untreated infection such as TB may mean the infection becomes active and severe.

You can also 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 catching TB:

• living or staying in a country with a high amount of TB for more than two 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 catching HIV, Hepatitis B and C:

• having unprotected sex with someone with HIV or hepatitis B or C
• having unprotected sex, (sex without a condom/barrier method of contraception), especially unprotected anal sex.
• sharing injection equipment (such as needles) or other drug equipment
• having a blood transfusion in some countries
• more information on sexual behaviour and infection risk can be read on the NHS website.

If you feel you are more at risk, talk to your dermatologist or dermatology nurse. You will probably be asked to have a more regular blood tests or chest x-rays for these infections, if your doctor or nurse thinks you are more at risk.

What happens if I need an operation?

After an emergency operation, you can restart your biologic once your medical/surgical team are happy for you to do so, and if they feel that any wound is healing and free of infection.

After the emergency operation, your medical/surgical team can contact your dermatologist or dermatology nurse specialist for advice on this.

You should stop your biologic or biosimilar before any planned operation. This is because biologics and biosimilars can affect 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 two 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.

Can I start a family or breast-feed?

There is not a large amount known about the effect of biologics and biosimilars on the unborn baby. Usually, we advise men and women to use contraception (for example, condoms, the coil, the contraceptive pill), to avoid women who are on biologics or biosimilars becoming pregnant.

Talk to your dermatologist or dermatology nurse if you think you would like to start a family and are female. Your dermatologist can use different treatments and suggest ways of coping with your skin disease whilst you are trying to get pregnant or become pregnant. There are different options: continuing your current biologic or biosimilar; switching treatment; or stopping biologic or biosimilar treatment while pregnant.

You should be seen by an obstetrician who specialises in women with medical conditions if you stay on biologic or biosimilar treatment when pregnant.

Your dermatologist may advise you on treatment with Cimzia (certolizumab pegol) if you have psoriasis. Cimzia is a biologic treatment known to not actively be passed to the baby when in the womb, unlike other biologics, although women with joint or gut disease on a type of biologic called anti TNF alpha (Adalimumab, Etanercept) have been known to have pregnancies with no problems.

Babies born to mothers who used biologics or biosimilars after 16 weeks’ gestation (being pregnant) must not have any live vaccines for the first 6 months of life.

There is little known about men who father children while they are on a biologic. There is no known larger risk for problems with children born to fathers on biologics such as birth defects or early birth.

For more information discuss this with your dermatologist, dermatology nurse specialist, obstetrician.

What happens if I travel?

You can go on holiday or travel while you are taking biologic or biosimilar medication, as long as you are able to look after your injection(s) and where you travel does not require a live travel vaccine.

It may be easiest to time trips between treatment. This is so you do not have to take your biologic or biosimilar away with you.

Wherever you travel, you will typically need to take your biologic or biosimilar injections in an insulated cool container. For example, a portable medical travel cooler case or an insulated sandwich bag with an ice pack. You can get these online or in stores.

The aim is to keep the injection(s) constantly cool, but not freezing. Injections could freeze if placed directly on an ice pack, so make sure the ice pack is insulated, even if only by wrapping a clean tea towel around it, or that the injection does not come in direct contact.

When you arrive at your destination, you will need to put your injections in a fridge. Check the fridge is working correctly. Think about who has access to the fridge. Some people may fiddle with, or take away, the injections without your knowledge or consent. This is more likely in a shared fridge. Do not use the biologic or biosimilar if you see that the injection has been tampered with.

Some biologics or biosimilars can be kept out of the fridge for several days before being used, as long as the temperature is not above 25 degrees centigrade or at freezing or below. This means they do not need to be kept at a constant cool temperature. You can look at the information sheet which is packed with each injection on its storage, or you can ask your pharmacist, dermatologist or dermatology nurse specialist to advise you.

You may need a letter if you are flying, explaining what the injections are for, (if you need to take your injections away with you). We would recommend that you also contact the airline you are flying with and check their own guidelines for travelling with injections. You may need to travel with a letter or card telling readers/officials who the injections are for, what they are, and what they are for. This can be given to you by the homecare company.

You should take your injections as hand luggage rather than leaving them in your main luggage to go into the airplane’s luggage hold. Remember, the injections will need to be kept cool, which may be a problem on long haul flights if your insulated ice pack does not last long.

Can I have travel vaccinations?

You may find that you are unable to have some travel vaccinations, as they are live vaccinations. This may mean you will have to change your travel plans, as you cannot receive live vaccines while you are on biologic or biosimilar medication.

Please read the NHS UK web page for useful information on required vaccinations, certificates, and how travel clinics work.

You should contact your GP surgery about travel at least 8 weeks before any travel. This is because some countries require vaccinations weeks or months before travel. If you are travelling to countries in northern and central Europe, North America or Australia, you are unlikely to need any vaccinations. Many GP surgeries have travel clinics, but not all, and you may need to get advice and vaccinations from a private travel clinic or pharmacy.

We do not recommend that people travel without the required vaccinations or certificates.

We also do not recommend that people stop their biologic or biosimilar so that it becomes safe to receive a live vaccine required for travel.

You should discuss any issues about live vaccines with your dermatologist or dermatology nurse if you require live vaccines and cannot change your travel plans.

What else should I do before I travel?

• Make sure you travel with health insurance when abroad, and that you tell the insurer about the biologic or biosimilar medication you are taking.
• Take an empty injection box or write down the name of the biologic or biosimilar you are on, (along with any other drugs you are on) when you are away from home. Show this to any doctor, nurse, or pharmacist/chemist, who may treat you, if you are unwell abroad.
• Make sure you have enough supplies for your skin condition before you travel. For example, that you have enough emollient (moisturiser), steroid cream, or dressings. This may mean you need to contact your GP surgery before you go on holiday to make sure you have enough supplies to use while you are away from home.
• Contact your home care company to ensure you will receive enough biologic or biosimilar to take away with you from your home delivery before you travel. Ideally contact them about four weeks before you travel.

Who can I contact for further information and advice?

Your dermatologist and dermatology nurse specialist are there to help with any worries or questions about biologic or biosimilar treatments. Do not be afraid to contact the dermatology Team for advice.

For patients attending Southlands Hospital, Worthing Hospital or St Richards Hospital, the dermatology nurses can be contacted on:

• 01903 205111 extension 83212
• email queries to uhsussex.dermatologysec@nhs.net
• Please call 01903 205111 extension 83607 if your question is urgent or you do not get a reply from the nurse.

For patients attending The Princess Royal Hospital, The Brighton General Hospital, or the Royal Alexandra Children’s Hospital, the dermatology clinicians can be contacted on:

• 01273 665035 (answer phone available) 
• Please ring the dermatology secretaries on 01273 665019 if your question is urgent or you do not get a reply.

Replies to phone calls or emails can take a few days.

The Dermatology Team may not get back to you straight away. If the matter is very urgent and cannot wait, especially on the weekend and outside of normal working hours (9am to 5pm), you will need to attend your local A&E department, ring 111, or ask your on-call GP for help.

Other sources of information and support on biologics or biosimilars for skin conditions can be through the following web sites or phone numbers:

Information on various treatments