New Medicines Committee Briefing

November 2013

Topical Corticosteroids

Topical corticosteroids are to be reviewed for use within:

Primary Care 

Secondary Care 

Formulary application:

Consultant submitting application: Dr Nicholas Craven (Consultant Dermatologist)

Clinical Director supporting application: Mr Gareth Rowland

Dr Craven has requested that the whole skin section of the formulation be reviewed. As part of
this process, the topical corticosteroid section is being reviewed. Dr Craven has requested that
fluocinolone acetonide 0.0025% cream, fluocinolone acetonide 0.00625% cream and ointment,
fluocinolone acetonide 0.025% cream, gel and ointment, fluocinolone acetonide 0.025% with
clioquinol 3% cream and ointment, fluocinolone acetonide 0.025% with neomycin 0.5% cream
and ointment, Haelan® tape, Trimovate® cream, Diprosalic® ointment and Nerisone Forte® oily
cream and ointment be included in the North Staffordshire Joint Formulary while the following
corticosteroids: hydrocortisone 0.5% cream and ointment 30g, hydrocortisone 1% cream and
ointment 50g, hydrocortisone 2.5% cream and ointment, Canesten HC® cream 15g, Daktacort®
cream 15g, Fucidin H® cream 60g, Betnovate® scalp application, Fucibet® cream 60g, and
Clarelux® Foam Scalp Application) be removed from the Joint Formulary.
Dr Craven states that Haelan® tape would be used in the following conditions: nodular prurigo,
lichen simplex, fissured dermatitis, stubborn plaques of psoriasis, chronic discoid lupus
erythematosus and granuloma annulare, plus any other stubborn localised steroid-responsive
dermatoses. The super-potent topical steroids such as Dermovate® and Nerisone Forte® are used
when the affected areas are more extensive. He also stated that the Synalar® products will be
used in patients allergic to hydrocortisone, clobetasone butyrate and betamethasone esters and
that Synalar gel is standard treatment for steroid-responsive dermatoses in the scalp.
1
He noted that these are well-established products which should be available in any dermatological
formulary. A healthy selection of topical corticosteroids ranging from mild to very potent, with or
without antimicrobials, are essential as there is wide inter-patient variability in response to
treatments.

Relevance in therapy:

Corticosteroids are synthetic analogues of the natural hormones that are produced by the adrenal
cortex. Like the natural hormones, synthetic corticosteroids can have glucocorticoid and/or
mineralocorticoid properties. Corticosteroids can be administered systemically (orally and
parenterally) or locally (topically to the skin, nose, and eyes; by inhalation; rectally and by intra-
articular injection). Local corticosteroids are predominantly glucocorticoids with anti-
inflammatory, immunosuppressive, anti-proliferative (anti-mitotic) and vasoconstrictive effects.
Topical corticosteroids exert these effects on the skin to treat various inflammatory skin
conditions (other than those arising from an infection), such as eczema, contact dermatitis, insect
stings, psoriasis, lichen planus, discoid lupus erythematosus and alopecia areata. Topical
corticosteroids are also available as compound preparations containing antibacterials, antifungals
and salicylic acid for use in inflammatory skin conditions associated with bacterial and fungal
infection according to the sensitivity of the infecting organism and hyperkeratosis respectively.
They may also be used in conjunction with other topical agents eg coal tar or dithranol.
Corticosteroids are not curative.1,2
Topical corticosteroids are available in four potencies: Mild, moderately potent, potent and very
potent. The potency is determined by the amount of vasoconstriction produced as well as the
formulation (ointments are more potent than creams), occlusion, the salt of the steroid, the
presence of other ingredients and fluorination. The occlusion involves the covering of the
treatment area is by a thin polythene film which enhances effectiveness as well as local and
systemic toxicity. The salt of the steroid do influence the potency as dipropionate and butyrate
salts are stronger than valerate salts. The presence of other ingredients such as salicylic acid or
urea and fluorination increases potency (fluorinated corticosteroids e.g. Dermovate®, Haelan®,
Metosyn® and Cutivate® have increased potency).1
There are no published systematic reviews comparing the effectiveness of different topical
corticosteroids. Choice of agent is made according to patient need.3 The British Association of
Dermatologists states that patients who fail to respond to one topical agent may respond to
another and it is worthwhile rotating different types of topical agents.4 They also noted there is
lack of evidence supporting twice-daily application of topical corticosteroids to be more effective
than once daily application. The choice of topical corticosteroid depends on the condition being
treated and its stage, the area of the body that is affected, and the age of the person. Mild forms
of dermatitis may only require a mild corticosteroid whereas psoriasis may require a more potent
steroid with the most potent treatments reserved for recalcitrant dermatoses.
The least potent steroid that relieves the symptoms should be prescribed, and at an appropriate
quantity. Patients should be advised to spread thinly over the affected area and use the fingertip
unit as a measuring guide.2 Where long-term topical corticosteroids are required, gradual

2
withdrawal of the steroid may be needed to prevent rebound exacerbation of the condition. Use
of emollient helps in reduction of use of steroids and where emollient is required, the
corticosteroid should be applied 30 minutes after the emollient to ensure full absorption of the
emollient. Areas where the skin is thin or flexural e.g. face, scrotum, groin, axillae and
submammary area, usually require a weak or moderately-potent corticosteroid whereas areas
where the skin is thick e.g. palms of the hands, soles of feet, scalp, or lichenified skin due to
constant scratching, typically require more potent preparations.1
Pregnancy: Mildly potent, moderately potent and potent corticosteroids, if used correctly, are
suitable for use during pregnancy. Some evidence suggested that very potent corticosteroids
might be associated with low birth weight and will need specialist advice.1
Breastfeeding: Mildly potent, moderately potent and potent corticosteroids are considered
suitable for use during breastfeeding. If applied to the breasts, the steroid should be washed off
before breastfeeding to prevent the infant ingesting it.1
Cautions: Steroids are not recommended to be applied to the face for prolonged periods or for
prolonged use in children. Potent and very potent corticosteroids are recommended to be used
under specialist supervision. The use of potent or very potent corticosteroids in psoriasis can
result in rebound relapse, development of pustular psoriasis, and local and systemic toxicity.. 1,2
Contraindications: Primary infections of the skin caused by bacteria, fungi or viruses, in acne, and
rosacea. Potent corticosteroids are contraindicated in plaque psoriasis.1,2
Side-effects: Long-term continuous topical steroid therapy, especially with the potent and very
potent preparations can produce atrophic skin changes such as thinning of the skin, irreversible
striae and telangiectasia, and even adrenal suppression and Cushing’s syndrome. Contact
dermatitis, irritation at site of application, spread and worsening of untreated infection, perioral
dermatitis, acne/worsening of acne or rosacea, reversible depigmentation and hypertrichosis are
other local side-effects reported.1,2
Tolerance may occur in response to continued use of any topical steroid and is related to duration
of use rather than potency. The British Association of Dermatologists therefore recommends that
No more than 100g of a moderately potent or higher potency preparation should be applied
per month.
Use of very potent preparations should be under dermatological supervision.
Use of fingertip unit as a measure to help patients know how much ointment or cream to
apply.
No topical corticosteroid should be used regularly for more than four weeks without critical
review.
Potent corticosteroids should not be used regularly for more than 7 days.
No unsupervised repeat prescriptions should be made. Patients should be reviewed every 3
months.4

3
Table 1: Practical guidance to formulation choice of topical steroids based on the condition being treated, patient’s preference, its severity and location. 1,5

Selection of products available

Formulation Formulation advantages Formulation disadvantages Body areas
(not an exhaustive list)

A low viscosity, alcohol- or water- Very drying if alcohol is the base, and Scalp Betnovate®
based liquids. Easy to apply and non- can sting sore skin. Betacap®
Solutions
greasy. Dermovate®
Scalp Application

A mixture of water suspended in oil, Contains preservatives in formulation, Face, limbs, trunks Cutivate® cream
thicker than lotions- good which may cause irritation/allergic Flexures and genitals Elocon® cream
moisturising qualities, absorb rapidly reactions. Lesser occlusive effect than Palms and soles Haelan® cream
Cream
into skin and cosmetically acceptable. ointments. Nerisone® cream
Useful for exudating (weepy) and
moist areas.

Less greasy and occlusive. Has a jelly- Lesser occlusive effect than creams and Face, Limbs, Trunk Synalar® gel
like consistency, beneficial for ointments. Flexures and genitals
Gel exudative inflammation and does not Palms and soles
cause hair matting. Scalp and hairy
areas

Less greasy and occlusive. Penetrate Contain alcohol, which has a drying Scalp and hairy Diprosone® lotion
well on hairy areas and leave little effect. areas Locoid Crelo® lotion
Lotions residue. Elocon® scalp lotion
Betnovate® lotion

4
 Selection of products available
Formulation Formulation advantages Formulation disadvantages Body areas
(not an exhaustive list)

Paraffin-based, providing an occlusive Ointments are not suitable for hairy Face Betnovate® ointment
emollient effect, which improved areas, flexures and genitals, as they Limbs Dermovate® ointment
steroid absorption (this formulation may cause maceration and folliculitis. Trunk Haelan® ointment
Ointment
slightly increases potency). Most Greasy nature means they are not Palms and soles Modrasone® ointment
useful for very dry skin and cosmetically acceptable. Paraffin-based
hyperkeratotic areas. products are flammable.

Effectively delivers steroids to the Can only be used on the scalp. Scalp Bettamousse® foam
Mousse (foam)
scalp. Non-greasy. Clarelux® foam

Scalp Etrivex® shampoo

Effectively delivers steroids to the Can only be used on the scalp. May be
Shampoo scalp. Needs to be applied to a dry confusing for patients as this shampoo
scalp and rinsed off 15 minutes. formulation is not used for washing
hair.

Flexible and effective delivery method
for targeted application under
occlusion. Helps protect easily
Tape damaged areas of skin (areas
constantly scratched), areas of very
thick skin, and areas difficult to treat
with other formulations (fingers).
Not suitable for flexures, as occlusion Limbs Haelan® tape
increases potency (Haelan® tape does Trunk
not increase potency). May not stick to Palms and soles
weepy areas. Courses limited to five
days for children.

5
Hypersensitivity Reactions to Corticosteroids:6
Contact allergy is occasionally a complication of topical corticosteroid treatment and can be
confirmed by appropriate patch testing. Patients generally present with a chronic dermatitis that is
not exacerbated by, but fails to respond to corticosteroid therapy. In general, corticosteroid-
sensitive patients react to several corticosteroids; this may be due to multiple sensitizations after
the use of various different preparations, or due to a true cross-reactivity mechanism. In 1989,
based on corticosteroid patch test results and their chemical structure, Coopman et al. concluded
that cross reactions between corticosteroids occurred primarily within 4 groups:
A: hydrocortisone type
B: triamcinolone acetone type
C: betamethasone type
D: hydrocortisone-17-byturate type
Group D was later subdivided into groups D1 and D2. The corticosteroids in each group have
similar chemical structure, a fact which might explain the existence of a high cross-reactivity
between the corticosteroids in each group (table 2). However, cases of cross reaction have also
been reported between corticosteroids from group D2 and groups A and B, with Group D1
exhibiting quite low cross-reactivity with the other groups. Coopman’s classification has proved
useful in the evaluation of reactions induced by topically administered corticosteroids, although it
is not accepted by all.
Table 2: Coopman classification of topical corticosteroids by the function of their allergenicity 6

6
In 1994, Wilkinson et al7 published a study that was contradicting Coopman et al’s classification
table as they found many of their patients with multiple positive patch-test reactions to
corticosteroids did not fit easily into the above four categories. Coopman and others have
subsequently stated that not all of the cross-reactions that they see, fit into corticosteroid classes
A to D. Wilkinson et al looked at the positive patch-test reactions to other corticosteroids in 96
patients who were allergic to hydrocortisone, to establish which substitutions were important in
determining concomitant reactions. These patients were patch tested with tixocortol pivalate (1%
petrolatum) as this compound is both a sensitive and specific marker for hypersensitivity to
hydrocortisone. Patients positive on patch testing to tixocortol pivalate were then patch tested to
a battery of corticosteroids, using Finn chambers® on Scanpor® tape, left on the skin of the back for
48 hours. The patch tests were read at 2 and 4 days and patients were asked to return for a
further reading if they developed a reaction after 4 days. Reactions were scored as recommended
by the International Contact Dermatitis Research Group, and were considered positive when a
palpable erythematous (+) reaction or greater was present with the frequency of positive
reactions to other corticosteroids being expressed as a percentage.

Results: It was found that the two commonest corticosteroid allergies occurring in patients
hypersensitive to hydrocortisone were to hydrocortisone-17-butyrate and budesonide (Table 3).
On the contrary, these three corticosteroids lie in different classes according to Coopman et al.
(i.e. Class A: hydrocortisone, Class B: Budesonide, Class D: hydrocortisone-17-butyrate). The effect
of the C6 and C9 substitution had greater statistical significance than that of the C16 and C17
substitutions as shown by the P-values after correction for other grouping (C6 and C9 P<0.0001; C16
and C17 P=0.005). The authors concluded that patients sensitised to topical hydrocortisone are
most likely to concomitantly react to other non-C6 and –C9 substituted corticosteroids. They added
that where facilities are not available to patch test to other corticosteroids (1% in ethanol), an
alternative topical agent should be chosen based primarily on the C 6 and C9 substitution, followed
by the C16 and C17 substitution.

Table 3: Other positive patch test reactions in 96 patients allergic to hydrocortisone

Corticosteroid % positive n
Hydrocortisone-17-butyrate 43.8 96
Budesonide 28.1 96
Methylprednisolone acetate 13.3 83
Alclometasone dipropionate 10.8 65
Flurandrenolone 7.23 83
Fluocortolone 3.61 83
Betamethasone valerate 5.21 96
Clobetasol butyrate 5.21 96
Clobetasol propionate 4.2 96

7
Triamcinolone acetonide 3.6 83
Desoxymethasone 2.4 83
Beclomethasone
2.4 83
dipropionate
Betamethasone
1.9 52
dipropionate
Halcinonide 1.2 83
Fluocinonide 3.6 83
Diflucortolone valerate 1.2 83
Fluocinolone acetonide 1.2 83

Current formulary status::

The North Staffordshire Joint Formulary currently lists the following agents:
13.3 TOPICAL CORTICOSTEROIDS   NICE TA81

Corticosteroid only preparations

Mild potency

Hydrocortisone (0.5%, 1%,

2.5%)

Moderate potency

Betamethasone valerate
0.025% (Betnovate-RD®)

Clobetasone butyrate
0.05% (Eumovate®)

Potent

Betamethasone valerate
0.1% (Betnovate®)

Hydrocortisone butyrate
0.1% (Locoid®)

Very potent

Clobetasol propionate
0.05% (Dermovate®)

Topical corticosteroids with antimicrobials

Mild potency

Canesten HC®

Daktacort®

Fucidin H®

8
Vioform-Hydrocortisone®

Moderate potency

Trimovate®

Potent

Betnovate-C®

FuciBET®

Very potent

Dermovate-NN®

Scalp applications

Potent

Betamethasone valerate
0.1% scalp application

Diprosalic®
(betamethasone 0.05%,
salicylic acid 3%) scalp
application

Very potent

Dermovate®

(clobetasol propionate
0.05%) scalp application

9
 RECOMMENDED CORTICOSTEROIDS

Recommended Pack Size and

Drug Strength (w/w) Brand Formulation
Primary Care Price*
Mild
Fluocinolone acetonide 0.0025% Synalar 1 in 10 dilution® Cream 50g (£4.58)
Hydrocortisone 0.5% Generic Cream / Ointment 15g (£1.42 / £3.39)
Hydrocortisone 1% Generic Cream / Ointment 15g (£1.12/£1.27)
Mild with Antimicrobial
Hydrocortisone / Clotrimazole 1% / 1% Canesten HC® Cream 30g (£2.42)
Hydrocortisone / Miconazole 1% / 2% Daktacort® Cream / Ointment 30g (£2.48 / £2.50)
Hydrocortisone acetate / Fusidic acid 1% / 2% Fucidin H® Cream 30g (£5.02)
Moderate
Fluocinolone acetonide 0.00625% Synalar 1 in 4 dilution® Cream / Ointment 50g (£4.84)
7.5 cm x 50cm (£9.27),
Fludroxycortide 4 µg / cm2 Haelan® tape Polythene Adhesive Film
7.5 cm x 200 cm (£24.95)
Betamethasone valerate 0.025% Betnovate-RD® Cream / Ointment 100g (£3.15)
Clobetasone butyrate 0.05% Eumovate® Cream / Ointment 30g (£1.86), 100g (£5.44)
Moderate with Antimicrobial
Clobetasone butyrate / Oxytetracycline 0.05% / 3% /
Trimovate® Cream 30g (£3.29)**
/ Nystatin 100,000 units/g
Potent
Fluocinolone acetonide 0.025% Synalar® Cream / Ointment 30g (£4.14), 100g (£11.75)
Hydrocortisone butyrate 0.1% Locoid® Cream / Ointment 30g (£1.60), 100g (£4.93)
Betamethasone valerate 0.1% Betnovate® Cream 30g (£2.73), 100g (£9.10)
Betamethasone valerate 0.1% Betnovate® ointment 30g (£3.16), 100g (£10.53)

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 Drug Strength (w/w) Brand Formulation Recommended Pack Size and
Primary Care Price*
Potent With Antimicrobial
Betamethasone valerate / Clioquinol 0.1% / 3% Generic Cream / Ointment 30g (£9.48)
Betamethasone valerate / Fusidic Acid 0.1% / 2% Fucibet® Cream 30g (£5.32), 60g (£10.63)
Fluocinolone acetonide / Clioquinol 0.025% / 3% Synalar C® Cream / Ointment 15g (£2.66)**
Fluocinolone acetonide / Neomycin 0.025% / 0.5% Synalar N® Cream / Ointment 30g (£4.36)**
Potent With Salicylic Acid
Betamethasone dipropionate / Salicylic
0.05% / 3% Diprosalic® Ointment 30g (£3.18), 100g (£9.14)
Acid
Potent Scalp Application
Betamethasone valerate 0.1% Betacap® Scalp Application 100ml (£3.75)
Betamethasone dipropionate / Salicylic
0.05% / 2% Diprosalic® Scalp Application 100ml (£10.10)
acid
Fluocinolone acetonide 0.025% Synalar® Gel 30g (£5.56), 60g (£10.02)
Very Potent
Clobetasol propionate 0.05% Dermovate® Cream / Ointment 30g (£2.69), 100g (£7.90)
Diflucortolone valerate 0.3% Nerisone Forte® Oily Cream /Ointment 15g (£2.09)
Very Potent Scalp Application
Clobetasol propionate 0.05% Dermovate® Scalp Application 30ml (£3.07), 100ml (£10.42)
Very Potent with Antimicrobial
Clobetasol propionate / Neomycin 0.05% / 0.5% / 100,000
Generic Cream / Ointment 30g (£64.00)***
sulphate / Nystatin units/g

*Primary care costs were obtained Drug Tariff December 2013.8

**Costs unavailable in the Drug Tariff. Costs obtained from the C&D.9
***Prices have been taken from the British National Formulary (BNF) 66 September 2013.10

Table updated by Monjur Ali (Clinical Pharmacist) – February 2014.

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 Cost analysis:

Expenditure in Primary and Secondary Care for a 12-month period (June 2012 - May 2013):

Product UHNS STOKE CCG NORTH STAFF CCG

Haelan® Tape £142.49 £2,575.16 £2,131.05

Trimovate® cream £1,335.67 £14,387.83 £11,532.92

Diprosalic® ointment £197.10 £7,939.59 £5,197.16

Nerisone Forte® oily cream £2.20 £3.90 £9.67

Nerisone Forte® ointment £0.00 £3.89 £3.87

Fluocinolone acetonide 0.0025%

£17.87 £343.50 £415.14
(Synalar 1 in 10 dilution®) cream
Hydrocortisone 0.5% cream £100.85 £4,728.99 £2,931.30
Hydrocortisone 0.5% ointment £48.30 £2,183.44 £1,041.39
Hydrocortisone 1% cream £332.19 £18,602.12 £14,969.59
Hydrocortisone 1% ointment £75.38 £5,799.51 £3,632.77
Hydrocortisone 2.5% cream £0.00 £5,020.17 £4,301.19
Hydrocortisone 2.5% ointment £0.00 £3,638.92 £2,173.13

Canesten HC® cream £155.36 £3,060.76 £2,524.74

Daktacort® cream £380.77 £7,255.88 £4,739.01

Daktacort® ointment £40.60 £1,501.36 £635.57
Fucidin H® cream £726.12 £12,689.87 £7,449.48
Synalar 1 in 4 dilution® (fluocinolone
£4.63 £527.90 £1,047.72
acetonide 0.00625%) cream / ointment
Betnovate-RD® (betamethasone valerate
£410.03 £14,184.51 £8,737.66
0.025%) cream / ointment
Eumovate® (clobetasone butyrate) cream /
£1,112.05 £5,471.59 £5,877.75
ointment
Fluocinolone Acetonide (Synalar®) 0.025%
£75.40 £2,663.10 £1,287.01
cream/ointment
Synalar® Gel (fluocinolone acetonide 0.025%) £152.65 £2,391.21 £1,102.45

12
 Product UHNS STOKE CCG NORTH STAFF CCG
Hydrocortisone butyrate (Locoid®) 0.1%
£12.59 £462.99 £384.44
cream /ointment
Betamethasone valerate (Betnovate®) 0.1%
£555.78 £22,159.58 £18,830.25
cream
Betnovate® 0.1% ointment £615.26 £12,145.12 £7,708.04
Betacap® (betamethasone valerate 0.1%)
£146.58 £563.15 £267.46
scalp application
Betnovate® (betamethasone valerate 0.1%)
£33.30 £10,226.11 £8,721.89
scalp application
Diprosalic® scalp application (betamethasone
£214.02 £4,562.93 £3,135.35
dipropionate 0.05% + salicylic acid 2%)
Betamethasone valerate 0.1% + Clioquinol
£1503.76 £1,529.98 £889.60
3% cream/ointment
Fucibet® cream £959.03 £20,128.90 £12,569.69

Synalar C® (fluocinolone acetonide 0.025% +

£3.04 £327.36 £231.49
clioquinol 3%) cream/ointment
Synalar N® (fluocinolone acetonide 0.025% +
£4.93 £197.72 £181.45
neomycin 0.5%) cream/ointment
Clobetasol propionate 0.05% (Dermovate®)
£2,079.24 £11,093.65 £7,416.87
cream / ointment
Clarelux® Foam (=scalp application) £527.56 £347.49 £10.23
(clobetasol propionate 0.05%) (inc Dermovate® and
Etrivex® brands)

Clobetasol propionate 0.05% + neomycin

£3,033.57 £8,851.84 £4,370.14
sulfate 0.5% + nystatin 100,000 units/g cream
Clobetasol propionate 0.05% + neomycin
sulfate 0.5% + nystatin 100,000 units/g £0.00 £650.00 £177.18
ointment

Expenditure for UHNS reflects items dispensed via UHNS dispensary (i.e. inpatients,) Lloyds
pharmacy &FPHP10 prescriptions

13
References

1
NICE CKS. Corticosteroids-topical (skin), nose and eyes. Available at:
http://cks.nice.org.uk/corticosteroids-topical-skin-nose-and-eyes. <accessed 1st Aug 2013>
2
British National Formulary (BNF) 65 March 2013. Available at: http://www.bnf.org
3
MeReC.Using topical corticosteroids in general practice. MeReC Bulletin 1999; 10(6):21-24.
Available at :
http://www.npc.co.uk/merec/therap/skin/resources/merec_bulletin_vol10_no06.pdf
4
British Association of Dermatologists. Topical Corticosteroids. Avaiable at:
http://www.bad.org.uk/site/1117/Default.aspx. <accessed 25th July 2013>
5
Topical Corticosteroids. Available at:
http://www.topicalsteroids.co.uk/how_to_use_topical_corticosteroids/topical_steroid_formulat
ion.htm#Formulation_selection_for_body_area_. <accessed 25th July 2013>
6
Canto G. et. Al. Hypersensitivity Reactions to Corticosteroids. Curr Opin Allergy Clin Immunol
2010;10(4):273-279. Available at: http://www.medscape.com. <accessed 27th July 2013>
7
Wilkinson SM, Hollis S, Beck MH. Reactions to other corticosteroids in patients with allergic
contact dermatitis from hydrocortisone. British Journal of Dermatology 1995;132:766-771.
8
NHS Electronic Drug Tariff, February 2014. Available from
http://www.ppa.org.uk/ppa/edt_intro.htm <accessed 03/02/14>
9
Chemist & Druggist. Product List. January 2014. C & D.
10
British National Formulary September 2013. Available at http://www.bnf.org/bnf/index.htm
<accessed on 04/02/14>

Produced by Susheela Sumelingam

Rotational Specialist Pharmacist
University Hospital of North Staffordshire
Telephone: 01782 674542
e-mail: Susheela.Sumelingam@uhns.nhs.uk

Produced for use within the NHS. Not to be reproduced for commercial purposes.

14