4.1. Therapeutic indications

Athlete's foot and candidal intertrigo where there are co-existing symptoms of inflammation.

Organisms which are susceptible to miconazole are dermatophytes and pathogenic yeasts (e.g. Candida spp.). Also many Gram-positive bacteria including most strains of Streptococcus and Staphylococcus.

The properties of Daktacort Hydrocortisone Cream indicate it particularly for the initial stages of treatment. Once the inflammatory symptoms have disappeared, treatment can be continued with Daktarin cream or Daktarin powder.

4.2. Posology and method of administration

For topical administration

Apply the cream twice a day to the affected area, rubbing in gently until the cream has been absorbed by the skin.

The maximum period of treatment is 7 days.

Elderly

Natural thinning of the skin occurs in the elderly, hence corticosteroids should be used sparingly and for short periods of time.

4.3. Contraindications

Known hypersensitivity to miconazole or other imidazole derivatives, hydrocortisone or to any of the excipients listed in section 6.1.

Tubercular or viral infections of the skin or those caused by Gram-negative bacteria.

Daktacort Hydrocortisone Cream should not be used in the following conditions:

• If the skin is broken

• On large areas of skin

• Used for longer than 7 days

• To treat cold sores and acne

• Use on the face, eyes and mucous membranes

• Children under 10 years of age, unless prescribed by a doctor

• On the ano-genital region unless prescribed by a doctor

• To treat ringworm unless prescribed by a doctor

• To treat secondary infected conditions unless prescribed by a doctor

4.4. Special warnings and precautions for use

When Daktacort Hydrocortisone Cream is used by patients taking oral anticoagulants, the anticoagulant effect should be carefully monitored.

Severe hypersensitivity reactions, including anaphylaxis and angioedema, have been reported during treatment with Daktacort Hydrocortisone Cream and other miconazole topical formulations (See Adverse reactions).

If a reaction suggesting hypersensitivity or irritation should occur, the treatment should be discontinued.

Daktacort Hydrocortisone Cream must not come into contact with the mucosa of the eyes.

Visual disturbance may be reported with systemic and topical corticosteroid use. If a patient presents with symptoms such as blurred vision or other visual disturbances, the patient should be considered for referral to an ophthalmologist for evaluation of possible causes which may include cataract, glaucoma or rare diseases such as central serous chorioretinopathy (CSCR) which have been reported after use of systemic and topical corticosteroids.

As with any topical corticosteroid, caution is advised when Daktacort Hydrocortisone Cream is to be applied to extensive surface areas or under occlusive dressings including baby napkins; similarly application to the face should be avoided.

Long term continuous topical corticosteroid therapy should be avoided. Adrenal suppression can occur even without occlusion. Once the inflammatory conditions have disappeared treatment may be continued with Daktarin Cream or Daktarin powder (see section 4.1).

Contact should be avoided between latex products such as contraceptive diaphragms or condoms and Daktacort Hydrocortisone Cream since the constituents of Daktacort Hydrocortisone Cream may damage the latex.

Daktacort Hydrocortisone Cream can damage certain synthetic materials. Therefore, it is recommended to wear cotton underwear if this clothing comes into contact with the affected area.

This medicine contains 2 mg/g of Benzoic acid (E210) which may cause local irritation.

This medicine also contains 0.052 mg/g of Butylhydroxyanisole (E320) which may cause local skin reactions (e.g., contact dermatitis), or irritation to the eyes and mucous membranes.

Miconazole administered systemically is known to inhibit CYP3A4/2C9, which can lead to prolonged effects of warfarin or other vitamin K antagonists. While systemic absorption is limited with topical formulations, the concomitant use of Daktacort Hydrocortisone Cream and warfarin or other vitamin K antagonists should be done with caution and the anticoagulant effect should be carefully monitored and titrated. Patients should be advised of the symptoms of bleeding events and to immediately stop treatment with miconazole and seek medical advice should they occur (see section 4.5).

4.5. Interaction with other medicinal products and other forms of interaction

Miconazole administered systemically is known to inhibit CYP3A4/2C9. Due to the limited systemic availability after topical application, clinically relevant interactions are rare. However, in patients on warfarin or other vitamin K antagonists, caution should be exercised and anticoagulant effect should be monitored.

Miconazole is a CYP3A4 inhibitor that can decrease the rate of metabolism of hydrocortisone. Serum concentrations of hydrocortisone may be higher with the use of Daktacort Hydrocortisone Cream compared with topical preparations containing hydrocortisone alone.

4.6. Fertility, pregnancy and lactation

Pregnancy

Clinical data on the use of Daktacort Hydrocortisone Cream in pregnancy are limited. Corticosteroids are known to cross the placenta and consequently can affect the foetus (See Section 5.3). Administration of corticosteroids to pregnant animals can cause abnormalities of foetal development. The relevance of these findings to humans has not been established.

As a precautionary measure, it is preferable to avoid the use of Daktacort Hydrocortisone during pregnancy. Treatment of large surfaces and the application under occlusive dressing should be avoided during that time.

Breastfeeding

There are no adequate and well-controlled studies on the topical administration of Daktacort Hydrocortisone Cream during lactation. It is not known whether concomitant topical administration of Daktacort Hydrocortisone Cream to the skin could result in sufficient systemic absorption to produce detectable quantities of hydrocortisone and miconazole in breast milk in humans. Caution is recommended during breast-feeding. Treatment of large surfaces and the application under occlusive dressing should be avoided during that time.

A risk to the newborn child cannot be excluded.

4.7. Effects on ability to drive and use machines

This medicine has no influence on the ability to drive and use machines.

4.8. Undesirable effects

The safety of Daktacort Hydrocortisone Cream was evaluated in 480 patients who participated in 13 clinical trials (six double-blind and seven open-label trials) of Daktacort Hydrocortisone Cream. These studies examined patients from 1 month to 95 years of age with infections of the skin caused by dermatophytes or Candida species in which inflammatory symptoms were prominent.

All patients

No adverse drug reactions (ADRs) were reported by ≥ 1% of the 480 Daktacort Hydrocortisone Cream-treated patients (adult and paediatric patients combined).

The frequency categories use the following convention: very common (≥1/10); common (≥1/100 to <1/10); uncommon (≥1/1,000 to <1/100); rare (≥1/10,000 to < 1/1,000); very rare (<1/10,000) and not known (cannot be estimated from the available clinical trial data).

Of the three ADR's identified from the 13 clinical trials of Daktacort Hydrocortisone Cream, skin irritation was reported in one clinical trial that included patients aged 17 to 84 years, skin burning sensation in two clinical trials that included patients aged 13 to 84 years, and irritability in one clinical trial of infants aged 1 to 34 months.

Paediatric population

The safety of Daktacort Hydrocortisone Cream was evaluated in 63 paediatric patients (1 month to 14 years of age) who were treated with Daktacort Hydrocortisone Cream in 3 of the 13 clinical trials noted above. One ADR term (irritability) was reported in these 3 trials. The frequency of irritability in Daktacort Hydrocortisone Cream-treated paediatric patients was common (3.2%).

All events of irritability occurred in one clinical trial of infants (aged 1 to 34 months) with napkin dermatitis. The frequency, type and severity of other ADRs in paediatric patients are expected to be similar to those in adults.

Table 1: Adverse Drug Reactions in Adult and Paediatric Patients Treated with Daktacort Hydrocortisone Cream

System Organ Class

Adverse Drug Reactions

Frequency Category

Uncommon

(≥1/1,000 to <1/100)

Not known

Immune System Disorders

Anaphylactic reaction, Hypersensitivity

Eye disorders

Vision, blurred (see also section 4.4)

Skin and Subcutaneous Tissue Disorders

Skin irritation, Skin burning sensation. Urticaria, Pruritis

Angioedema, Rash, Contact dermatitis, Erythema, Skin inflammation, Skin hypopigmentation, Application site reaction

General Disorders and Administration Site Conditions

Irritability

Reporting of suspected adverse reactions

Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions via the Yellow Card Scheme at: www.mhra.gov.uk/yellowcard or search for MHRA Yellow Card in the Google Play or Apple App Store.

4.9. Overdose

Prolonged and excessive use can result in skin irritation, which usually disappears after discontinuation of therapy. Topically applied corticosteroids can be absorbed in sufficient amounts to produce systemic effects.