13. Skin. Page 1 of 15

Transcription

1 KEY: Green: Recommended as first line Blue: Alternative when first line not suitable Amber: Specialist initiated drugs. They are suitable for long term prescribing in primary care but specialist knowledge is required when initiating therapy. GP s may be invited to Red: formally share patient care, through a shared care agreement. Hospital only products 13. Skin For further information on dermatology guidelines please see the British Association of Dermatologists web site Samples:- Generally the use of samples of medicinal products is not recommended within the Trust. However in dermatology, offering a range of emollient samples enables patients to choose an emollient they feel works, and are therefore more likely to comply with, and helps minimise costs by reducing wastage, and encouraging good compliance with emollient regimens (ref NICE guidelines) Drug 1. All samples are over the counter and no prescription or pharmacy only medications are supplied 2. Patients try a range of emollients and decide which suits them before we or the GP prescribe larger quantities. This reduces the amount of creams prescribed which are never used 3. There is an approved disclaimer within the department 4. There is an approved referral letter back to the GP detailing which products have been supplied 5. All the emollient samples are approved for use within the Herefordshire Joint Formulary 6. Samples are only given out by clinicians with expertise in Dermatology restrictions Comments 13.2 Emollient and barrier preparations Emollients All the emollient preparations stocked (except Emollin spray) may also be used as soap substitutes. Aqueous cream containing sodium lauryl sulphate (SLS) is not included as it is not recommended for use as an emollient. Patients using aqueous cream who continue to have dry skin should be prescribed an alternative eg Epimax cream. E45 cream contains lanolin and is generally not considered suitable for use in eczema or for those with lanolin sensitivity Epimax cream SLS free, cost effective first line cream for patients intolerant of, or unwilling to use, ointment based products Page 1 of 15

2 Doublebase gel Oilatum Cream Zerobase cream Dermol cream and lotion (B) Epimax Oatmeal (B) Emollin spray (B) Emulsifying ointment Liquid paraffin / white Soft paraffin 50/50 Hydromol ointment (B) Yellow soft paraffin (B) Zeroderm ointment (B) Bath / shower emollients LPL 63.4 emollient & bath additive Hydromol bath & shower emollient Oilatum plus emollient Oilatum shower gel Balneum Plus bath oil (B) Dermol 600 bath emollient (B) Barrier creams Conotrane cream Sorbaderm Cream and spray Alternative to Diprobase cream with similar formulation Only use if there is secondary infection (contains antimicrobials) or as a preventative measure in those prone to infection Colloidal oatmeal, replacement for Aveeno cream Only for patients unable to use lotions, creams or ointments Prescribe as brand Fifty:50 ointment in primary care and on FP10 Can be obtained through NHS logistics (alternative to Epaderm ointment) Direct like for like replacement for Oilatum emollient & bath additive (both 63.4% light paraffin) Contains an antimicrobial. Use if frequent secondary skin infections Anti-pruritic Contains an antimicrobial. Use if frequent secondary skin infections or as a preventative measure in those prone to infection First line in primary care - See guidelines in wound care formulary and continence guidance Barrier cream of choice for hospital in-patients. Available in the hospital through NHS Logistics and not pharmacy. Page 2 of 15

3 Zinc and castor oil Metanium Cream (B) 13.3 Topical anti-pruritic Crotamiton (Eurax ) cream Balneum plus Contains urea 5% cream Eucerin intensive (B) Contains urea 10% Dermacool (Menthol in aqueous 1%) (B) Use sparingly. Anecdotally if applied too heavily it may reduce absorption onto incontinence, sanitary and nappy pads and cause more excoriation. Obtained through NHS logistics For insect bites and stings: Topical antihistamines are only marginally effective and a short course of topical corticosteroid is appropriate. Alternatively an oral sedating antihistamine may be necessary Only indicated where there is an itchy sensation but no accompanying dry skin condition It should not be applied to broken skin, or in suspected menthol sensitivity. Some patients may benefit from a 2% preparation. Prescribe by brand name Dermacool on FP10 to ensure continuity of preparation and minimise costs 13.4 Topical corticosteroids Mild Hydrocortisone 0.5% cream and ointment 1% hydrocortisone cream and ointment Moderate Betnovate RD cream and ointment (betamethasone 0.025%) Eumovate cream and ointment (Clobetasone butyrate 0.05%) For use in paediatrics Eumovate is considered less potent than Betnovate RD and can be used for face and flexures for short periods of 1-2 weeks Page 3 of 15

4 Haelan tape (fludroxycortide) (B) Potent Betnovate cream and ointment (betamethasone 0.1%) Elocon cream and ointment (mometasone 0.1%) (B) Very Potent Dermovate cream and ointment (clobetasol 0.05%) Scalp applications: Steroids Betamethasone valerate 0.1% scalp application Fluocinolone 0.025% (Synalar ) gel Betamethasone dipropionate 0.05% lotion (Diprosone ) (B) Clobetasol 0.05% (Dermovate ) scalp application (B) Clobetasol 0.05% (Etrivex) shampoo (B) For use in small areas where pressure may be helpful e.g. keloid scars, or where damage is likely to the area due to knocking or catching Unlicensed use in ENT for severe inflammatory oral conditions such as lichen planus and severe mouth ulcers This is aqueous based and may be less irritant and better tolerated if the scalp skin is inflamed and broken Only if other scalp steroid scalp applications have failed or are not tolerated Not stocked at WVT Page 4 of 15

5 Topical steroids plus antifungals Daktacort Cream and ointment (hydrocortisone 1% + miconazole 2%) Topical steroids plus antimicrobials Fucidin H (Hydrocortisone 1% and fusidic acid 2%) Betnovate C cream, (betamethasone 0.1% and clioquinol 3% (B) Fucibet cream (betamethasone 0.1% plus fusidic acid 2% (B) Synalar N ointment (fluocinolone and neomycin (B) Topical steroids plus others Diprosalic ointment (Betamethasone 0.05% and salicylic acid 3%) (B) Proplylene Glycol 40% in Dermovate (A) ENT use otitis externa Contains a mild potency steroid Contains a potent steroid Contains a potent steroid For use if there is thick psoriatic scale WVT to obtain on an individual patient basis if required For use on thick psoriatic scale Page 5 of 15

6 13.5 Preparations for eczema and psoriasis oral preparations for eczema Alitretinoin (R) Dermatology use Preparations for psoriasis Topical preparations Coal tar preparations Exorex lotion (coal tar 1%) Alphosyl HC cream, (coal tar 5% plus hydrocortisone 0.5%) (B) LPC 5% in betnovate RD ointment (B) Coal tar in emulsifying ointment 1%, 2.5% and 5% (B) Dithranol preparations Dithrocreme 0.1%, 0.25%, 0.5%, 1% and 2% (B) Vitamin D analogues Calcipotriol ointment Oral immunosuppressants, which may also be used in eczematous conditions are included in section 8.2: drugs affecting the immune system For severe chronic hand dermatitis as per NICE guidance Pregnancy prevention programme applies. For women of childbearing age pregnancy should be excluded 1 month before, 3 days before and every month during treatment, and 5 weeks after stopping treatment. Prescriptions should be limited to a 30 day supply and are valid for 7 days only from the date of stated on the prescription Contains a mild potency steroid Contains a moderate potency steroid WVT to obtain on an individual patient basis if required Not suitable for guttate psoriasis. Only appropriate if there are large areas of psoriatic plaque. WVT to obtain on an individual patient basis if required When calcipotriol preparations are used the maximum weekly dose of calcipotriol = 5mg (equivalent to 30g of cream or ointment or 60ml scalp application) Page 6 of 15

7 Calcitriol ointment Dovobet ointment or gel (calcipotriol plus Betamethasone 0.5%) (B) Salicylic acid Salicylic acid 2% ointment (B) (450g) Salicyclic acid 2% and 10% in WSP (A) Diprosalic ointment (Betamethasone 0.05% and salicylic acid 3%) (B) Anti psoriatic scalp applications Alphosyl 2 in 1 (alcoholic coal tar 5%) Capasal (coal tar 1%, coconut oil, salicylic acid 0.5% Polytar liquid 1% Sebco scalp application (coal tar 12%, salicylic acid 2% precipitated sulphur 4%) Diprosalic scalp application (betamethasone 0.05% + salicylic acid 2%) (B) For use on flexures or face Contains potent steroid The gel may also be used as a scalp application Consider step down to Calcipotriol ointment after 2-4 weeks to minimise steroid exposure For use where there is very thick scale particularly on the feet Do not prescribe 2% in aqueous cream which is unlicensed and may cost over 200 for 100g WVT use, to obtain on an individual patient basis For use if there is thick psoriatic scale Contains arachis oil. Not suitable for patients with a nut allergy Replaces Cocois For thickened scale on scalp Page 7 of 15

8 Dovobet gel (calcipotriol + betamethasone 0.05%) (B) CADE (cade oil 6%, salicylic acid 3% in emulsifying ointment) (A) Oral retinoids for psoriasis Acitretin (A) Drugs affecting the immune response WVT use, to obtain on an individual patient basis The pregnancy prevention programme does not apply (see entries for isotretinoin and alitretinoin) but for women of child bearing age pregnancy must be excluded before instituting therapy with Acitretin (negative pregnancy test within 2 weeks prior to therapy). Whenever practicable a monthly repetition of the pregnancy test is recommended during therapy. Topical calcineurin inhibitors Pimecrolimus 1% cream (Elidel ) (A) Tacrolimus ointment 0.03% 0.1% (Protopic ) (A) As a second line alternative in moderate to severe atopic eczema As a second line alternative in moderate to severe atopic eczema Tacrolimus ointment (Protopic): reminder of a possible risk of malignancies including lymphomas and skin cancers Protopic should not be prescribed to patients younger than 2 years, and that the use of Protopic in children aged 2 16 years is restricted to the lower strength 0.03% ointment only. In addition, Protopic should not be applied to lesions that are considered to be potentially malignant or premalignant, or used in patients with congenital or acquired immunodeficiencies, or in patients on therapy that causes immunosuppression. N Systemic immunosuppressants Azathioprine (A) Ciclosporin (A) Wherever possible patients should be maintained on the Capimune brand Dapsone (A) Page 8 of 15

9 Methotrexate 2.5mg tablets only (A) or subcutaneous injection (R) Mycophenolate mofetil (A) Dimethyl Fumarate (R) Thalidomide (R) Biologic agents Adalimumab (R) Dupliumab (R) Etanercept (R) Guselkumab (R) Infliximab (R) Ixekizumab (R) Ustekinumab (R) Apremilast (R) Secukinumab (R) Restricted to dermatology NPSA guidance for safe prescribing must be followed In line with NICE TA475 for moderate to severe plaque psoriasis Pregnancy prevention documentation should be completed for each prescription For use in psoriasis For use in moderate to severe atopic dermatitis in line with NICE TA534 For use in psoriasis For use in moderate to severe plaque psoriasis in line with NICE TA521 For use in psoriasis For use in moderate to severe plaque psoriasis in line NICE For use in psoriasis For chronic plaque psoriasis in line with TA419 and active psoriatic arthritis in line with TA433 For moderate to severe plaque psoriasis in line with TA Preparations for acne Azelaic acid 15% (Finacea ) Benzoyl peroxide aquagel 2.5 & 5% and wash 10% For acne rosacea Not stocked at WVT Euro guidelines 2012.pdf Page 9 of 15

10 Metronidazole 0.75% Azelaic acid 20% (Skinoren ) (B) Clindamycin 1% lotion (B) Duac gel (B) benzoyl peroxide/clindamycin Epiduo gel (B) adapalene 0.1% / benzoyl peroxide 2.5% Treclin gel (B) clindamycin 1% / tretinoin 0.25% Zineryt Topical solution (erythromycin / zinc) (B) First line for acne rosacea. Suggest Anabect brand For melasma Unlicensed indication For use with recurrent boils. Not stocked at WVT Not stocked at WVT Not stocked at WVT Not stocked at WVT Not stocked at WVT Retinoids Adapalene (Differin ) cream and gel (B) Isotretinoin oral Oral antimicrobial preparations for acne Oxytetracycline Doxycycline Lymecycline (B) Restricted to dermatology Pregnancy prevention programme applies. For women of childbearing age pregnancy should be excluded 1 month before, 3 days before and every month during treatment, and 5 weeks after stopping treatment. Prescriptions should be limited to a 30 day supply and are valid for 7 days only from the date of stated on the prescription onandadvice/productspecificinformationandadvice/isotretinoinforsevereacne/index.htm Page 10 of 15

11 13.7 preparations for warts and calluses Salicylic acid solution 26% (Occlusal ) Salicylic acid 50% ointment (Verrugon ) Podophyllum cream 0.15% (Warticon ) (R) Podophyllum Solution 0.5% (Condyline ) (R) 13.8 Sunscreens Sunsense Ultra SPF 50 Photodamage / skin cancer Diclofenac 3% (Solaraze ) Fluorouracil (Efudix ) (B) Actikerall solution fluorouracil 0.5% plus salicyclic acid 10% (A) Imiquimod cream Aldara 5% (A) Ingenol mebutate gel Picato 150mcg/g mcg/g aminolevulinic acid gel 28mg/g 2g (Ameluz ) (R) Restricted to sexual health Restricted to sexual health Face/scalp Trunk / extremities For treatment of actinic keratosis (AK) Useful for hyperkeratotic AKs Note 2 different strength preparations with different license, area of application and dosing In conjunction with photodynamic therapy Page 11 of 15

12 Camouflages Obtained on individual patient basis 13.9 Shampoos and other preparations for scalp and hair Ketoconazole 2% shampoo Selenium sulphide 2.5% (Selsun ) Anti-infective skin preparations Antibacterials Microbiology advice: Metronidazole gel 0.75% Mupirocin cream and nasal ointment Silver sulphadiazine 1% (Flamazine ) Fusidic acid cream (B) MRSA only Avoid widespread use of topical antibiotics (especially where those agents are also available as systemic preparations) Impetigo: - Systematic review indicates topical and oral treatment produces similar results. As resistance is increasing reserve topical antibiotics for much localised lesions. Eczema:- Avoid routine use of topical antibiotics (or steroid/antibiotic combinations) but treat specific instances of infection with a 7-day course of oral antibiotics (flucloxacillin or erythromycin) as for impetigo Fungating and malodorous wounds Not suitable for ongoing use Ensure swabs are taken prior to commencing treatment Antifungal Topical preparations: For oral preparation see section 5.3 Clotrimazole 1% cream Miconazole 2% cream Terbinafine 1% cream Page 12 of 15

13 Antiviral Aciclovir cream 5%, 2g (cold sores), 10g Parasiticidal For latest HPA advice please see leaflet Adobe Acrobat Document For patients are admitted to WVT who are heavily infested with head lice For community practice wet combing is the preferred first line option and insecticides are not normally NHS prescribed. If necessary use a Mosaic approach eg use two applications of insecticide 7 days apart and change to an alternative agent from a different class if adult lice present 2-3 days after final application. Not for prescription in primary care self care only. Dimeticone 4% Malathion 0.5% Permethrin (Lyclear) dermal cream Ivermectin 1% cream Ivermectin tablets (R) Skin cleansers and antiseptics Chlorhexidine 0.05% (Unisept ) Chlorhexidine 0.05% alcoholic (pink and clear) Hydrogen peroxide 3% solution Iodine weak solution Head lice only for self care in primary care For self care in primary care Scabies only For inflammatory lesions of rosacea (papulopustular) in adults second line after topical metronidazole Unlicensed order on individual basis for Norwegian Scabies Refer to wound care formulary for information relating to specific dressing types. Skin cleansers are available through NHS logistics and are not listed here Page 13 of 15

14 Octenidine lotion Potassium permanganate tabs Povidone and iodine dry powder spray Sodium Chloride 0.9% Octenilin wound gel and rinsing solution (B) Octenisan antimicrobial wash (B) Antiperspirants Driclor MRSA eradication only Infection Prevention or TVN advice only Infection Prevention or TVN advice only WVT to obtain on an individual patient basis Patients should have tried Aluminium Salts products before referral to secondary care Others: Miscellaneous Zinc paste bandages (Viscopaste ) (B) Zinc oxide (Zipzoc ) impregnated tubular bandages (B) Silicone gel (A) Hydroquinone 5%, hydrocortisone 1%, tretinoin 0.1% in aqueous cream (Pigmanorm) As kelacote gel or Dermatix gel sheets Page 14 of 15

15 Methoxypsoralens (MOP) 5 tablets Methoxypsoralens (MOP) 8 capsules, gel Methoxypsoralens (MOP) 1.2% bath lotion and 0.005% gel Trichloroacetic acid 30, 50 & 60% For use in Phototherapy Unit only For use in Phototherapy Unit only For use in Phototherapy Unit only For use in Xanthelasma. obtained on an individual patient basis KEY: Green: Recommended as first line Blue: Alternative when first line not suitable Amber: Specialist initiated drugs. They are suitable for long term prescribing in primary care but specialist knowledge is required when initiating therapy. GP s may be invited to formally share patient care, through a shared care agreement. Red: Hospital only products Page 15 of 15