West Essex Dermatology Formulary

Transcription

1 West Essex Dermatology Formulary With thanks to Dr Verdolini, Consultant Dermatologist, Dr Kim Gerlis, Speciality Doctor Dermatology PAHT and GPwSI Dermatology Drs Rogers, Ralph and Pavlou for their help in creating this document The purpose of the formulary is to ensure evidence based and cost effective prescribing in Dermatology. Prescribers should select from the formulary, whenever possible for treatment initiation and where treatments are being reviewed. For treatment failures and difficult cases, other treatments may be used on an exceptional basis and the reasons for use documented in the patients notes. The formulary should be used in conjunction with the relevant local clinical guidelines, manufacturers Summaries of Product Characteristics (SPC), and national guidelines. NICE CKS Local Guidelines National Guidelines Atopic Eczema Acne Rosacea Hyperhidrosis Contact Dermatitis Urticaria Warts & Verrucae Fungal Nail Infection Emollient PIL_Bath Oils & Shower Products Acne Treatment Guidelines Hyperhidrosis Pathway in Primary Care Ciclosporin Shared Care Guidelines Methotrexate Shared Care Guidelines Mycophenolate Shared Care Guidelines Hydroxychloroquine Prescribing Support Rosacea Treatment Guidelines Primary Care Dermatology Society National Eczema Society British Association of Dermatologists Psoriasis Association

2 1. Emollients for dry skin conditions Emollients are essential in the management of diagnosed dermatological conditions but are often underused. When used correctly, emollients can help maintain and/or restore skin suppleness, reduce the number of flare ups and the need for corticosteroid treatment. They should continue to be used even after the skin condition has cleared if the clinical condition justifies continued use e.g. evidence of chronic relapsing eczema Emollients should only be prescribed for patients with a dermatological condition such as eczema, psoriasis or symptomatic xerosis or pruritus caused by systemic disease that threatens skin integrity e.g. in older patients. Ensure the indication is documented on the patients notes Emollients can be purchased over the counter by patients who do not have a diagnosed dermatological condition or risk to skin integrity Choose a cost effective emollient from the suggested list after discussion with the patient in order to match choice to patient lifestyle and increase compliance. Patient preference as well as severity of condition and site of application should be considered when making a suitable choice. Check sensitivities and previous emollients that have been unsuccessfully tried before prescribing. Initially, prescribe a small amount of emollient on an acute prescription to gauge suitability to patient. Once a suitable emollient is decided, add to repeat prescriptions Sufficient quantities should be prescribed to enable patients to apply emollients regularly, frequently and in sufficient volumes. Prescribe up to two different types of emollients to use at different times of the day/ different body areas one of which can be used as a soap substitute as well. Review Emollients use and patients compliance regularly and readjust prescribing accordingly This table suggests suitable quantities to be prescribed for an adult for a minimum of twice daily application for one week. For children approximately half this amount is suitable Area Affected Face Both Hands Both arms or both legs Creasms & Ointments 15 30g 25 50g g Lotion 100mL 200mL 200mL Area Affected Scalp Trunk Groins and Genitalia Creasms & Ointments g 400g 15 25g Lotion 200mL 500mL 100mL Paraffin based emollients are flammable, risk of fire should be assessed and patients should be counselled to keep away from open or gas fires or hobs and naked flames, and to change clothing and bedding regularly to prevent the emollients from soaking into fabric. Aqueous cream is no longer considered suitable as a leave on emollient or soap substitute for diagnosed dermatological conditions due to its tendency to cause irritant reactions and availability of emollient creams with a lower acquisition cost Ointments (except 50:50) can be dissolved in some hot water and added to the bath water as a bath additive and/or use of a cream emollient as a soap substitute in the bath will offer similar emollient effect to bath additives Provide a patient information leaflet (follow link for British Association of Dermatologists) and direct to the National Eczema Society

3 Emollients for Dry Skin Conditions Emollients for Oxygen Patients Paraffin based products are flammable and medical oxygen strongly support combustion, therefore patients on Medical Oxygen who require an emollient should not use any paraffin based products in order to avoid fires MHRA Alert: Fire Hazard with paraffin based skin products NPSA Alert: Fire hazard with paraffin based skin products Below is a list of non paraffin products that can be prescribed for Oxygen patients KY Jelly Prescribe for patients who use nasal cannula for oxygen administration. Can be applied to lips and nose to prevent drying and cracking ImuDerm Urea Emollient Contains Urea 5%, glycerol 5% (500g pump= 6.50) Balneum Cream Contains urea 5%, ceramide 0.1% (500g= 9.97) Balneum Plus Cream Contains Lauromacrogols 3%, urea 5% (100g= 3.29, 500g pump pack= 14.99) Nutraplus Cream Contains Urea 10% (100g= 4.37) Calmurid Cream Contains Urea 10%, lactic acid 5% (100 g = 5.75, 500 g pump = 33.40) QV Gentle Wash only prescribed for thos patients wo require bath/ shower products Cream Based Emollients Creams and gels are emulsions of oil and water and their less greasy consistency often makes them more cosmetically acceptable Emollient Creams per 500g Aquamax cream Light. Contains paraffin (<30%) Epimax cream Use as soap substitute and emollient. Contains paraffin (<30%) Oilatum Junior cream Contains paraffin (<30%) Oilatum cream Contains paraffin (<30%) ZeroAQS Light.Use as soap substitute and emollient. Contains paraffin (<30%) Zerocream Light. Contains lanolin and paraffin (<30%) Emollient Creams per 500g Zerobase Rich. Contains paraffin (<30%) Cetraben cream Contains paraffin (<30%) E45 cream Light. Contains paraffin (<30%) Diprobase cream Rich. Contains paraffin (<30%) Emollient Creams more than 7 per 500g Epaderm cream Use as soap substitute and emollient. Contains paraffin (<30%) Only consider after other more cost effective emollients have failed. ACBS: For endogenous and exogenous eczema, xeroderma, ichthyosis, Aveeno cream and senile pruritus associated with dry skin. AVEENO BABY is blacklisted i.e NOT ALLOWED ON FP10

4 Liquid and white soft paraffin ointment 50:50 % Emulsifying ointment Hydromol ointment Zeroderm ointment Emollient Ointments 5 6 per 500g Epaderm ointment 3 in 1 use: soap substitute, emollient and bath additive Cetraben ointment Diprobase ointment Gel Based Emollient Gels are emulsions of oil and water and their less greasy consistency often makes them more cosmetically acceptable Emollient gels 2 4 per 500ml / 500g Isomol Gel Contains paraffin (<30%) Aproderm gel Contains paraffin (<30%) MyriBase gel Emollient Gels 5 6 per 500ml / 500g Zerodouble Gel Doublebase Gel Contains paraffin (<30%) Contains paraffin (<30%) Ointment Based Emollients Ointments are the greasiest preparations, being made up of oils or fats. They do not usually contain preservatives and may be more suitable for those with sensitivities. However they can exacerbate acne, cause folliculitis when overused, and they should not be used where infection is present. Emollients should be applied in the direction of hair growth to reduce the risk of folliculitis. Ointments come in tubs and so can easily become cross infected with bacteria from the skin patients must not place hands into tubs but instead use a utensil to scoop out the ointment Fire Hazard (High Paraffin Content 70%w/w) Risk of fire when using large quantities as a leave on emollient. Patient should be advised not to smoke, use naked flames or go near anything that may cause a fire while emollients are in contact with their medical dressings or clothing. Patients clothing and bedding should be changed regulary preferably daily. Patient information leaflet available from NPSA Emollient Ointments less than 5 per 500g Use as soap substitute and bath additive 3 in 1 use: soap substitute, emollient and bath additive

5 Lotion Based Emollient Lotions have a higher water content than creams, which makes them easier to spread but less effective as emollients. They may be preferred for very mildly dry skin, as well as for hairy areas of skin. Emollient Lotions less than 5.75 per 500ml / 500g Cetraben Lotion Contains paraffin (<30%) Contains paraffin (<30%). ACBS; For symptomatic relief of dry skin conditions, such as those associated with atopic eczema and contact E45 Lotion dermatitis Emollient Lotions more than 6.60 per 500ml / 500g AproDerm Colloidal Oat Cream Aveeno Lotion ACBS: For endogenous and exogenous eczema, xeroderma, ichthyosis, and senile pruritus associated with dry skin Spray Emollient Aerosol formulations such as sprays and a mousse are also available. They are generally more costly, but sprays may have a role where application without touching the skin is advantageous Emollient Spray 5.97 per 250ml Dermamist Spray Flammable. Contains paraffin (<30%) Urea based emollients Urea products are very expensive and should be reserved when a keratin softener and hydrating agent is required. Emollient products containing urea are not all interchangeable. The urea content of products varies widely and some contain additional active ingredients such as salicylic acid or lactic acid (keratolytic properties), or lauromacrogols (local anaesthetic properties, and soothes and relieves itchy skin). Emollients containing urea less than 10 per 500ml / 500g Balneum cream Contains 5% urea 0.1% ceramide Emollients containing urea per 500ml / 500g Balneum Plus cream Contains 5% urea and lauromacrogols Dry, hyperkeratotic fissured feet in diabetic patients may benefit from emollients containing 10% urea. Limited published evidence suggests 25% urea may increase skin hydration compared to 10% urea. Flexitol 10% Urea cream 10% urea. Contains lanolin Flexitol Heel Balm 25% urea. Contains lanolin. Emollients containing urea 15 per 500ml / 500g Hydromol Intensive cream 10% urea. Lanolin free

6 Soap substitute without antimicrobial Patients like soaps as they make a lather, but they damage the skin barrier and so should be avoided where possible Although specific soap substitutes can be prescribed it is more cost effective to use one of the prescribed leave on Emollient as a wash ointments in particular can provide an effective wash. Soap substitutes can be applied before or during bathing, showering or washing, and then rinsed off. Usual leave on moisturiser See above QV Gentle Wash 5.25 / 500g cost effective alternative to Doublebase Emollient Wash Gel E45 Emollient Wash Cream 3.19 / 250g cost effective alternative to Doublebase Emollient Wash Gel Antiseptic based Emollient/ soap substitute Use should be targeted and short term. Contain chlorhexidine and benzalkonium chloride as antimicrobials. May be useful for preventing recurrent bacterial infections. Some people become sensitised to the leave on forms if they are used for a long time. NICE CG 57 Dec 2007 Atopic eczema in children: Antiseptics such as triclosan or chlorhexidine should be used, at appropriate dilutions, as adjunct therapy to decrease bacterial load in children who have recurrent infected atopic eczema. Long term use should be avoided. Dermol 500 lotion 6.05 / 500ml Lotion is useful for hairy areas and as a soap substitute to prevent staph infections Use as soap substitute and emollient / 500g Thicker formulation. Use as for lotion. Presence of antiseptic can be irritating and cause contact dermatitis. Use as soap substitute Dermol cream and emollient Emollient bath additives The use of bath and shower emollients is controversial and evidence to inform practice is lacking. It is, however, generally accepted that soap is drying and potentially irritating to skin and is best avoided by those with dry skin conditions. Therefore people with dry skin conditions should be advised of alternatives to soap to wash with. First choice A regular leave on emollient that is also suitable for use as a soap substitute. Many standard emollients can be used in this way but products that are completely immiscible with water such as 50:50 white soft paraffin and liquid paraffin ointment are not suitable. Hydration improved by soaking in the bath for minutes. Antiseptic Bath Additive Antimicrobials added, may be useful when there are recurrent bacterial infections switch back to ordinary emollients as bath / soap substitute when infection clear. NB benzalkonium chloride may be irritant Bath emollient 6.30 per 500ml Dermol 600 Bath emollient Contains benzalkonium chloride. Short term use only, not on repeat prescription. Antiseptic component can be useful when patient favours a bath rather than shower and eczema is getting infected recurrently. Rarely used as a hand soak for eczema hands with recurrent infection

7 Simple Bath Additive An emollient product designed specifically for washing within the bath or shower should only be used when above options are inadequate. Review use to ensure benefit is given. Click here for patient information leaflet. These preparations make skin and surfaces slippery, particular care is needed when bathing. Encourage use of anti slip bath mats/handles for the young and elderly. Bath/shower/soap emollients 4 5 per 500ml Hydromol Bath & Shower Useful across all ages and works for bath and shower. Use on wet skin and rinse is useful. Some patients struggle with compliance to general Emollient emollients but will have bath/ shower each day and use this product. Oilatum Jnr Bath Additive Contains lanolin Oilatum Emollient Contains lanolin Antipruritic Bath Additive Very expensive but may be helpful for use at night time to relieve itching in patients who cannot tolerate leave on emollients Bath emollient per 500ml Balneum Plus Bath Oil Contains lauromacrogols Consider only after other cost effective options have failed when control of itch / scratch cycle is a really important factor, especially in atopic Aveeno Bath Oil patients. ACBS: for endogenous and exogenous eczema, xeroderma, ichthyosis, and senile pruritus (pruritus of the elderly) associated with dry skin. Miscellaneous Omega 3 fish oils MOPB June 2017 not recommended as regarded as low priority, poor value for money. There are no good quality data for the use of omega 3 fish oils in prevention of dementia, pre menstrual syndrome, attention deficit hyperactivity disorder (ADHD), atrial fibrillation, eczema, osteoarthritis or age related macular degeneration.

8 Barrier Preparations Barrier preparations, now known as skin protectants, are used to minimise the damage to skin around particularly sensitive area such as stoma sites and pressure areas in the elderly. Where the skin has broken down, barrier preparations can have a limited role in helping to protect adjacent skin. With an increasing range of products available in a variety of different formulations, including sprays and wipes, local tissue viability leads have undertaken a review to identify a local list of preferred products Please note barrier preparations are available to purchase over the counter (OTC) Conotrane Cream Vasogen Cream AproDerm Cream 100g 500g 100g 30g 100g 3M Cavilon Durable Barrier Cream: 20g, 28g, 92g Cavilon 3M Cavilon No Sting Barrier Film Pump Spray (sterilised) 28mL Foam Applicators (sterile) 1mL & 3mL Stoma Wipe 30 Topical Local Anaesthetics and Anti Pruritic Available to purchase over the counter (OTC) Calamine aqueous cream 100ml ( 0.93) Crotamiton cream 10% Emla and ametop 30g ( 2.38), 100g ( 4.15) Emla 5g= 1.73, 30g = Ametop 4% Gel 1.5g = 1.15 Eurax Can be useful to help the itching post scabies infection Specialist use only

9 Topical Corticosteroids Topical corticosteroids should be prescribed with an emollient to maximise cutaneous absorption. Appropriate use of emollients can have a steroid sparing effect. Choice of formulation: Creams: Suitable for moist or weeping areas contain preservatives, avoid with chronic eczema Ointments: Generally chosen for dry, thickened or scaly lesions, or where more occlusive effect required Lotions: May be useful when minimal applications to a large or hair bearing area are required The preparation containing the least potent drug at the lowest strength which is effective is the one of choice Proprietary preparations should always be used where possible. Special extemporaneous preparations are unlicensed and expensive. (There is considerable variation in cost of the same preparation dependent upon the special supplier used.) NICE has recommended that corticosteroids should not be applied to the affected skin of people with atopic eczema more than twice a day. If there is more than one type of topical corticosteroid that would be appropriate for a persons eczema, then the cheapest should be used. Topical steroids should ideally be prescribed as short courses to be used in parallel with regular emollients: For an acute exacerbation, use for 3 to 7 days no need to withdraw slowly Chronic exacerbation use for 4 to 6 weeks or until inflammation settled should be withdrawn by either reducing the frequency of application or reducing the potency over 2 to 3 weeks. It is recommended that the clinical response of an initiated topical corticosteroid is reviewed after 2 weeks. Patient should be re assessed on an on going basis. Review diagnosis if not responding MHRA August 2017 Corticosteroids: rare risk of central serous chorioretinopathy with local as well as systemic administration Topical Corticosteroid Potencies Hydrocortisone 0.5% 1% Mild Hydrocortisone combinations Hydrocortisone with antimicrobials Moderate Clobetasone butyrate Betametasone valerate Potent Betametasone dipropionate Mometasone furoate Very Potent Clobetasol propionate

10 Hydrocortisone Cream Hydrocortisone Ointment 0.5%: 15g ( 1.44), 30g ( 5.19) 1%: 15g ( 1.13), 30g ( 1.40) 0.5%: 15g ( 2.99), 30g ( 5.23) 1%: 15g ( 2.45), 30g ( 1.89) Hydrocortisone 1% is available OTC but can only be sold for treatment of allergic contact dermatitis, irritant dermatitis, insect bites and mild to moderate eczema. It is not to be sold for children under 10 years, pregnant women or for use on the face, anogenital region or broken or infected skin. Compound Preparations They should be regularly reviewed and if no improvement re assesses diagnosis. The topical steroid component of combination preparations is only required for a short time if itch / irritation is present Crotamiton 10% + hydrocortisone 0.25% cream Clotrimazole 1% + hydrocortisone 1% cream 30g ( 0.87) Eurax HC 30g ( 2.42) MILD potency topical corticosteroids 1% is the usual strength used If prescribing 0.5% strength 30g please prescribe 2x15g. Can be a trigger for contact dermatitis Canesten HC Good for post scabies itching OTC (15g) for contact dermatitis and insect bites OTC (15g) for fungal infections Nystatin 100,000 units + dimeticone + benzalkonium chloride + hydrocortisone 0.5% Fusidic acid 2% + hydrocortisone 1% Daktacort CLOBETASONE BUTYRATE 0.05% FLUDROXYCORTIDE 4mcg/cm 2 Clobetasone butyrate 0.05% + oxytetracycline 3% + nystatin 100,000units 30g ( 2.44) 30g cream ( 4.99) Cream 30g = 2.49 Ointment 30 g = 2.50 Cream: 30g, 100g Ointment: 30g, 100g Tape: 7.5cm x 50cm Tape: 7.5cm x 200cm 30g cream Timodine Fucidin H See note under anti infective skin preparations. Max 2 weeks. Please note fusidic acid bacterial resistance exists. Restricted in hospital consultant only MODERATELY potent topical corticosteroids Eumovate 15g is available OTC but can only be sold for short term treatment of eczema in patients over 12 years. Haelan For chronic localised recalcitrant dermatoses (but not acute or weeping), cut tape to fit lesion, apply to clean, dry skin shorn of hair, usually for 12 hours daily Hospital only Compound Preparations Trimovate : Stains Clothing

11 BETAMETHASONE VALERATE 0.1% MOMETASONE FUROATE 0.1% Cream: 30g, 100g Ointment: 30g, 100g Scalp application: 100ml Cream: 30g, 100g Ointment: 30g, 100g Scalp lotion: 30ml Betnovate Elocon POTENT Topical corticosteroids First Line Second Line Prescribe generically Check prices branded cheaper? Apply once daily. More expensive. Has s/e profile of a moderate steroid. FLUOCINOLONE ACETONIDE 0.025% Gel: 30g, 60g Synalar Restricted for scalp conditions Compound preparations BETAMETHASONE DIPROPIONATE 0.05% + SALICYLIC ACID 3% Ointment: 30g, 100g Scalp appl 100ml Salicylic acid only 2% in scalp application. Check if available VERY potent topical corticosteroids CLOBETASOL PROPIONATE 0.05% Cream: 30g ( 2.69) Ointment: 30g ( 2.69), Dermovate Not for use in children, face or flexures. Do not put on repeat for short term use only Advise Specialist initiation only ORAL RETINOID for ECZEMA Alitretinoin Capsules: 10mg, 30mg Toctino : Duration of treatment weeks; discontinue if no response after 12 weeks. RED drug only suitable for prescribing in secondary care or by an accredited specialist. NICE Guidance: Alitretinoin for the treatment of severe chronic hand eczema in adults (August 2009). Alitretinoin is recommended for the treatment of severe chronic hand eczema that has not responded to potent topical corticosteroids. Treatment should be stopped as soon as an adequate response has been achieved (hands clear or almost clear), or if the eczema remains severe after 12 weeks, or if an adequate response has not been achieved by 24 weeks.

12 Preparations for Psoriasis The scale on the psoriasis plaques needs to be removed in order for topical psoriasis treatments to penetrate them. Emollients can be effective to remove the scale. The vehicle of the chosen topical treatment can be sufficiently moisturising to reduce the need for regular emollients. First Line Generic ointment available. Calcipotriol 50mcg/g Ointment: 120g Dovonex Cream 120G Dovonex ointment 120G Apply once or twice daily. Avoid face and flexures Compound Preparations Dovobet : once daily application, max 30% body area for a maximum of 8 weeks for non scalp areas and 4 Betamethasone dipropionate Ointment: 60g, 120g weeks for the scalp. Dovobet is for intermittent use only, the patient should be advised to have a 4 week 0.05% + calcipotriol 50mcg/g treatment break after each course of treatment, max: 100g per week When different preparations containing calcipotriol used together, max. Total calcipotriol 5mg in any one week. Management of scalp psoriasis Coal tar first line Coal tar solution 12%, salicylic acid 2%, precipitated sulphur 4%, in a coconut oil emollient basis Ointment: 40g, 100g Sebco : shampoo off after 1 hour. Coal tar 1% + salicylic acid shampoo 0.5% 250ml ( 4.69) Coal tar extract 2% shampoo 250ml ( 4.78) Capasal : apply daily as necessary T/Gel : apply as necessary Vitamin D and Analogues second line Betamethasone dipropionate 0.05% + calipotriol 50mcg/g Betamethasone dipropionate 0.05% + salicyclic acid Dithranol Scalp gel: 60g ( 36.50) Scalp app.: 100ml ( 10.10) 0.1% Cream 50g ( 3.77) 0.25% Cream 50g ( 4.04) Dovobet gel (Please note similar composition to Xamiol ) Apply once daily, shampoo off after leaving on scalp overnight or during the day; usual duration of therapy, 4 weeks. Not for children under 18 years. Topical Corticosteroids (POTENT) third line Diprosalic : contains salicylic acid in an alcoholic base Dithranol Preparations for Psoriasis Dithrocream 0.1%, 0.25%; 0.5%; 1%; 2%. Micanol if 3% required

13 Acitretin Capsules: 10mg, 25mg caps Oral retinoids for PSORIASIS Neotigason Under Specialist Supervision Only Drugs Affecting the Immune Response Topical Treatment Pimecrolimus 1% Cream: 30g, 60g 0.03% Oint: 30g, 60g For specialist initiation only (Elidel ) Tacrolimus 0.03%, 0.1% 0.1% oint: 30g, 60g For specialist initiation only (Protopic ) Systemic Treatment Specialist initiation then may be prescribed in Primary Care under shared care agreement Ciclosporin 10, 25, 50 & 100mg caps Deximune Regular monitoring required. must be prescribed and dispensed by brand name Oral soln.: 100mg/ml MHRA alert Methotrexate Tablets: 2.5mg **Weekly dosing** see NPSA Improving compliance with oral methotrexate guidelines Methotrexate 10mg tablets are NOT recommended for safety to ensure strengths are not confused MHRA new pregnancy prevention advice for women and men Mycophenolate mofetil 500mg tabs MHRA risk of hypogammaglobulinaemia and risk of bronchiectasis MHRA pure red cell aplasia Azathioprine 25mg, 50mg Hydroxychloroquine 200mg tablets Prescribing support document available Treatments used prior to PUVA treatment 5 methoxypsoralen Tablets: 20mg NAMED PATIENT prior to PUVA treatment: Take 3 hours before treatment 8 methoxypsoralen Methoxypsoralen Tablets: 10mg Psoralen Gel 0.005% 50g 1.2% bath lotion 30ml NAMED PATIENT prior to PUVA treatment: Take 2 hours before treatment NAMED PATIENT prior to PUVA treatment used in dilution of 1.3ml in 4 litres of water Preparations for Acne All treatment should be tried for at least TWO months before deciding on efficacy. Some may be irritant, in which case the frequency of use may be reduced and/or use a lower strength. Anti microbial / anti inflammatory Benzoyl Peroxide BPO preparations Azelaic acid 20% Azelaic acid 15% 30g = 5.44, 60g= g= g= g 30g Acnecide 5% gel Acnecide Wash 5% gel useful for large area Brevoxyl 4% Cream Skinoren cream Finacea gel also licenced for papulopustular rosacea

14 Topical Retinoids and related drugs Use sparingly initially, contraindicated in pregnancy, women of child bearing age must use effective contraception (oral progesterone only contraceptives not considered effective). Increased sensitivity to sunlight or UVB light. Patients should be warned that some redness and skin peeling can occur initially but settles with time. If undue irritation occurs, the frequency of application should be reduced or treatment suspended until the reaction subsides; if irritation persists, discontinue treatment. Isotretinoin 0.05% Adapalene 0.1% Adapalene 0.1% + BPO 2.5% Benzoyl peroxide 3% or 5% + clindamycin 1% Isotretinoin 0.05% + erythromycin 2% Tretinoin 0.025% + erythromycin 4% Tretinoin 0.025% + clindamycin 1% Erythromycin 40mg/ml + zinc acetate 12mg/ml Clindamycin 1% Gel 30g Gel or cream 45g Gel 45g Gel: 3% 30g 5% 25g & 50g Gel: 30g Isotrexin Isotrex Differin Topical Retinoid with BPO use sparingly initially Epiduo Topical Antibiotic with BPO Duac Once Daily Note: cost effectiveness disputable (cost differential of individual agents). Apply in the evening Topical Antibiotic with Topical Retinoid Solution: 25ml Aknemycin Plus may be less irritant than Isotrexin Gel: 30g Treclin Topical Antibiotics for patients who wish to avoid oral anti bacterials or who cannot tolerate them Lotion: 30ml, 90ml Zineryt Aqueous Lotion: 30ml Dalacin T Lotion: Apply Twice Daily Aqueous solution: 30ml Dalacin T solution Gel 30g Zindaclin gel

15 Oral Treatment Antibiotics Useful for inflammatory acne if topical treatment not adequately effective or if it is inappropriate Concomitant use of different topical and systemic antibiotics is undesirable owing to the increased likelihood of the development of bacterial resistance. 500mg twice daily. Not to be used in children under 12, breastfeeding, pregnant or women of childbearing age Oxytetracycline Tablets: 250mg without adequate contraception. See BNF counselling. Doxycycline Capsules: 100mg 100mg daily see BNF counselling. Capsules should be swallowed whole with plenty of fluid during meals while sitting or standing. Not to be used in children under 12, breastfeeding, pregnant or women of childbearing age without adequate contraception. Photosensitivity reported. Avoid exposure to sunlight or sun lamps Lymecycline Capsules: 408mg 408mg daily. Not to be used in children under 12 years, breastfeeding, pregnant or women of childbearing age without adequate contraception. See BNF counselling Macrolides Microbial resistance an increasing problem for erythromycin, therefore reserve for patients where tetracyclines are not tolerated or are contraindicated e.g. pregnancy or breast feeding Eythromycin 250mg e/c tablet 500mg twice daily Clarithromycin 250mg tablet 250mg twice daily an alternative if GI effects of erythromycin not tolerated. Avoid clarithromycin particularly in first trimester of pregnancy unless potential benefit outweighs risk. Minocycline should not be used routinely for acne as there are safety risks and it is an expensive treatment. Minocycline can cause gastrointestinal and dermatological adverse reactions. Minocycline has also been associated with hyperpigmentation and systemic lupus erythematosus (SLE) and autoimmune hepatitis. The BNF advises that if treatment continues beyond six months, GPs should monitor patients every three months for hepatotoxicity, pigmentation and SLE. Co cyprindiol (cyproterone acetate 2mg and ethinylestradiol 35mcg) Isotretinoin Tablets (63 ) 10mg 30caps = mg 30 caps = Hormonal Prescribe generically. Licensed for use in women with moderate to severe acne that has not responded to topical therapies or oral antibacterials. Co cyprindiol is not licensed for the sole purpose of contraception and should be discontinued three to four menstrual cycles after the woman s acne has resolved. Avoid in patients that have a pre disposition to thrombosis Oral retinoids Prescribed by or under the supervision of a consultant dermatologist. Contra indicated in pregnancy and avoid in breastfeeding. If referring for oral isotretinoin consider providing the patient with the isotretinoin Patient Information Leaflet (British Association Dermatologists) and requesting baseline bloods (FBC, renal function, LFT, lipid profile, BG, Ferritin) MHRA Drug Safety Update Oct 2017 Isotretinoin (Roaccutane): rare reports of erectile dysfunction and decreased libido

16 Preparations for Rosacea Topical Antibiotics Metronidazole 0.75% Cream: 30g / 40g Rozex Inflammatory papules, pustules and erythema of rosacea. Gel 40g Apply twice a day Anti microbial / anti inflammatory Azelaic acid 15% 30g Finacea gel, licenced for papulopustular rosacea Apply twice a day Ivermectin 10mg/g 30g Soolantra cream, papulopustular rosacea, if Rozex and Finacea are ineffective. OD for 4 months. Oral Treatment Antibiotics Concomitant use of different topical and systemic antibiotics is undesirable owing to the increased likelihood of the development of bacterial resistance. Oxytetracycline Tablets: 250mg 500mg twice daily. Not to be used in children under 12 breastfeeding, pregnant or women of childbearing age without adequate contraception. See BNF counselling. Doxycycline Capsules: 50mg, 100mg mg daily See BNF counselling. Capsules should be swallowed whole with plenty of fluid during meals while sitting or standing. Not to be used in children under 12 breastfeeding, pregnant or women of childbearing age without adequate contraception. Photosensitivity reported. Avoid exposure to sunlight or sun lamps Lymecycline Capsules: 408mg 408mg daily. Not to be used in children under 12 years breastfeeding, pregnant or women of childbearing age without adequate contraception. See BNF counselling. Macrolides Microbial resistance an increasing problem for erythromycin, thus reserve for when tetracyclines are not tolerated / contraindicated e.g. pregnancy or breast feeding Eythromycin 250mg e/c tablet 500mg twice daily Clarithromycin 250mg tablet 250mg twice daily an alternative if GI effects of erythromycin not tolerated. Avoid clarithromycin particularly in first trimester of pregnancy unless potential benefit outweighs risk. Flushing, erythema(without inflammation), telangiectasia Can sometimes be the predominant symptoms. Tend not to respond to antibiotics. Flushing can be aggravated by some drugs such as calcium channel blockers Propranolol 40mg Twice daily Flushing may be helped by non selective beta blockers Clonidine 50mcg Twice daily considered by the Joint Formulary Committee to be less suitable for prescribing Brimonidine 0.33% topical gel Mirvaso : initiated only by consultant or GPwSi for symptomatic treatment of moderate to severe persistent facial erythema associated with rosacea in adult patients. Usage should be limited to important events such as interviews, presentations or important social events where symptoms may be particularly embarrassing to the patient. Please note may lead to significant rebound erythema.: MHRA Alert risk of systemic cardiovascular effects MHRA risk of exacerbation of rosacea

17 Preparations for Urticaria Antihistamines Non sedating Antihistamines BNF Statement: Although drowsiness is rare, nevertheless patients should only be advised that it can occur any may affect performance of skilled tasks (e.g. driving); excess alcohol should be avoided. First Line Cetirizine (Generic) Tablets: 10mg Liquid: 1mg/ml Age > 6 yrs: 10mg daily (OTC) Age 2 6 yrs: 5mg daily (OTC) Loratadine (Generic) Tablets: 10mg Liquid: 5mg/5ml Age > 6yrs: 10mg daily (OTC) Age 2 6 yrs: 5mg daily (OTC) Second Line For patients who do not respond to first line choices or are at risk of adverse effects, especially when consultants may recommend higher than licensed doses. Fexofenadine Tablets: 180mg Not recommended for children under 12 years. Only the 180mg tablet is licensed for urticaria Sedating Antihistamines Can be used in combination with non sedating antihistamines particularly for additional relief/control of pruritus at night. Chlorphenamine Tablets: 4mg Not recommended under 1 year. Child: 1 2 yrs 1mg bd, 2 5yrs 1mg 4mg 4 to 6 hrly (Max 24 mg/24 Hrs) Liquid: 2mg/5ml 4 6hrly, 6 12yrs 2mg 4 6hrly Hydroxyzine Tablets: 10mg, 25mg Liquid: 10mg/5ml 25mg at night increased to 25mg 3 to 4 times daily if necessary (See BNF for child doses) Preparations for Warts and Calluses Paint 16.7% (salactol 1.71) OTC. Will give 80% clearance if applied daily for 3/12. If used for 3/12, it is as effective as cryotherapy. Salicylic acid (Purchase OTC) Cuplex : salicylic acid 11% + lactic acid 4% GEL Gel 12% Salactol : salicylic acid 16.7% + lactic acid 16.7% PAINT Maximum 3 applications for warts, 6 applications for verrucas. CKS states the evidence base to support its use Silver nitrate Caustic pencil 95% for warts is very limited Remove dead skin before use by gentle filing and to cover with adhesive dressing after application. Anogenital warts Treatment of ano genital warts should be accompanied by screening for other sexually transmitted diseases. Aldara : Should be rubbed in and allowed to stay on the treated area for 6 10 hours for warts, then washed off Imiquimod 5% sachets ( 48.39) with mild soap and water. The cream should be washed off before sexual contact. May Damage latex condoms and diaphragms. Hospital Consultant Use Only

18 Sunscreen Preparations & Camouflages Sunscreens and camouflages are borderline substances and should be prescribed in accordance with the recommendations of the Advisory Committee on Borderline Substances Sunscreen Preparations (ACBS CRITERIA ONLY ) Sunscreen preparations can be prescribed for protection from UV radiation in abnormal cutaneous photosensitivity resulting from genetic disorders (albinism, xeroderma, pigmentosum, vitiligo), photodermatoses resulting from radiotherapy, and Lupus, both cutaneous and systemic and chronic or recurrent herpes simplex labialis For routine sun protection patients should be advised to self purchase sunscreen preparations with dual protection against UVB and UVA rays, with an SPF value minimum of 30. Advisory sunscreen because of risk of skin cancer is not a qualifying condition and should be regarded as routine sun protection. Anthelios XL SPF 50+ Cream 50ml= 3.80 Lotion 50ml roll on ( 4.44) 125ml ( 7.22), 500ml ( 16.12) Water resistant Water resistant Sunsense Ultra (UVB SPF 50+) Uvistat (UVB SPF 30 and UVB SPF 50) Covermark Classic Foundation Covermark Finishing Powder Dermacolor Camouflage Cream Dermacolor Fixing Powder Keromask Finishing Powder Keromask Masking Cream Veil Cover Cream Veil Finishing Powder 0.5% Fluorouracil and 10% Salicylic Acid Ingenol Mebutate 150mcg/g Ingenol Mebutate 500mcg/g Diclofenac 3% Gel Cream 125ml (SPF , SPF ) 15ml= g= ml= g= g= ml= g= 22.42; 44g= 33.35; 70g= g= ml 3x0.47g single use tubes 2x0.47g single use tubes 50g Non water resistant Camouflages (ACBS CRITERIA ONLY) They can prescribed only for postoperative scars and other deformities (birthmarks, mutilating lesions) and as an adjunctive therapy in the relief of emotional disturbances due to disfiguring skin disease, such as Vitiligo Actinic Keratosis First Line Treatment choices, to be prescribed by GPs Please see guidelines for place in therapy and further information Link Actikerall Picato Picato Solaraze

19 Fluorouracil 5% Cream Imiquimod 5% cream Imiquimod 3.75% cream 40g 12 sachets 12 sachets Cream: 15g ( 4.38) Mupirocin 2% Ointment: 15g ( 4.38) Nasal ointment Polymyxins Ointment: 20g ( 4.62) Cream: 20g( 3.10), 50g ( 4.11), Silver Sulfadiazine 1% 250g ( 11.00) 500g ( 19.48) Fusidic acid 2% Clotrimazole 1% Cream: 15g, 30g Ointment: 15g, 30g Metronidazole 0.75% Gel: 15g ( 4.47), 30g ( 7.89) Cream: 20g, 50g Spray: 40ml ( 4.99) Solution: 20ml ( 2.43) Miconazole 2% Cream: 30g ( 1.82) Terbinafine 1% Cream: 30g ( 2.40) Second line treatments for use by GPwSI /specialist Please see guidelines for place in therapy and further information Link Efudix Aldara Zyclara Anti Infective Skin Preparations Antibacterial preparations only used topically Bactroban Note may sting Polyfax Flamazine Tubes, 20g,50g have a 7 day expiry Tubs, 250g/500g have a 24 hour expiry Antibacterial preparations also used systemically Fucidin TDS for 14 days Use only when necessary due to emergence of resistance of staphylococci to fusidic acid. Note this is consultant only in hospital Anabact Malodorous fungating tumours and malodorous gravitational and decubitus ulcers. Antifungal preparations Prescribe generically. OTC Spray useful for management of Tinea pedis (athletes foot) in toe webs. Daktarin OTC for Tinea Pedis Apply for 10 days after lesions have healed Prescribe generically Review after 2 weeks

20 Terbinafine Griseofulvin Itraconazole 125mg, 500mg tabs Oral suspension 125mg/5ml Capsules 100mg: Oral liquid 10mg/ml 150ml Shampoos and some other scalp preparations (See Psoriasis section also) Ketoconazole 2% Shampoo 120ml ( 3.59) Nizoral OTC. First line for seborrhoeic dermatitis Polytar liquid 250mL Scalp psoriasis seborrhoeic dermatitis (including dandruff). Cetrimide 10%, undecenoic acid 1%, phenylethyl alcohol 7.5% Tablets: 250mg (14 = 1.93, 28 = 2.46) 150mL, 500mL Oral Treatment Only consider treatment if symptomatic. If treating nail infection take nail clippings: start therapy only if infection is confirmed by laboratory. DO NOT PUT ON REPEAT Idiosyncratic liver reactions occur rarely with terbinafine. Baseline LFT prior to commencement of treatment is advised. Not effective on candida and yeasts Ceanel Concentrate Check if available Scalp psoriasis, seborrhoeic dermatitis, dandruff, apply 3 times in first week then twice weekly Alcoholic coal tar extract 5% 125ml, 250ml Alphosyl 2 in 1 Dandruff, use once or twice weekly as necessary; psoriasis, seborrhoeic dermatitis, scaling and itching, use every 2 3 days Dermax therapeutic shampoo 250ml = 5.69 For seborrhoeic dermatitis Treatment of nail infections in Adults If the fungal infection has been confirmed by positive microscopy or positive culture and the condition is severe and debilitating, painful or in patients with peripheral vascular disease, diabetes or those who are immune compromised consider oral treatment as first line due to improved outcomes. For systemic treatment, oral terbinafine is recommended for first line use, with itraconazole as an alternative. Topical treatment should only be used in superficial white onychomycosis and possibly in early distal and lateral subungual onychomycosis (DLSO) where the infection is confined to the distal edge of the nail, or when systemic treatment is contraindicated. Current UK guidelines advise against the routine use of oral and topical treatments in combination, as there is insufficient evidence of benefit. If topical treatment is appropriate, there is limited evidence that Amorolfine nail lacquer, applied for 6 months (fingers) or 12 months (toes), is most effective. Recommend buying OTC. Should only be prescribed for cases where presence of fungal infection is confirmed by laboratory MOPB June 2017 regarded as low priority, poor value for money Nail Lacquers Pack Instructions for use Comments Amorolfine 5% 3mL 1 2x weekly, fingers: 6 months, toes: 12 months, review every 3 months OTC mild cases 2 nails, Max strength 5%

21 Aciclovir 5% Cream: 2g (OTC), 10g Antiviral Preparations Prescribe Generically. Cold sores resolve after 7 10 days without treatment. Topical antiviral applied prodromally reduce duration by Hrs Aciclovir 800mg Tabs 800mg five times a day for 7 days Parasiticidal Preparations For Scabies Apply liberally to the whole body from ear/chin downwards and under nails. If under 2 years/elderly, also treat face/scalp. Apply to cool, dry skin NOT after a hot bath, and leave on the skin for 8 to 24 hours as directed on the product. Treat all home and sexual contacts within 24hours. Apply a second treatment after 7 days as first treatment will not have killed the unhatched mites. The itch may persist for a couple of weeks even if treatment is successful. Please advise patients to wash all clothes, including bed linen and bed clothes at temperature over 60ºc. Treat partners and close contacts Please counsel patients to expect the rash to continue after treatment Permethrin 5% Cream: 30g ( 5.71) Lyclear dermal cream See BNF/Product literature for usage instructions Malathion 0.5% Aqueous liquid: 200ml Derbac M 2nd line option if allergy to permethrin. See BNF/ SPC for usage instructions Oral Treatment: Ivermectin 3mg tabs ( Special) Named patient. Hospital Only For Head Lice Wet combing method (at least 30 minutes each time at 4 day intervals for minimum 2 weeks see BNF for more details). Mechanically removes head lice and is the preferred method of treatment. Available to purchase OTC Only to be used if live lice are seen Leave in contact for 12 hours, (2 hours is insufficient contact time to kill eggs) Repeat after 7 days If live lice still found after 2 3 days, second treatment using a different agent and repeat as above All related cases of confirmed infection should be treated at same time with the same insecticide Avoid alcoholic formulations where severe eczema or asthma or small children Malathion 0.5% Aqueous lotion: 50ml, 200ml OTC, Derbac M Dimeticone 4% Lotion: 50mL, 150mL. Spray: OTC, Hedrin 60mL, 100mL Patient should be told to keep hair away from fire and flames during treatment. For Crab Lice Permethrin and Malathion are used to eliminate crab lice. An aqueous preparation should be applied, allowed to dry naturally and washed off after 12 hours; a second treatment is needed after 7 days. All surfaces of the body should be treated, including the scalp, neck and face (paying particular attention to the eyebrows and other facial hair). A different insecticide should be used if a course of treatment fails.

22 Aluminium chloride hexahydrate 20% Propranolol Oxybutynin Tolterodine Darifenacin Propantheline Glycopyrronium bromide Botulinum toxin Iontophoresis Antiperspirant Hyperhidrosis UK website for more information and patient self help East Of England Prescribing Advisory Committee Patient self management leaflet hyperhidrosis Roll on applicator 75mL Driclor OTC pack available (20ml) Roll on applicator 60mL Anhydrol Forte. See Hyperhidrosis UK website for more information Other hyperhidrosis treatments 10mg tablet 40mg tablet Where patients are anxious 80mg tablet 2.5 mg, 5mg IR tablet 5mg MR 10mg MR 1mg, 2mg IR tablet 7.5mg MR 15mg MR Unlicensed use, start 2.5mg OD and gradually titrate according to response to a maximum 5mg QDS. Modified release (MR) tablets for use when immediate release oxybutynin not tolerated. Dose as in BNF: Lyrinel XL Unlicensed use, could be offered if oxybutynin effective but not well tolerated Unlicensed use, could be offered if oxybutynin effective but not well tolerated Licensed. Start at 15mg OD and gradually titrate according to response, see SPC for more details. However it is Tablets: 15mg more expensive option than above, only use if first line options are not tolerated Not recommended for prescribing in Primary or Secondary Care. Licensed product available, but unlicensed use. 1mg, 2mg tablets Very expensive: 1mg (30) 108; 2mg (30) 138. Review patients on glycopyrronium bromide if suitable for switch to oxybutynin. For iontophoresis axillae/palms/soles. The addition of anti muscarinic drugs e.g. glycopyrronium bromide to the Glycopyrrolate 0.05% w/v in water is not routinely funded within West Essex. Specialist should apply for funding if there are exceptional water circumstances. Weccg.funding@nhs.net Routinely funded for axillae only. Specialist use only. Apply for funding using toxin.htm Botox Injection: 50/100iu vial Not routinely funded for craniofacial, palms and soles. If there are exceptional circumstances specialist to apply for funding using an Individual Funding Request A trial of plantar, palmar and axillary iontophoresis with water available from secondary care, via referral to GPwSI Dermatology, Dermatology Dept. or Vascular Surgeons, after failure of antiperspirants and anticholinergics. Trial of 7 10 iontophoresis sessions, then assessment after 1 month. Patients are expected to purchase their own machine for home treatment if successful. Vascular Surgeons, Dermatology dept. and GPwSI Dermatology apply for funding via iontophoresis proforma.

23 Proflavine 0.1% Cream: 100ml ( 2.40) Collodion, Flexible BP Liquid: 10ml 38p Histoacryl Tissue Adhesive Chlorhexidine gluconate Povidone iodine Potassium permanganate Sodium chloride 4% Solution 250ml, 500ml 10% alcoholic 500ml 10% Solution 500ml 2.5% dry powder spray; 400mg tablets 0.9% irrigation solution Preparations for minor cuts Note: Stains clothing May cause skin sensitisation. Should be applied by an appropriately trained healthcare professional Skin Cleansers and Antiseptics Hibiscrub Videne alcoholic tincture Videne antiseptic solution Betadine dry powder spray Permitabs 25x20mL units, 200mL can Miscellaneous Elfornithine MOPB June 2017 regarded as low priority, poor value for money. The treatment of hirsutism is considered cosmetic procedure which is low priority for funding. If hirsutism is mild and does not significantly interfere with the woman s quality of life, consider no additional treatment. Hirsutism is not usually associated with any significant medical abnormality. Eflornithine 11.5% cream offers very little benefit for the management of facial hirsutism in women. There is limited evidence for efficacy and patient satisfaction with eflornithine. In women with moderate or severe hirsutism, test for elevated androgen levels. Eflornithine cream should only be used in patients with a raised free androgen index associated with an androgenic disease e.g. polycystic ovary syndrome. Silicone gel E.g: Bapscarcare, Ciltech, Dermatix, Kelo Cote, NewGel, ScarSil, Silgel, Advasil, Ciltech, Mepiform MOPB June 2017 regarded as low priority, poor value for money. Silicone scar gels and dressings should not be routinely prescribed for management of hypertrophic and keloid scars. Prescribing may only be considered in exceptional circumstances as those outlined in the scar revision section of West Essex service restriction policy