BNF CHAPTER 13: SKIN Some of the emollients listed in this chapter are classed as appliances and are listed in part IXA of the Drug Tariff e.g. Epimax cream, Hydromol ointment and products from the Zeroderma range (list not exhaustive). Please prescribe only preparation listed in the DT or licensed as medicinal product (http://www.medicines.org.uk/emc/ ) Warning: Paraffin-based emollients are flammable. Dressings and clothing that have contact with paraffin-based products are easily ignited by a naked flame. Advise patients to keep them away from fire or flames and not smoke when using them. The risk of fire should be considered when using large quantities of any paraffin-based emollient. Products should be applied in direction of hair growth to prevent folliculitis Ensure that the indication is a documented dermatological condition. Prescribing of emollients for non-clinical cosmetic purposes such as dry skin in the absence of a diagnosed dry skin condition such as eczema or psoriasis is not supported and should be stopped. 1
13.1 MANAGEMENT OF SKIN CONDITIONS Prescribe pump dispensers to minimize the risk of bacterial contamination, when they are available for the patient s selected emollient. For Preparations that come in pots, using a clean spoon or spatula (rather than fingers) to remove the emollient helps to minimize contamination. Use licensed medicines whenever they are likely to be of benefit. Prescribe Dermatology Specials only from the BAD list BNF 13.2 EMOLLIENT AND BARRIER PREPARATIONS Suitable quantities of Emollients to be prescribed for specific areas of the body: Area of the body Cream / ointment Lotion One week supply One month supply One week supply One month supply Face and neck 15 30g 60-120g 100ml 400ml Both hands 25 50g 100-200g 200ml 800ml Scalp 50 100g 200-400g 200ml 800ml Both arms or both legs 100-200g 400-800g 200ml 800ml Trunk 400g 1600g 500ml 2000ml Groins and genitalia 15 25g 60-100g 100ml 400ml These amounts are usually suitable for an adult for twice daily application. 2
Generally the greasier the product the more effective it is as emollient, as it is able to trap more moisture in the skin. However, greasier emollients can be less acceptable or tolerable. Products below are listed following a cost criteria and also according to number of sensitisers. Please refer to PrescQIPP Bulletin 76 May 2015; and Emollients Potential Skin Sensitisers table for more information. EMOLLIENT LOTIONS Product Name E45 Lotion Product Name QV skin lotion Cetraben Lotion s Potential Sensitisers Lanolin/Derivatives Hydroxybenzoates (Parabens) Benzyl Alcohol Sensitisers Cetyl/Cetostearyl/Stearyl Alcohol Hydroxybenzoates (Parabens) Cetyl/Cetostearyl/Stearyl Alcohol Phenoxyethanol 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. 3
EMOLLIENT CREAMS Product Name Epimax Cream - Pump Product Name Epimax oat cream - Pump ZeroAQS Cream - Pot Cetomacrogol Cream (Form A) BP 1988 - Pot Aquamax Cream - Pot Zerobase Cream - Pump Zeroveen cream - Pump Potential Sensitisers Cetyl/Cetostearyl/Stearyl Alcohol Phenoxyethanol s Potential Sensitisers Cetyl/Cetostearyl/Stearyl Alcohol Chlorocresol/Benzyl alcohol/phenoxyethanol/ Isopropyl palmitate Cetyl/Cetostearyl/Stearyl Alcohol Chlorocresol SPC: Cetostearyl alcohol Chlorocresol Cetyl/Cetostearyl/Stearyl Alcohol Phenoxyethanol Cetyl/Cetostearyl/Stearyl Alcohol Chlorocresol Cetyl/Myristyl/Stearyl Alcohol Isopropyl palmitate Benzyl alcohol EMOLLIENT GELS Product Name Isomol Gel Easy Squeeze flexi dispenser Potential Sensitisers Triethanolamine Phenoxyethano Isopropyl mysristate 4
Product Name Zerodouble Gel Top down bottle s Potential Sensitisers Triethanolamine Phenoxyethano Isopropyl mysristate Creams and gels are emulsions of oil and water and their less greasy consistency often makes them more cosmetically acceptable. EMOLLIENT OINTMENTS Product Name Emulsifying ointment Product Name White soft paraffin Zeroderm ointment s Potential Sensitisers SPC: Cetostearyl alcohol Phenoxyethanol Potential Sensitisers None Cetyl/Cetostearyl/Stearyl Alcohol 50:50 White soft and liquid paraffin ointment None Hydromol ointment Hydrous ointment (also known as oily cream ) Cetyl/Cetostearyl/Stearyl Alcohol Phenoxyethanol 5
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, can 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. EMOLLIENTS WITH ANTIMICROBIALS Product Name Dermol 500 lotion (for weeping infected skin) Dermol cream (for dry infected skin) Potential Sensitisers Cetyl/Cetostearyl/Stearyl Alcohol Phenoxyethanol Benzalkonium chloride Cetostearyl Alcohol; Cetomacrogol; Phenoxyethanol; Disodium Phosphate Dodecahydrate; Sodium Dihydrogen Phosphate Dihydrate; Benzalkonium chloride Antiseptic products are more likely to cause skin sensitisation reactions and may cause bacterial resistance Preparations containing an antibacterial (e.g. Dermol) should be avoided unless infection is present or is a frequent complication. Use should be targeted and short term. EMOLLIENTS CONTAINING UREA Product Name Imuderm Urea Emollient 6 Potential Sensitisers Cetyl/Cetostearyl/Stearyl Alcohol Benzalkonium Chloride; Phenethyl Alcohol Cetrimonium Bromide
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 (reputed to reduce itch). Ensure that product(s) selected are indicated for the intended use. It is reasonable to target use of emollients containing urea (a keratin softener and hydrating agent) to specific groups, e.g. those with scaling skin, or those who have tried other emollients without success. BATH AND SHOWER EMOLLIENTS AND SOAP SUBSTITUTES Evidence around the use of bath and shower preparations is limited. Many standard emollients can be used as a soap substitute. Any ointment (except 50:50) can be dissolved in some hot water and added to the bath water as a bath additive. Bath additives and shower gels are not recommended for prescribing It is recommend to use a standard emollient as a soap substitute (e.g. by applying it to the skin before bathing/showering then rinsing it off), as they believe this provides better moisturisation of the skin. Regardless of the type of product the person uses to wash with, it should not replace the regular use of a leave-on emollient. Please advise people to continue using standard emollients in addition to any bath/shower product or soap substitute used. 7
BNF 13.4 TOPICAL CORTICOSTEROIDS Fingertip units of topical corticosteroid cream or ointment to apply to specific areas Number of fingertip units Age Face & neck One arm & hand One leg & foot Trunk (front) Trunk (back) inc. buttocks Adult 2.5 4 8 7 7 3-6 month old child 1 1 1.5 1 1.5 1-2 month old child 1.5 1.5 2 2 3 3-5 month old child 1.5 2 3 3 3.5 6-10 month old child 2 2.5 4.5 3.5 5 Suitable quantities of corticosteroid preparations to be prescribed for specific areas of the body - These amounts are usually suitable for an adult for a single daily application for 2 weeks. Area of body Face and neck Both Hands Scalp Both Arms Both Legs Trunk Groins and genitalia Creams and Ointments 15 30g 15 30g 15 30g 30 60g 100g 100g 15 30g 8
Topical corticosteroids should be spread thinly on the skin but in sufficient quantity to cover the affected areas. The length of cream or ointment expelled from a tube can be measured in terms of a fingertip unit (the distance from the tip of the adult index finger to the first crease, equivalent of approximately 500mg). Match the potency of topical corticosteroid to the severity of the condition, taking into account the patient s age and site of application. Use topical corticosteroids short term or intermittently wherever possible. Regular emollient use and strategies such as treating frequently flaring atopic eczema with topical corticosteroid for two days a week, or the use of non-steroid based treatments in between topical corticosteroid courses in psoriasis can support this. Use the more potent topical corticosteroids with appropriate caution. Potent or very potent topical corticosteroids may be contraindicated or restricted to use under specialist supervision depending on the age of the person, the condition being treated and the site of application. Topical corticosteroids are contraindicated in acne, rosacea, perioral dermatitis and untreated bacterial, fungal, or viral skin lesions. They should not be used for the routine treatment of urticaria or pruritis of unknown cause, and they may worsen ulcerated lesions. Small packs of hydrocortisone 1% (alone or combined with other ingredients) and clobetasone butyrate 0.05% are available over the counter (OTC) for short-term use (maximum seven days) in skin conditions such as mild to moderate eczema, dermatitis and insect bites. The licence of OTC products is more restrictive, but when appropriate patients can be directed to purchase items for self care. Products listed below are generally with the generic name first, except where a brand is available at a lower price to the Drug Tariff price, where brand name is listed first. 9
The list of excipients listed below correspond to the brand names as generic products contain different excipients depending on their manufacturer MILD TOPICAL CORTICOSTEROIDS cost less than 0.20 per gram or ml - 6 per 30g or 30ml Hydrocortisone 1% cream s Synalar 1 in 10 Dilution (fluocinolone acetonide 0.0025% cream) MODERATE TOPICAL CORTICOSTEROIDS cost less than 0.10 per gram or ml - 3 per 30g or 30ml Audavate RD 0.025% cream/ointment (betamethasone valerate) s Clobavate 0.05% ointment (clobetasone butyrate) Modrasone 0.5% cream (alclometasone dipropionate) Haelan (fludroxycortide 0.0125% cream/ointment) Ultralanum Plain cream (fluocortolone pivalate 0.25%, fluocortolone hexanoate 0.25%) Ultralanum Plain ointment (fluocortolone monohydrate 0.25%, fluocortolone hexanoate 0.25%) Eumovate (clobetasone butyrate 0.05% cream) 10
Alphaderm (hydrocortisone 1%, urea 10% cream) Synalar 1 in 4 Dilution (fluocinolone acetonide 0.00625% cream/ointment) POTENT TOPICAL CORTICOSTEROIDS cost less than 0.10 per gram or ml - 3 per 30g or 30ml Audavate 0.1% ointment (betamethasone valerate) Betnovate (betamethasone valerate 0.1% lotion) s Betnovate 0.1% cream/ointment (betamethasone valerate) Locoid (hydrocortisone butyrate 0.1% cream/ointment) Locoid 0.1% Lipocream (hydrocortisone butyrate) Locoid Crelo 0.1% emolsion (hydrocortisone butyrate) VERY POTENT TOPICAL CORTICOSTEROIDS cost less than 0.10 per gram or ml - 3 per 30g or 30ml Clobaderm 0.05% cream/ointment (clobetasol propionate) s Dermovate (clobetasol propionate 0.05% cream/ointment) 11
PRODUCTS CONTAINING ANTIMICROBIALS OR ANTIFUNGALS The benefit of including antibacterials or antifungals with a topical corticosteroid is uncertain. NICE advise that use of topical antibiotics in children with atopic eczema, including those combined with topical corticosteroids, should be reserved for cases of clinical infection in localised areas and limited to a maximum of two weeks treatment. Longer use increases the risk of resistance and sensitization. Limiting use to a maximum of two weeks for adults and children Only issuing these items as acute issues and reviewing any currently prescribed as repeats Potency of corticosteroid: Mild Product Active Ingredients Canesten HC 30gr hydrocortisone 1%, clotrimazole 1% Daktacort cream/ ointment - 30gr hydrocortisone 1%, miconazole nitrate 2% Timodine cream Hydrocortisone 0.5%, Benzalkonium chloride 0.20%, nystatin 100 000 units/g Terra-Cortril ointment - 30gr hydrocortisone 1%, oxytetracycline (as hydrochloride) 3% Fucidin H cream - 30gr hydrocortisone acetate 1%, fusidic acid 2% Product Potency of corticosteroid: Potent Active Ingredients Synalar N cream/ ointment 30gr fluocinolone acetonide 0.025%, neomycin sulfate 0.5% Fucibet cream/lipid cream - 30gr betamethasone (as valerate) 0.1%, fusidic acid 2% Lotriderm cream - 30gr betamethasone dipropionate 0.064%, clotrimazole 1% 12
TAPES AND PLASTERS The use of these products should be short term but it can be intermittent and under the supervision of a specialist: Haelan tape is polythene adhesive film impregnated with fludroxycortide 4 micrograms/cm 2 Betesil medicated plasters contain betamethasone (as valerate) 2.25 mg BNF 13.5.2 PREPARATIONS FOR PSORIASIS Use licensed medicines whenever they are likely to be of benefit. Prescribe Dermatology Specials only from the BAD list except in special circumstances. They can be prescribed by GP after initiation by specialist and prescriptions can be taken to hospital pharmacy (Basildon Hospital) or fax to Hospital Pharmacy (Southend hospital), see Specially made up ointments and creams - Process to follow for Southend Hospital input and review. Vitamin D and analogues Tars Tacalcitol 4 micrograms/g ointment (Curatoderm ) Calcipotriol 50 micrograms/g ointment (Dovonex ) Calcipotriol 50micrograms/ml scalp solution Calcipotriol 0.005% / Betamethasone 0.05% gel Calcipotriol 50micrograms/g / Betamethasone dipropionate 500micrograms/g foam (Enstilar ) Psoriderm cream - coal tar 6%, lecithin 0.4% Cocois scalp ointment - coal tar solution 12%, salicylic acid 2%, precipitated sulfur 4%, in a coconut oil emollient basis 13
Exorex lotion - coal tar solution 5% in an emollient basis Sebco scalp ointment - coal tar solution 12%, salicylic acid 2%, precipitated sulfur 4%, in a coconut oil emollient basis Prescribing information for Calcipotriol/Betamethasone In adults apply no more than 15g/day (or 100g per week). The body surface area treated with calcipotriol containing medicinal products should not exceed 30%. Side effects: hypercalcaemia if > 100g/ week. Local skin reactions: itching, erythema, burning, paraesthesia, dermatitis, are common. Further counselling points: Application under occlusive dressings should be avoided since it increases the systemic absorption of corticosteroids. Not recommended to take a shower or bath immediately after application of Dovobet ointment or gel. Hands must be washed after each application. When different calcipotriol containing preparations are used together, the maximum total calcipotriol dose is 5mg in any one week (e.g. 60ml calcipotriol scalp solution with 30g ointment or 30ml scalp solution with 60g ointment). Calcipotriol/Betamethasone is contraindicated in patients with known disorders of calcium metabolism. Also contraindicated in erythrodermic, exfoliative and pustular psoriasis. Do not use on facial or flexural References 1. National Institute for Health and Care Excellence (NICE). Clinical Guideline 153. The assessment and management of psoriasis. October 2012. Available http://www.nice.org.uk/guidance/cg153 2. SPC. Dovobet gel. Leo Laboratories Ltd. Last updated 29/10/14. 3. SPC. Dovobet ointment. Leo Laboratories. Ltd Last updated 29/10/14. 14
Algorthm 1: Topical treatment of psoriasis in adults. Adapted from Herts Valley Clinical Commissioning Group TRUNKS AND LIMBS FACE, FLEXURES AND GENITALS SCALP 1 st line 2 nd line 3 rd line Potent corticosteroid DAILY plus vitamin D / vitamin D analogue DAILY (apply separately, one in the morningand the other in the evening) for up to 4 weeks# If ineffective after maximum of 8 weeks treatment VitaminD / vitamin analogue TWICE DAILY If ineffective after maximum of 8-12 weeks Potent corticosteroid TWICE daily for 4 weeks Coal tar preparation ONCE or TWICE daily Short term mild or moderate potency corticosteroid^ applied ONCE or TWICE daily. Maximum of 2weeks# If ineffective or continuous treatment required to maintain control and serious risk of steroid induced local side effects Calcineurin inhibitor (tacrolimus or pimecrolimus) TWICE daily for up to 4 weeks. ONLY to be initiated by healthcare professionals with expertise in psoriasis Topical agents to remove adherent scale, e.g. salicylic acid, emollients, before applying potent corticosteroid# Potent corticosteroid ONCE daily for up to 4 weeks# If ineffective after 4 weeks# Consider using a different formulation of the potent corticosteroid, e.g. shampoo or mousse If ineffective after a further 4 weeks# Betametasone 0.05% and Calcipotriol 50mcg/g ONCE daily for up to 4 weeks# Vit D/Vit D analogue ONCE daily for 8 weeks (only if cannot use steroids and mild/moderate psoriasis) 4 th line If these cannot be used or require once daily product to increase adherence Betametasone 0.05% and Calcipotriol 50mcg/g ONCE daily for up to 4 weeks REFER adults not controlled on topical treatment to secondary care for further treatment options (phototherapy and/or systemic treatment) Very potent corticosteroid TWICE daily for 2 weeks# If ineffective after treatment duration Coal tar ONCE or TWICE daily Referral to a specialist for support and advice Psoriasis that cannot be controlled by topical treatment should be referred to secondary care for further assessment and treatment options (these include phototherapy and systemic treatment) # Aim for a break of 4 weeks between courses of treatment with potent or very potent corticosteroids. Consider non-steroid products (coal tar, vit D/vit D analogues) as needed to maintain control of psoriasis during this period ^ Unlicensed indication, i.e. off-label use. 15
16
BNF 13.5.3 DRUGS AFFECTING THE IMMUNE RESPONSE There are topical and systemic drugs affecting the immune response which are used for eczema or psoriasis; please use them only under specialist supervision. BNF 13.6 ACNE ACNE AND ROSACEA Antibacterial resistance of Propionibacterium acnes is increasing; there is cross-resistance between erythromycin and clindamycin. To avoid development of resistance: when possible use non-antibiotic antimicrobials (such as benzoyl peroxide or azelaic acid); avoid concomitant treatment with different oral and topical antibacterials; if a particular antibacterial is effective, use it for repeat courses if needed (short intervening courses of benzoyl peroxide may eliminate any resistant propionibacteria); do not continue treatment for longer than necessary (however, treatment with a topical preparation should be continued for at least 6 months). Mild to moderate acne Topical preparations Start with a lower strength and increase the concentration of benzoyl peroxide gradually (Over The Counter). Topical antibacterials are probably best reserved for patients who wish to avoid oral antibacterials or who cannot tolerate them. Topical retinoids Moderate to severe acne Oral antibiotics. For women only - co-cyprindiol Severe acne Refer to dermatologist Isotretinoin is a Red Traffic Light drug that should be prescribed only by a Secondary Care. 17
Benzoyl peroxide and azelaic acid Benzoyl peroxide 2.5-5-10% 40g (Over the Counter) Skinoren - Azelaic acid 20% cream-30g (Over the Counter) Topical antibacterials Dalacin T Topical solution, clindamycin 1% (as phosphate), in an aqueous alcoholic basis-30ml Lotion, clindamycin 1% (as phosphate) in an aqueous basis-30ml Prescribing benzoyl peroxide (Over the Counter) and Dalacin T (clindamycin 1%) separately is more cost effective than combined products. If two separate products are used, they should be applied 12 hours apart. Typically, benzoyl peroxide is applied at night and the topical antibiotic in the morning. Topical retinoids Oral antibacterials Topical benzoyl peroxide may also be required. Isotrexin - Gel, isotretinoin 0.05%, erythromycin 2% in ethanolic basis-30g Oxytetracycline Tetracycline Doxycycline Lymecycline 18
KEY LEARNING POINTS when using antibiotics The right antimicrobial Benzoyl peroxide is the topical antimicrobial of first choice When an antibiotic is clinically justified, combine topical systemic therapy with benzoyl peroxide to combat resistance Topical delivery is preferable to oral when acne is localised For the right patient When topical non-antibiotic remedies have failed to bring about adequate control For moderate or severe acne while awaiting referral to secondary care For extensive inflammatory acne on the trunk For the right time Keep courses of antibiotics short (preferably 3 4 months) Use to achieve control but not to maintain control ROSACEA Topical ivermectin Gel (Soolantra ) applied once daily for 4 months with sunscreen. Treatment can be repeated ONCE only in 12 month period. Discontinue after 3 months if no improvement. The pustules and papules of rosacea respond to topical metronidazole or to topical azelaic acid ly, oral administration of oral antibiotics, see above recommendation as for acne Isotretinoin is occasionally given in refractory cases. Specialist only. 19
13.7 PREPARATIONS FOR WARTS AND CALLUSES Preparations of salicylic acid, formaldehyde, gluteraldehyde or silver nitrate are available OTC for purchase by the public; they are suitable for the removal of warts on hands and feet. Anogenital warts The treatment of anogenital warts (condylomata acuminata) should be accompanied by screening for other sexually transmitted infections through referral to GUM clinic Podophyllotoxin 0.15% cream - direct medical supervision for lesions greater than 4cm 2 Podophyllotoxin 0.5% solution - direct medical supervision for lesions in the female and for lesions greater than 4cm 2 13.8.1 SUNSCREENS PREPARATIONS Imiquimod 5% (Aldara ) Specialist initiation under GUM To be able to prescribe Sunscreens, ACBS (borderline substance) criteria needs to be satisfied, this is, protection against ultraviolet radiation in abnormal cutaneous photosensitivity resulting from genetic disorders or photodermatoses, including vitiligo and those resulting from radiotherapy; chronic or recurrent herpes simplex labialis. Preparations with SPF less than 30 should not be prescribed. For optimum photoprotection, sunscreen preparations should be applied thickly and frequently (approximately 2 hourly). In photodermatoses, they should be used from spring to autumn. As maximum protection from sunlight is desirable, preparations with the highest SPF should be prescribed. 20
Sunsense Ultra Lotion (UVA and UVB protection; UVB-SPF 50+). Please prescribe 125ml or 500ml pump pack Uvistat cream (UVA and UVB protection; UVB-SPF 50) 125g Anthelios SPF50+ melt 50ml Photodamage An emollient may be sufficient for mild actinic keratosis lesions Diclofenac gel is suitable for the treatment of superficial lesions in mild disease. Fluorouracil cream is effective against most types of non-hypertrophic actinic keratosis; a solution containing fluorouracil and salicylic acid is available for the treatment of low or moderately thick hyperkeratotic actinic keratosis Imiquimod 3.75% (Zyclara ) and Imiquimod 5% (Aldara ) are used for lesions on the face and scalp when cryotherapy or other topical treatments cannot be used. Ingenol mebutate (Picato ) is licensed for the treatment of non-hypertrophic actinic keratosis. To be used when other topical treatments cannot be used or have been ineffective. Use of preparations containing Fluorouracil and Imiquimod will require counselling on side effects and consider referral to a specialist if concerns about diagnosis or suitability of treatment. Imiquimod 3.75% Imiquimod 5% Diclofenac sodium 3% Gel Fluorouracil 5% Cream Fluorouracil 0.5%, salicylic acid 10% Ingenol mebutate 21
13.8.2 CAMOUFLAGERS ACBS (borderline substance) criteria: Post-operative scars and other deformities and as an adjunctive therapy in the relief of emotional disturbances due to disfiguring skin disease, such as vitiligo. Dermacolor Camouflage crème 25ml / Fixing powder 60g Keromask Masking cream 15ml / Finishing powder 20g 13.9 SHAMPOOS AND OTHER PREPARATIONS FOR SCALP AND HAIR CONDICIONS Psoriasis - Avoid tar shampoos as only ingredient very low clinical efficacy. Capasal shampoo coal tar, salicylic acid and coconut oil is accepted. Seborrhoeic dermatitis - medicated, anti-dandruff shampoos containing agents such as zinc pyrithione, selenium sulphide or ketoconazole can be used regularly Corticosteroids See section 13.4 Psoriasis See section 13.5 22
Selenium sulfide 2.5% Shampoo (Selsun ) - 150 ml Ketoconazole 2% shampoo - 120 ml Hirsutism Weight loss can reduce hirsutism in obese women. Women should be advised about local methods of hair removal, and in the mildest cases this may be all that is required. Co-cyprindiol (section 13.6.2) may be effective for moderately severe hirsutism. Metformin (section 6.1.2.2) is an alternative in women with polycystic ovary syndrome [unlicensed indication]. Systemic treatment is required for 6 12 months before benefit is seen. Eflornithine (as hydrochloride monohydrate) 11.5% (Vaniqa ) cream is not included in the formulary as offers very little benefit for the management of facial hirsutism in women and there is limited evidence for efficacy and patient satisfaction with its use, see Eflornithine position statement (NHS England Low value medicine) 23
13.10. ANTI-INFECTIVE SKIN PREPARATIONS For more information see our Chapter 5 - Infections Formulary Antibacterial preparations Topical antibacterials should be avoided on leg ulcers unless used in short courses for defined infections; treatment of bacterial colonisation is generally inappropriate. To minimise the development of resistant organisms it is advisable to limit the choice of antibacterials applied topically to those not used systemically Fusidic acid 2% cream/ointment (Fucidin ) Rozex - metronidazole 0.75% cream/gel Mupirocin should be used only to treat meticillin-resistant Staphylococcus aureus Silver sulfadiazine is used in the treatment of infected burns. Antifungal preparations Clotrimazole 1% cream Miconazole nitrate 2% cream Terbinafine hydrochloride 1% cream Zinc undecenoate 20%, undecenoic acid 2% (Mycota ) Amorolfine 5% medicated nail lacquer remains non formulary item as there is limited evidence of effectiveness 24
Antiviral preparations Aciclovir 5% cream Parasiticidal preparations These amounts are usually suitable for an adult for single application Suitable quantities of parasiticidal preparations Area of body Skin creams Lotions Cream rinses Scalp (head lice) 50 100 ml 50 100 ml Body (scabies) 30 60 g 100 ml Body (crab lice) 30 60 g 100 ml These amounts are usually suitable for an adult for single application. Dimethicone 4% - Head lice only. Less active against eggs and treatment should be repeated after 7 days. Lyclear dermal cream - Permethrin 5% Malathion 0.5% Liquid in an aqueous basis Products for head lice could be bought Over The Counter (OTC) in Community Pharmacies. 25
13.11. SKIN CLEANSERS, ANTISEPTICS, AND DESLOUGHING AGENTS Alcohols and saline Sodium Chloride 0.9% Flowfusor Bellows pack (120ml) Irriclens aerosol (240ml) Clinipod pod (25x20ml) Sal-e Pods pod (25x20ml) The exact number of containers (ie aerosols, bellows packs, bottles, cans, pods, pour bottles or sachets) should be prescribed Chlorhexidine salts Iodine Hibiscrub - chlorhexidine gluconate 4% Hydrex - chlorhexidine gluconate 2.5% in denatured ethanol 70% Betadine dry powder spray povidone-iodine 2.5% Savlon dry - dry powder spray povidone-iodine 1.14% Oxidisers and dyes Hydrogen peroxide 6% (20 vols) Permitabs - Potassium Permanganate 400mg tablets Wound Care Octenilin Bottle 350ml. Refer to EPUT Wound Formulary. MRSA Decolonisation - Octenisan. Refer to Management of High Risk MRSA Colonised/Infected Adult Patients in Nursing Homes and Primary Care Settings 26
13.12. ANTIPERSPIRANTS Aluminium chloride hexahydrate 20% in an alcoholic basis - OTC Antimuscarinics in tablet form Oxybutynin 5mg BD Refer patients to Integrated Dermatology Services to try next step Iontophoresis Botulinum toxin A Botulinum toxin type A complex (Botox ) injections can be prescribed and administered in specialist clinics (needs agreement) Formulary Chapter 13 SKIN Date ratified by D&T Committee April 2016 1 st review update bath emollients information following position statement April 2017 Date ratified by D&T Committee April 2017 2 nd review Introduce Isomol gel, Zeroveen, update bath emollients information following September 2017 advice from dermatologists Botulinum toxin type A included Date ratified by D&T Committee September 2017 3 rd review Epimax OAT added. Bath additives, shower gels and bath oils remove from formulary. Dovobet to Enstilar changed. Corticosteroid creams reviewed, Timodine added. Scalp Psoriasis reviewed. Treatment for Acne and Rosacea reviewed, Isotrex and Stiemycin removed as discontinued. Treatment for Anogenital warts to be started in Secondary Care. Imiquimode 5% added for photodamage. Refer to Dermatology Services for Iontophoresis Botulinum toxin A. Date ratified by D&T Committee Next Review Date November 2020 27