1 13 Skin 13.1.1 Vehicles Both vehicle and active ingredients are important in the treatment of skin conditions. The vehicle affects the degree of hydration of the skin, has a mild anti-inflammatory effect, and aids the penetration of active drug. Creams are generally more cosmetically acceptable than ointments because they are less greasy and easier to apply. Gels are particularly suitable for application to the face and scalp. Lotions have a cooling effect and may be preferred for application over a hairy area. Lotions in alcoholic basis can sting if used on broken skin. Ointments are greasy preparations and are more occlusive than creams. They are particularly suitable for chronic, dry lesions. Pastes can be used to protect inflamed, lichenified, or excoriated skin. Unlicensed / Special Manufacture Preparations The British Association of Dermatologists (BAD) list of preferred unlicensed dermatological preparations ( Specials ) is available at http://www.bad.org.uk/healthcare-professionals/clinical-standards/specials Specially manufactured products can often be very expensive (often in excess of 100 per item). They should only be used when a suitable proprietary product is unavailable. If a Specials product is required Dermatologists in Fife have agreed to use only BAD approved Specials whenever possible. 13.2.1 Emollients Soap Substitutes Emulsifying Ointment Dermol (contains an antimicrobial) Doublebase Gel Hydromol Ointment QV Gentle Wash Soap substitutes can be used for hand washing and in the bath. Emollients Medium Weight Emollients - preferable for use during daytime Aveeno Cream Cetraben Cream Diprobase Cream Doublebase Gel E45 Cream Oilatum Cream QV Cream, Lotion
2 Heavy Weight Emollients - Useful at night time or when using occlusive dressings Diprobase Ointment Hydromol Ointment Hydrous Ointment Liquid Paraffin 50% and White Soft Paraffin 50% Ointment QV Intensive Ointment Emollients soothe, smooth and hydrate the skin and are indicated for all dry or scaling disorders. They should be applied frequently (at least 3-4 times per day) even after improvement occurs. The choice of emollient should be based on the severity of the condition, patient preference, site of application and preparation cost. Cheaper emollients are often as good as more expensive ones. Products that come in pump dispensers may be more suitable for long term use in order to reduce the risk of microbial contamination. Emollients should be applied in the direction of hair growth. Aveeno Cream should only be prescribed in line with ACBS recommendations. Spray formulations of emollients are more expensive than creams / ointments but may be useful in patients unable to apply other formulations. Patients should be informed of the potential fire hazard when using paraffin based emollients e.g. Emulsifying ointment or 50% Liquid Paraffin and 50% White Soft Paraffin Ointment. (See BNF). Preparations containing Urea Calmurid E45 Itch Relief cream Preparations containing urea are suitable for the treatment of dry, scaling conditions (including ichthyosis). Preparations containing Antimicrobials/Antiseptics Dermol cream, lotion and shower emollient 13.2.1.1 Emollient Bath Additives Balneum Dermol 600 (fragrance free, contains antimicrobial) Oilatum Emollient QV Bath Oil
3 Shower preparations Dermol 200 shower emollient Oilatum shower emollient (gel) Fragrance free emollients are preferable in eczema. 13.2.2 Barrier preparations Cavilon Dimeticone Conotrane preparations Metanium Zinc preparations Zinc and castor oil ointment Sudocrem 13.3 - Topical local anaesthetic and antipruritic preparations Crotamiton cream or lotion (Eurax ) Pruritus may be caused by systemic disease, skin disease or as a side-effect of medication. Where possible the underlying cause should be identified and treated. An emollient may be of value where the pruritus is associated with dry skin. Topical antihistamines and local anaesthetics are not recommended as they are only marginally effective and can cause sensitisation. 13.4 - Topical Coricosteroids For appropriate quantities of steroids to be prescribed for specific areas of the body see section 13.1.2. Topical corticosteroids are classified according to their potency: Mildly potent Moderately potent Hydrocortisone 1% Fluocinolone acetonide 0.0025% (Synalar 1 in 10 ) Betamethasone (as valerate) 0.025% (Betnovate-RD ) Clobetasone butyrate 0.05% (Eumovate ) Fluocinolone acetonide 0.00625% (Synalar 1 in 4 )
4 Potent Very Potent Betamethasone dipropionate 0.05% (Diprosone ) Betamethasone valerate 0.1% (Betnovate ) Betamethasone diproprionate 0.05% + Salicylic acid 3% (Diprosalic ) Fluocinolone acetonide 0.025% (Synalar ) Hydrocortisone butyrate 0.1% (Locoid ) Mometasone 0.1% (Elocon ) Clobetasol propionate 0.05% (Dermovate ) The choice of steroid will depend on the nature of the inflammatory condition being treated, the age of the patient and the site of application. In order to minimise the side-effects of a topical corticosteroid, it is important to apply once or twice daily to the affected areas only. Use the least potent formulation which is fully effective for the shortest duration of treatment. Topical steroids should be applied once daily initially. If there is no benefit after 7 10 days then change to a twice daily application. There is no benefit in increasing the strength of hydrocortisone from 1% to 2.5%. Instead, patients should be moved up the steroid potency ladder i.e. to a moderately potent steroid. The potency of the steroid should be stepped up or stepped down depending on the severity of symptoms. Potent corticosteroids should generally be avoided on the face and skin flexures. In general, the most potent topical corticosteroids should be reserved for recalcitrant dermatoses such as chronic discoid lupus erythematosus, lichen simplex chronicus, hypertrophic lichen planus, and palmoplantar pustulosis. Topical use of potent corticosteroids on widespread psoriasis can lead to systemic as well as to local side-effects. It is reasonable, however, to prescribe a mild to moderate topical corticosteroid for a short period (2 4 weeks) for flexural and facial psoriasis and to use a more potent corticosteroid such as betamethasone for psoriasis of the scalp, palms, or soles. Potent topical corticosteroids should be avoided or used only under specialist supervision in psoriasis because, although they may suppress the psoriasis in the short term, relapse or vigorous rebound occurs on withdrawal. Patients prescribed very potent topical corticosteroids should be reviewed regularly (at least monthly) and the preparation should not be prescribed on repeat prescription except on specialist advice. Choice of formulation Water-miscible corticosteroid creams are suitable for moist areas e.g. axillae or groin or for weeping lesions.
5 Ointments are generally chosen for dry, lichenified or scaly lesions or where a more occlusive effect is required. Gels / Lotions may be useful when minimal application to a large or hair-bearing area is required or for the treatment of exudative lesions. The inclusion of urea or salicylic acid increases the penetration of the corticosteroid. Mixing topical preparations (e.g. steroid, emollient) on the skin should be avoided where possible; several minutes should elapse between application of different preparations. Topical Corticosteroids with Antimicrobials/ Antifungals Mildly potent Potent Moderately Potent Canestan HC (hydrocortisone 1% + clotrimazole 1%) Daktacort (hydrocortisone 1% + miconazole 2%) Fucidin H (hydrocortisone 1% + Fusidic acid 2%) Timodine (hydrocortisone 0.5% + nystatin 100 000 units/g +benzalkonium chloride + dimeticone) Trimovate (clobetasone 0.05% + oxytetracycline 3% + nystatin 100 000 units/g) FuciBet (betametasone valerate 0.1% + fusidic acid 2%) The advantages of including antibacterials or antifungals with corticosteroids in topical preparations are uncertain, but such combinations may have a place where inflammatory skin conditions are associated with bacterial or fungal infection, such as infected eczema. Treatment with Fucidin H or FuciBET should be for a maximum of 7 days to prevent bacterial resistance. 13.5 - Preparations for Psoriasis and Eczema 13.5.1 Preparations for eczema Emollients see section 13.2.1 Topical corticosteroids see section 13.4 Ichthammol preparations (for chronic lichenified eczema) - Systemic drugs Ciclosporin, Azathioprine (off label use) H - Alitretinoin (Toctino )
6 Further information on managing atopic eczema can be found at www.pathways.scot.nhs.uk Click on link for Dermatology. The use of emollients should continue even if the eczema improves or if other treatment is being used. Bandages (including those containing zinc and ichthammol) are sometimes applied over topical corticosteroids or emollients to treat eczema of the limbs. Bacterial infection (commonly with Staphylococcus aureus) can exacerbate eczema and may require treatment with topical or systemic antibacterial drugs. See section 13.10. or NHS Fife Guidance on Management of Common Infections http://www.fifeadtc.scot.nhs.uk/media/6055/primary-care-antibiotic-guidelines-final-april- 2014.pdf Sedating antihistamines (see section 3.4) may be helpful short-term for night time itch. In severe refractory eczema, systemic immunosupressants e.g. ciclosporin, azathioprine may be prescribed after specialist initiation. Alitretinoin is accepted for use in adults with severe hand eczema unresponsive to treatment with potent topical corticosteroids. It should be prescribed only by, or under the supervision of, a consultant dermatologist and be dispensed by a hospital-based pharmacy. Topical immunomodulator preparations - Pimecrolimus 1% Cream (Elidel ) - Tacrolimus 0.03%, 1% ointment (Protopic ) Topical pimecrolimus and tacrolimus are options for atopic eczema not controlled by maximal topical corticosteroid treatment or if there is a risk of important corticosteroid side-effects (particularly skin atrophy). They can cause a transient sensation of warmth or burning. Short-term treatment with topical pimecrolimus or topical tacrolimus should be initiated only by prescribers experienced in treating atopic eczema; continuous long-term treatment should be avoided. Pimecrolimus is recommended for moderate atopic eczema on the face and neck of children aged 2 16 years. Tacrolimus is recommended for moderate to severe atopic eczema in adults and children over 2 years. The 0.03% strength should be used in children aged 2-16 years. The 0.1% strength in those over 16 years of age. 13.5.2 Preparations for Psoriasis Topical preparations Emollient bath preps. see section 13.2.1
7 Topical corticosteroids see section 13.4 Coal tar based preparations Dithranol Carbo-Dome (coal tar solution 10%) Exorex lotion (coal tar 1%) Ichthammol 1% + zinc Oxide 15% in Yellow soft Paraffin (Special Ointment No 1 Specials) Further information on managing psoriasis can be found at www.pathways.scot.nhs.uk. Click on link for Dermatology. Emollients are useful in softening scaling and reducing irritation in inflammatory / plaque psoriasis. It may be appropriate to treat psoriasis in specific sites, such as the face and flexures, usually with a mild corticosteroid, and psoriasis of the scalp, palms, and soles with a potent corticosteroid. Potent topical corticosteroids should be avoided or used only under specialist supervision in psoriasis because, although they may suppress the psoriasis in the short term, relapse or vigorous rebound occurs on withdrawal. Coal tar preparations are of benefit in mild psoriasis or for treating multiple small plaques. Coal tar has anti-inflammatory properties that are useful in chronic plaque psoriasis; it also has antiscaling properties. Milder tar extracts can be used on the face and flexures. Non-proprietary coal tar preparations may be difficult to obtain and tend to be relatively expensive. Patients may find newer proprietary preparations more acceptable Dithranol (Micanol, Dithrocream ) Dithranol is effective for chronic plaque psoriasis. Its major disadvantages are irritation (for which individual susceptibility varies) and staining of skin and of clothing. Dithranol should be applied to chronic extensor plaques only, carefully avoiding normal skin. Dithranol is not generally suitable for widespread small lesions nor should it be used in the flexures or on the face. Treatment should be started with a low concentration such as dithranol 0.1%, and the strength increased gradually every few days up to 3%, according to tolerance. Preparations are usually washed off after 30 to 60 minutes ( short contact ). Vitamin D analogues 1st Choice Calcipotriol Dovobet (calcipotriol 50mcg/g and betamethasone 0.05%)
8 2nd Choice Tacalcitol (Curatoderm ) Vitamin D analogues are used as first-line treatment for plaque psoriasis; they do not smell or stain and they may be more acceptable than tar or dithranol products. Tacalcitol is less likely to irritate. Local skin reactions (itching, erythema, burning, paraesthesia, dermatitis) are common. Hands should be washed thoroughly after application to avoid inadvertent transfer to other body areas. Aggravation of psoriasis has also been reported. Dovobet can be used once daily with a maximum 15g daily or 100g weekly. The recommended treatment period is 4 weeks. After a 4 week interval a subsequent course can be repeated. Dovobet should not be used on a continual basis and should not be used for patients under 18 years of age. The use of Dovobet may lead to rebound exacerbation of the psoriasis when treatment is discontinued. When different preparations containing calcipotriol are used e.g. cream and scalp solution, the total maximum weekly dose should not be exceeded e.g. 60g cream or ointment with 30ml of scalp solution or 60ml of scalp solution with 30g of cream or ointment. Tacalcitol is of use for face and flexures. It should be used once daily with a maximum of 10g per day. Scalp Psoriasis Vitamin D analogues 1st Choice Calcipotriol scalp solution 2nd Choice Dovobet Gel (calcipotriol 50mcg/g and betamethasone 0.05%) Topical Corticosteroid Preparations Potent Very Potent Betamethasone valerate 0.1% lotion (Betacap, alcohol based) Betamethasone valerate 0.1% foam (Bettamousse, alcohol Based) Betamethasone dipropionate 0.05%, salicylic acid 2% scalp application (Diprosalic, alcohol based) Hydrocortisone butyrate 0.1% liquid emulsion (Locoid Crelo, aqueous based) Fluocinolone acetonide 0.025% gel (Synalar Gel )
9 Coal Tar preparations Shampoos "Leave on" products Mild scalp psoriasis should be treated with a tar based shampoo. Acitretin is teratogenic and must not be given to women of child-bearing age unless they practice effective contraception. Women must also be registered with a pregnancy prevention programme. 13.5.3 Drugs affecting immune response Systemic Drugs 1st Choice 2nd Choice Clobetasol propionate 0.05% scalp application (Dermovate ) Clobetasol propionate 0.05% foam (Clarelux ) Capasal (coal tar 1%, coconut oil 1%, salicylic acid 0.5%) Polytar (arachis oil extract of coal tar 0.3%, cade oil 0.3%, coal tar solution 0.1%, oleyl alcohol 1%, tar 0.3%) T/Gel (coal tar extract 2%) Sebco (Coal tar solution 12 %, salicylic acid 2%, sulphur 4% in a coconut oil base) For moderate scalp psoriasis or for itchy scalps a steroid scalp application can be used shortterm. Normally applied in the morning. Mousse/foam formulations of steroids can be used in patients with sensitive skin or where there is local scalp irritation. Calcipotriol scalp application can provide a safe maintenance treatment when long-term therapy is required. Scalp psoriasis is usually scaly, and the scale may be thick and adherent. This requires softening with an ointment, cream, or oil and usually combined with salicylic acid as a keratolytic. Salicyclic acid preparations may be useful where there is a marked scaling of the skin or scalp. Sebco should be left on for at least an hour, often more conveniently overnight, before washing it off. Oral retinoids for psoriasis H - Acitretin (Neotigason ) Methotrexate 2.5mg tablets Ciclosporin (Capimune )
10 ) 3rd Choice H Adalimumab (Humira ) H Etanercept (Enbrel ) H Infliximab (Remicade ) H Ustekinumab (Stelara ) Methotrexate can be used for severe psoriasis. The usual dose is methotrexate 10 to 25 mg once weekly. To avoid prescribing, dispensing and administration errors only the 2.5mg strength of methotrexate should be prescribed and dispensed. The patient should be advised on the dose and frequency for taking methotrexate. The patient should be advised to report immediately any signs of methotrexate toxicity. Regular monitoring of full blood count, renal function and liver function should be undertaken in line with local protocols. Ciclosporin should be considered as 2 nd line therapy in patients intolerant of or unresponsive to methotrexate. It can be used 1 st line in patients where methotrexate is unsuitable. Ciclosporin preparations should be prescribed by brand name only due to differences in bioavailability. The formulary choice for ciclosporin is Capimune (10mg capsules and liquid formulation must be prescribed as Neoral ). Patients on ciclosporin should be regularly monitored for adverse effects including hypertension and renal impairment. Adalimumab is recommended for the treatment of chronic plaque psoriasis in adults which has failed to respond to standard systemic treatments (including ciclosporin and methotrexate) or to PUVA therapy, or when standard treatments cannot be used because of intolerance or contraindications. Its use should be restricted to severe disease (PASI score > or equal to 10 and a DLQI score of >10). Adalimumab should be withdrawn if the response is not adequate after 16 weeks (PASI 75 response from baseline). Etanercept is recommended for the treatment of severe plaque psoriasis which has failed to respond to standard systemic treatments (including ciclosporin and methotrexate) or to PUVA therapy, or when standard treatments cannot be used because of intolerance or contraindications. Etanercept should be withdrawn if the response is not adequate after 12 weeks. Infliximab is recommended for the treatment of severe plaque psoriasis in adults which has failed to respond to standard systemic treatments (including ciclosporin and methotrexate) or to PUVA therapy, or when standard treatments cannot be used because of intolerance or contraindications. Infliximab should be withdrawn if the response is not adequate after 10 weeks (PASI 75 response from baseline or a 50% reduction and a 5 point reduction in DLQI from baseline). Ustekinumab is approved as a 3 rd choice treatment option for the treatment of severe plaque psoriasis (for treatment of psoriatic arthritis see section 10.1.3.).
11 13.6 - Acne and Rosacea Mild to moderate papulopustular rosacea prescribe a topical agent 1st Choice Metronidazole 0.75% cream or gel 2nd Choice Azelaic Acid 15% gel (Finacea ) Moderate to severe papulopustular rosacea prescribe an oral agent 1st Choice Oxytetracycline or Tetracycline 2nd Choice Erythromycin Doxycycline (off label use) Moderate severe facial erythema predominant rosacea Brimonidine 0.3% gel (Mirvaso ) Acne Further information on the management of rosacea can be found at www.pathways.scot.nhs.uk. Click on link for Dermatology. The pustules and papules of rosacea respond to topical metronidazole or to topical azelaic acid. Courses of oral antibiotics usually last 6 12 weeks and are repeated intermittently. Brimonidine gel should only be used in patients with moderate severe erythema predominant rosacea. Patients should be reviewed after 1 month to determine benefits of ongoing treatment. General Points The choice of treatment depends on whether the acne is predominantly inflammatory or comedonal and its severity. Acne can be broadly classified as mild, moderate and severe. Mild to moderate acne is generally treated with topical preparations. Systemic treatment with oral antibacterials is generally used for moderate to severe acne or where topical preparations are not tolerated or are ineffective or where application to the site is difficult. 13.6.1 Topical preparations for acne 1st Choice Benzoyl Peroxide 2.5% - 10% 2nd Choice Azelaic acid 20% cream (Skinoren ) Further information on the management of acne can be found at www.pathways.scot.nhs.uk. Click on link for Dermatology. In mild to moderate acne, comedones and inflamed lesions respond well to benzoyl peroxide. The lower concentrations seem to be as effective as higher concentrations in reducing inflammation. It is usual to start with a lower strength and to increase the concentration of benzoyl peroxide gradually.
12 Adverse effects include local skin irritation, particularly when therapy is initiated, but the scaling and redness often subside with treatment continued at a reduced frequency of application. If the acne does not respond after 2 months then use of a topical antibacterial should be considered. Azelaic acid has antimicrobial and anticomedonal properties. It can be used as an alternative to benzoyl peroxide for treating mild to moderate comedonal acne, particularly of the face. Some patients prefer azelaic acid because it is less likely to cause local irritation than benzoyl peroxide. Topical antibacterials for acne Topical antibacterials are effective in inflammatory acne and are probably best reserved for patients who wish to avoid oral antibacterials or who cannot tolerate them. Topical antibacterials are as effective as oral antibiotics but encourage resistance and are more expensive. Clindamycin solution (alcohol base) should be replaced with clindamycin lotion (aqueous base) or clindamycin gel if skin irritation or drying out develops with the solution. Erythromycin topical solution on its own is not recommended due to antibiotic resistance. Duac Gel may be considered if benzoyl peroxide on its own is ineffective. Alcohol based antibacterials can produce mild irritation of the skin. Topical retinoids and related preparations for acne Useful for treating comedones and inflammatory lesions in mild to moderate acne. Patients should be warned that some redness and skin peeling may occur initially but settles with time. Exposure to sunlight of areas treated with retinoids should be avoided or minimised. Topical retinoids are best applied at night. Several months of treatment may be needed to achieve an optimal response and the treatment should be continued until no new lesions develop. Adapalene is less irritant than other topical retinoids. Clindamycin 1% (gel, lotion or solution) Duac (Clindamycin 1% + benzoyl peroxide 5%) Zineryt (erythromycin 40mg +zinc acetate 12mg/ml) Adapalene Isotretinoin gel Tretinoin Epiduo (adapalene 0.1% +benzoyl peroxide 2.5%) Treclin (Clindamycin 1% + tretinoin 0.025%) Topical retinoids should be avoided in severe acne involving large areas and are contraindicated
13 in pregnancy. Epiduo is a combination product approved for use in patients with mild to moderate facial acne when monotherapy with benzoyl peroxide or adapalene has been ineffective. Treclin may be considered in patients where monotherapy with clindamycin or tretinoin has been ineffective. 13.6.2 Oral preparations for acne 1st Choice Oxytetracycline 2nd Choice Doxycycline Lymecycline Erythromycin Systemic antibacterial treatment is useful for inflammatory acne if topical treatment is not adequately effective or if it is inappropriate. Anticomedonal treatment (e.g. with topical benzoyl peroxide) may also be required. Oxytetracycline is usually given at a dose of 500 mg twice daily. Maximum improvement usually occurs after 4 to 6 months but in more severe cases treatment may need to be continued for 2 years or longer. Erythromycin at a dose of 500 mg twice daily is suitable for those under 12 or in pregnant women. Oral antibiotics may require up to 6 months of compliant use to achieve maximum benefit. Switch to an alternative antibiotic if no response after 3 months. Hormone Treatment for Acne Co-cyprindiol Co-cyprindiol (cyproterone acetate with ethinylestradiol) is no more effective than an oral broadspectrum antibacterial but is useful in women who also wish to also receive oral contraception. Co-cyprindiol should be stopped 3-4 months after the acne has completely resolved. Courses may be repeated if there is a recurrence of the acne. The Committee on Safety of Medicines (CSM) has reminded prescribers that co-cyprindiol is licensed for women with severe acne which has not responded to oral antibacterials and should not be used solely for contraception due to a higher risk of venous thromboembolism than lowdose combined oral contraceptives. Oral Retinoid for Acne Isotretinoin is used in severe acne, acne unresponsive to prolonged courses of oral antibacterials, scarring, or acne associated with psychological problems. Isotretinoin is a toxic drug that should be prescribed only by, or under the supervision of, a H Isotretinoin
14 consultant dermatologist. It is given for at least 16 weeks; repeat courses are not normally required. The drug is teratogenic and must not be given to women of child-bearing age unless they practice effective contraception. Women must also be registered with a pregnancy prevention programme. 13.7 - Warts and calluses Occlusal (salicylic acid 26%) Salactol (salicylic acid 16.7% +lactic acid 16.7%) Further information on the management of warts can be found at www.pathways.scot.nhs.uk. Click on link for Dermatology. Warts may regress on their own and treatment is required only if the warts are painful, unsightly, persistent, or cause distress. Wart removing preparations are keratolytic. They can cause irritation and application to normal or broken skin should be avoided. Surrounding skin to the wart can be protected by applying soft paraffin. Anogenital warts Podophyllotoxin 0.15% cream (Warticon ) 1st Choice or 0.5% solution Cryotherapy 2nd Choice S - Imiquimod 5% cream (Aldara ) Podophyllotoxin and cryotherapy are appropriate first line therapies in most instances. Patients with a limited number of external warts or keratinised lesions may be better treated with cryotherapy rather than using podophyllotoxin. Podophyllotoxin cream is recommended for use by women and the solution for use by men. Surrounding skin should be protected when treating anogenital warts. Treatment of warts should also be accompanied by screening for other sexually transmitted infections and counselling on various sexual health issues. Consider referral to GU Medicine when there are extensive warts, perianal warts, keratinised warts, recalcitrant warts and if warts are in immunocompromised/hiv patients, in men who have sex with men or pregnant patients. Imiquimod is relatively expensive and should be used only when other treatments have failed. Podophyllotoxin and imiquimod should not be used during pregnancy. Imiquimod is the only drug licensed for perianal warts. 13.8 - Sunscreens and Camouflagers 13.8.1 Sunscreen Preparations (ACBS) Sunsense Ultra lotion (UVB-SPF50+)
15 Uvistat cream (UVB-SPF50) Sunscreen preparations may rarely cause allergic reactions. For optimum photoprotection, sunscreen preparations should be applied thickly and frequently (approximately 2 hourly). Preparations with SPF less than 30 should not normally be prescribed. Sunscreen preparations should only be prescribed in line with ACBS recommendations. See BNF. Photodamage Lesional Small Field Large Field 13.8.2 Camouflagers (ACBS) R- Actikerall (Fluorouracil 0.5%, salicylic acid 10% solution) Cryotherapy 1 st Choice Solaraze (Diclofenac 3% gel) 2 nd Choice Fluorouracil 5% cream (Efudix ) Ingenol mebutate gel (Picato ) 3 rd Choice S Imiquimod 5% cream ( Aldara ) Solaraze (Diclofenac 3% gel) Fluorouracil 5% cream (Efudix ) Dermacolor Veil Should only be prescribed in line with ACBS recommendations. See BNF. 13.9 - Shampoos and other preparations for scalp and hair conditions Shampoos Ketoconazole Selenium sulphide (Selsun ) Tar preparations Capasal (coal tar 1%, coconut oil 1%, salicylic acid 0.5%) Polytar (arachis oil extract of coal tar 0.3%, cade oil 0.3%, coal tar solution 0.1%, oleyl alcohol 1%, tar 0.3%) T/Gel (coal tar extract 2%) Other Scalp preparations Sebco (Coal tar solution 12 %, salicylic acid
16 2%, sulphur 4% in a coconut oil base) Ketoconazole shampoo should be considered for persistent or severe dandruff or for seborrhoeic dermatitis of the scalp. Shampoo formulations are preferred for moderate scaly scalp conditions whereas more severe conditions require the use of an ointment. Hirsutism 1st Choice Co-cyprindiol 2nd Choice Eflornithine (Vaniqa ) Eflornithine is relatively expensive and should only be used when co-cyprindiol can not be used. It should be discontinued if there is no improvement after 4 months of treatment. Co-cyprindiol may be effective for moderately severe hirsutism. Treatment is required for 6 12 months before benefit is seen. Co-cyprindiol should be stopped 3-4 months after the hirsutism has completely resolved. Courses may be repeated if there is a recurrence. 13.10 Anti-infective skin preparations 13.10.1 Antibacterial preparations 13.10.1.1 Topical only Hydrogen Peroxide cream (Crystacide ) R- Mupirocin (Bactroban ) Silver sulfadiazine (Flamazine ) 13.10.1.2 Antibacterial preparations also used systemically Fusidic acid Metronidazole Topical antibiotics should only be used for localised skin infections and for a short duration to minimise the risk of bacterial resistance. Hydrogen peroxide cream (Crystacide ) may be used as an alternative agent to topical antibiotics. In the community, for acute impetigo systematic review indicates topical and oral treatment produce similar results. As resistance is increasing topical antibiotics should be reserved for very localised lesions. Small areas of the skin may be treated by short-term topical application of fusidic acid three to four times daily for 5 days. Mupirocin should be used only to treat Methicillin-Resistant Staphylococcus Aureus (MRSA). To avoid the development of resistance, topical mupirocin or fusidic acid should not be used for longer than 5 days and local microbiology advice should be sought before using in hospital. If the impetigo is extensive or longstanding, an oral antibacterial such as flucloxacillin (or
17 erythromycin in penicillin-allergy) should be used. Topical antibacterials should be avoided on leg ulcers unless used in short courses for defined infections; treatment of bacterial colonisation is generally inappropriate. Silver sulfadiazine is used in the treatment of infected burns. 13.10.2 Antifungal Preparations Further information on the management of nail dystrophy can be found at www.pathways.scot.nhs.uk. Click on link for Dermatology. Most localised fungal infections are treated with topical preparations. To prevent relapse, local antifungal treatment should be continued for 1 2 weeks after the disappearance of all signs of infection. Topical application of amorolfine or tioconazole may be useful for treating early onychomycosis when involvement is limited to mild distal disease in up to 2 nails, or for superficial white onychomycosis, or where there are contra-indications to systemic therapy. More extensive nail infections require oral treatment (see section 5.2). Skin scrapings should be examined if systemic therapy is being considered or where there is doubt about the diagnosis. Combination of an imidazole antifungal and a mild corticosteroid may be of value in the treatment of eczematous intertrigo and, in the first few days only, of a severely inflamed patch of ringworm. Combination of a mild corticosteroid with either an imidazole or nystatin may be of use in the treatment of intertrigo associated with candida. 13.10.3 Antiviral preparations Amorolfine Clotrimazole Miconazole Nystatin Terbinafine Tioconazole Combination products with corticosteroids see section 13.4 Aciclovir cream Aciclovir cream can be used for the treatment of initial and recurrent labial herpes simplex infections (cold sores). It is best applied at the earliest possible stage, usually when prodromal changes of sensation are felt in the lip and before vesicles appear.
18 13.10.4 Parasiticidal preparations Head lice "Bug busting Kit" Dimeticone 4% lotion (Hedrin ) Malathion 0.5% aqueous liquid (Derbac-M ) Scabies Crab lice Head Lice 1st Choice Permethrin 5% cream 2nd Choice Malathion 0.5% aqueous liquid (Derbac-M ) Malathion 0.5% aqueous liquid (Derbac-M ) Permethrin 5% cream Dimeticone coats head lice and interferes with water balance in lice by preventing the excretion of water; it is less active against eggs. Head lice can not become resistant to dimeticone due to its mode of action. Malathion is recommended for scabies, head lice and crab lice. Available as both aqueous and alcoholic formulations. Permethrin is effective for scabies and crab lice but is unsuitable for treatment of head lice. Head lice must be seen before any insecticidal treatments are used. Nits (empty egg shells) do not constitute an infection. Treat only if head lice are found. There is no need to treat members of the family or close contacts that do not have head lice. The policy of rotating insecticides on a Fife-wide basis is now considered outmoded. To overcome the development of resistance, a mosaic strategy is required whereby, if a course of treatment fails to cure, a different insecticide is used for the next course. A Bug Busting Kit can be recommended / prescribed as an alternative to insecticides for the detection and treatment of head lice. Only one kit is required per family and it is reusable. Aqueous formulations (liquids) are preferred. Shampoos or mousses should not be used as they are diluted too much in use and have a limited contact time to be effective. A contact time of 12 hours or overnight treatment is recommended to ensure eggs are killed. In general, a course of treatment for head lice should be 2 applications of product 7 days apart to prevent lice emerging from any eggs that survive the first application. No more than 3 applications of insecticidal preparations per infection are recommended. Applied no more frequently than once per week. Wet combing can be used to mechanically remove head lice by combing wet hair meticulously
19 Scabies Crab Lice with a detection comb (probably for at least 30 minutes each time) over the whole scalp at 3- day intervals for a minimum of 3 weeks; hair conditioner can be used to facilitate the process. All members of the affected household and close contacts should be treated simultaneously, even if symptom free. Permethrin 5% dermal cream is the recommended 1 st line treatment of scabies; malathion 0.5% aqueous liquid can be used if permethrin is inappropriate. Aqueous preparations are preferable. Alcoholic lotions are not recommended due to irritation of excoriated skin and the genitalia. Treatment should be applied to the whole body including the scalp, neck, face, and ears. Particular attention should be paid to the webs of the fingers and toes and lotion brushed under the ends of nails. Treatment should be left on the skin for 8-12 hours with permethrin and for 24 hours with malathion, before washing off. Malathion and permethrin should be applied on two occasions for treatment at least one week apart. It is important to warn users to reapply treatment to the hands if they are washed. The itch and eczema of scabies can persist for 4-6 weeks after the infestation has been eliminated and treatment for pruritus and eczema may be required. Crotamiton (see section 11.3), a topical corticosteroid (see section 11.4) or a sedating antihistamine (see section 3.4) at night may be of benefit. 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 to kill lice emerging from surviving eggs. 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. Aqueous preparations are preferable. Alcoholic lotions are not recommended due to irritation of excoriated skin and the genitalia. 13.11.6 Oxidisers and Dyes Hydrogen Peroxide cream (Crystacide ) Hydrogen peroxide solution Potassium Permanganate (Permitabs ) Crystacide cream is applied 2-3 times daily on the affected skin area. The treatment period should not exceed 3 weeks. Crystacide cream may be used as an alternative agent to topical antibiotics in the treatment of
20 impetigo. 13.12 - Antiperspirants Aluminium Chloride Hexahydrate (Anhydrol Forte, Driclor )