Chapter 13 page number 1 Chapter 13 Skin First line drugs Drugs recommended in both primary and secondary care Second line drugs Alternatives (often in specific conditions) in both primary and secondary care Specialist initiated drugs Secondary care or GP with special interest initiation. Suitable for continuation by primary care. Shared care agreements may be applicable. Secondary care only drugs Drugs only suitable for secondary care use and initiated by appropriate team or specialist. Primary care prescribers should not be asked to prescribe. Primary & Secondary Notes Secondary Care Care General points The majority of extemporaneous preparations listed in this chapter are restricted to secondary care use. Please be aware that extemporaneously prepared creams and ointments can be very costly and are often difficult to obtain through normal routes. Discussion may be necessary either with your medicines management team at the PCT or the formulary team at GWH for advice on licensed alternatives and appropriate supply routes. Patients can be allergic to excipients or preservatives in preparations. Creams generally contain preservatives; ointments do not. Some preparations contain nut oils, (e.g. zinc and castor oil cream); please check SPC or BNF if treating young children or those with nut allergy. 13.2 Emollient & barrier preparations 13.2.1 Emollients Consider using generic preparations before proprietary. Use cheapest emollient, which is effective, cosmetically acceptable and that the patient is prepared to use regularly. When prescribing an emollient for the first time the patient should be encouraged to trial the product to ensure they find it acceptable, to facilitate this the initial amount issued should be as small as possible (e.g. initial supply of 50g, a 500g container can then be supplied if the patient is happy to use that preparation) Patients should be encouraged to use liberally and 500g is the suggested minimum quantity to prescribe following initial trial; many patients may need 500g a week. Any patient prescribed a paraffin based preparation must be given information regarding fire risk. Please refer to Wiltshire Emollient Prescribing Guideline for further information. Very light moisturisers for mild dry skin Isomol gel AproDerm Colloidal Oat cream Creams for mild to moderate dry skin Please note this replaces Doublebase gel. ONLY for use in very sensitive patients and ONLY if Isomol Gel has been tried and failed, as AproDerm Colloidal Oat cream is considerably more expensive. Please note this replaces Aveeno cream. Epimax cream Please note this replaces aqueous cream, zerocream, E45 cream, cetraben cream (except if recommended by Tissue Viability- see below), and diprobase cream. Oilatum cream Greasy moisturisers for severe dry skin Please MHRA Drug Safety Update on fire risk: https://www.gov.uk/drug-safety-update/paraffin-based-skinemollients-on-dressings-or-clothing-fire-risk. Emulsifying Ointment Soft paraffins Zeroderm ointment Please note this replaces cetraben ointment. Diprobase Ointment for sexual health use only Hydromol ointment Please note Hydromol cream is NON-formulary due to its high cost compared to formulary options. Very greasy moisturisers for severe dry skin and acute flares (low risk of sensitivity) Please MHRA Drug Safety Update on fire risk: https://www.gov.uk/drug-safety-update/paraffin-based-skinemollients-on-dressings-or-clothing-fire-risk. Liquid paraffin 50% & white soft paraffin 50% ointment
Chapter 13 page number 2 Antimicrobial-containing preparations Use long-term if needed to prevent frequent skin infections or for handwashing in carers with occupational irritant hand dermatitis. Use short-term if a single episode of skin infection- not for repeat prescription if this circumstance. Dermol cream Dermol 500 lotion Urea- and/ or lauromacrogol -containing preparations Use after other emollients have been tried and failed to control symptoms of itching or dehydration. Imuderm Cream Contains 5% urea. Please note this replaces Balneum cream Dermatonics Once Contains 25% urea. Heel Balm Please note this replaces Flexitol Heel Balm. Tissue Viability Recommendation ONLY Please MHRA Drug Safety Update on fire risk: https://www.gov.uk/drug-safety-update/paraffin-based-skinemollients-on-dressings-or-clothing-fire-risk. Cetraben cream For use in patients with varicose eczema, induration, lipodermatosclerosis, etc, who need a cream that will sink in and not sit on the surface of the skin, and ONLY on the advice of Tissue Viability. 13.2.1.1 Emollient bath additives Please note that any cream or ointment listed in the Wiltshire Emollient Prescribing Guideline (except 50:50 ointment) may be used as a soap substitute during baths or showers. Alternatively, patients may choose to selfpurchase bath oils from community pharmacies or supermarkets. 13.2.2 Barrier preparations Greasier emollients are as effective as barrier creams. Hospital Tissue Viability Nurse recommends the use of Cavilon barrier cream against irritation from bodily fluids, prevention of skin damage associated with incontinence and as a moisturiser for severely dry skin. For more information, contact: Hospital Tissue Viability Nurse on 01793 (60)5555. Hospital Vascular Nurse Specialist on 01793 (60) 4374. Hospital Dermatology Care Nurse on ext. 3168. Zinc & castor oil ointment Conotrane Cream Vasogen Suitable for nappy rash. Cavilon barrier cream Sprilon spray Sudocrem Proshield Proshield available on Tissue Viabilty advice only (continence dermatitis)
Chapter 13 page number 3 13.3 Topical local anaesthetics & antipruritics Topical antihistamine preparations are not recommended for prescribing (1) Topical local anaesthetics are not recommended for prescribing (1) apart from use prior to venepuncture see Anaesthetics (Chapter 15). Calamine Lotion Menthol 1% in aqueous cream (Dermacool ) Doxepin cream (Xepin ) Check with community pharmacist what strength they have in stock to minimise delay to patient. For Dermatologist initiation only (licensed indication). The hospital dermatologists are happy for pharmacy staff to substitute this for other prescribed strengths. Please note oral doxepin has been removed from 3Ts Formulary, as it is prohibitively expensive. Specialists are asked to utilise the other oral tricyclic antidepressants on formulary if topical antipuritic agents prove ineffective. 13.4 Topical corticosteroids Use the weakest that controls symptoms. Mild and moderately potent steroids are rarely associated with side-effects (1), unlike the potent and very potent ones. Topical steroids for eczema should always be prescribed in conjunction with an emollient. FP10s must state whether cream or ointment is required. Topical corticosteroids should be applied no more than twice a day, if used for more than 7 days specialist advice should be sought. If more than one preparation is suitable the product with the lowest acquisition cost should be chosen Application to the face - Hydrocortisone only. Initiate at a strength of 0.5% or 1%. Consider increasing to 2.5% if 1% is ineffective. Please note hydrocortisone cream 2.5% is considerably more expensive than lower strengths. Application to eyelids - use 0.5% or 1% Hydrocortisone only. Patients should be advised to apply for no more than 2-3 weeks, with infrequent intermittent use thereafter. Please be mindful that clobetasone butyrate 0.05% (Eumovate) has moderate potency, whilst clobetasol propionate 0.05% (Dermovate) has very high potency, and prescribe with care according to potency required. For Cheiropompholyx, use potent topical steroids. Refer to 3Ts guidance on quantities of topical corticosteroids to prescribe and apply. Actual potency may vary considerably depending on: site of application, skin condition, use of occlusion and individual patient variation. Refer to NICE guidance TA 81 for frequency of application of topical corticosteroids in atopic eczema. (2) Please see MHRA Drug Safety Update Aug 2017 for information and advice on the rare risk of central serous chorioretinopathy with local and systemic administration of corticosteroids.
Chapter 13 page number 4 Mild Hydrocortisone- 0.5%, 1% & 2.5% Fluocinolone acetonide (Synalar 1 in 10 cream ) Moderately potent Clobetasone butyrate 0.05% (Eumovate ) Betamethasone (as valerate) 0.025% (Betnovate RD ) Please note 2.5 % is considerably more expensive than lower strengths. It should ONLY be used where 0.5% and 1% have been ineffective AND a more potent topical corticosteroid would be inappropriate e.g. in a young child, on the face, etc. Useful if steroid allergy suspected. Fludroxycortide (Haelan cream/ointment ) Potent Betamethasone valerate 0.1% Fluocinolone 0.025% (Synalar ) Hydrocortisone butyrate 0.1% (Locoid ) Mometasone furoate 0.1% (Elocon ) Betamethasone 0.05%, Salicylic acid 3% (Diprosalic ) Useful if steroid allergy suspected. Ointment and Cream. Ointment. Very potent Clobetasol propionate 0.05% (Dermovate ) Diflucortolone 0.3% (Nerisone Forte ) Fludroxycortide tape (Haelan tape ) May be appropriate for short-term use in primary care overseen by experienced GPs. Available as an oily cream and ointment. Not for long-term use. Useful for hypertropic scars, fissures on extremities.
Chapter 13 page number 5 Steroid Scalp applications See sections 13.5.2 and 13.9 for further scalp applications. Fluocinolone 0.025% (Synalar gel ) Betamethasone (as valerate) 0.1% Scalp Application (Betacap ) Betamethasone (as valerate) 0.1% Foam (Bettamousse ) Diprosalic scalp Useful if Synalar gel is not tolerated. Only for use in patients who find Betacap unsuitable Useful for moderately scaly inflamed scalps. Clobetasol propionate 0.05% shampoo (Etrivex ) Clobetasol propionate 0.05% scalp application (Dermovate ) Combination creams & ointments Topical antibiotics should be used with care, if needed they should be used regularly for limited periods only because of the risk of resistance and sensitisation. They may be useful in babies and young children with infected atopic eczema for short courses only. Consider using oral antibiotics if infection is severe. Refer to primary care and secondary care antibiotics guidelines. Mild Canesten HC Cream Daktacort Timodine Cream Nystaform HC ointment and cream Fucidin H Cream High level of Fucidin resistant staph aureus. Terra-Cortil Ointment Potent Synalar N Synalar C Aureocort Ointment Dermovate NN cream and ointment Fucibet Cream Please note Trimovate cream has been removed from formulary, as it is unlicensed & prohibitively expensive (Mar 18).
Chapter 13 page number 6 13.5.1 Preparations for eczema May be prescribed by GPs experienced with their use. (3) Topical preparations for eczema Pimecrolimus See NICE guidance on use (NICE TA82). Use outside of license by consultant dermatologists only. Tacrolimus 0.03% & 0.1% ointment See NICE guidance on use (NICE TA82). 0.03%- for use in 2 to 16 year olds. 0.1% - for adults only. Oral retinoid for eczema Alitretinoin see NICE guidance on use (TA177).
Chapter 13 page number 7 13.5.2 Preparations for psoriasis Topical preparations for psoriasis Patients should ALWAYS be prescribed proprietary products, ahead of unlicensed, special- order products, which are prohibitively expensive in primary care (on average 300 per item per prescription). A patient MUST have tried and failed to tolerate the combination of proprietary products equivalent to the ingredients of an unlicensed, special- order product, before a dermatology specialist may consider initiation of an unlicensed, special-order product. Calcitriol 3mcg/g (Silkis ointment ) Coal tar preparations Coal tar 5% lotion (Exorex ) Psoriderm Cream Coal Tar Cream 10% (Carbo-Dome ) Coal tar solution 5% in Betnovate RD ointment Dithranol preparations Dithrocream all strengths Coal tar containing bath emollients Polytar emollient Scalp preparations Calcipotriol scalp application Dovobet Gel Psorin Scalp Gel Can be used safely on the face and flexures. Needs to be used liberally twice a day for maximum effectiveness. Max 210g per week (adult) Unlicensed, special order medicine. Patient MUST have tried and failed to tolerate combination therapy with branded Exorex 5% lotion and branded Betnovate RD ointment, before a dermatology specialist may consider initiation of this unlicensed special, which may be prohibitively expensive in primary care. Please note: PCTs will require an individual funding request to be completed and approved before prescribing this unlicensed combination product. Needs to be used liberally twice a day for maximum effectiveness. Licensed for use on scalp or skin psoriasis. All medications used in hospital in this section require consultant dermatologist approval. Puvasoralen gel 0.005% Puvasoralen bath solution 1.2%. 5 - Methoxypsoralen tablets 20mg 8 - Methoxypsoralen tablets 10mg all unlicensed. 50% Propylene glycol in 50% Dermovate cream order as required for palmoplantar psoriasis. Coal tar preparations Various strengths of coal tar preparations obtained as required. Usual order time of 2-3 days, but can be up to 1 week. Dithranol preparations Dithranol in lassar s paste 0.1% 0.5%, 1%, 2%, 4%, 8%, 10%,15% and 20%. See BAD specials list. Sebco Scalp Ointment Oral retinoids for psoriasis Acitretin consultant dermatologist approval required. 13.5.3 Drugs affecting immune response All require consultant dermatologist approval.
Chapter 13 page number 8 Ciclosporin Azathioprine Methotrexate 2.5mg tablets only Hydroxycarbamide (Hydroxyurea) Mycophenolate Amber for licensed indications. Red for unlicensed indications. Unlicensed use Note ONCE WEEKLY dose. Please refer to primary and secondary care guidelines for prescribing and monitoring of Methotrexate Unlicensed use Unlicensed use See MHRA Drug Safety Update Jan 2015 for information on risk of bronchiectasis and risk of hypogammaglobulinaemia. For new pregnancy-prevention advice for women and men see MHRA Drug Safety Update Dec 15. See MHRA Drug Safety Update Feb 18 for updated contraceptive advice for male patients. Nicotinamide tablets/capsules Used with a tetracycline as a steroid sparing agent for immunobullous disorders. Unlicensed preparation. Yellow script only. Biologic Treatments Please note biologic treatments for plaque psoriasis MUST be prescribed in line with NHS BANES, Swindon & Wiltshire CCGs Plaque Psoriasis Biologic Treatment Pathway in Adults and require CCG Bluteq application. Apremilast See NICE TA419. Refer to MHRA Drug Safety Update Jan 17 for further information and advice on risk of suicidal thoughts and behaviour. Dimethyl Fumarate (Skilarence) Adalimumab Brodalumab Etanercept Guselkumab Infliximab Ixekizumab Secukinumab Ustekinumab For the treatment of moderate to severe plaque psoriasis in line with NICE TA 475. See NICE TA146 & NICE TA455. See MHRA Drug Safety Update for information on risk of TB or reactivation of latent TB. See NICE TA511. See MHRA Drug Safety Update for information on risk of TB or reactivation of latent TB. See NICE TA103 & NICE TA455. See MHRA Drug Safety Update for information on risk of TB or reactivation of latent TB. See NICE TA 521. See MHRA Drug Safety Update for information on risk of TB or reactivation of latent TB. See NICE TA134. See MHRA Drug Safety Update for information on risk of TB or reactivation of latent TB. See NICE TA442. See NICE TA 350 See NICE TA180 & NICE TA455. See MHRA Drug Safety Update Jan 2015 for information on risk of exfoliative dermatitis.
Chapter 13 page number 9 13.6.1 Topical preparations for acne (4) Treatment should start as early as possible, with early referral in severe cases to prevent scarring. Treat mild acne initially with topical agents. Oral antibiotics should be added to topical therapy in moderate to severe acne. Erythromycin is best reserved for patients in whom other antibiotics are unsuitable as resistance is common. Where a topical antibiotic is indicated, Clindamycin is the topical antibiotic of choice. Assess response of an adequate dose taken for at least three months. Benzoyl peroxide for acne Please see 3Ts Acne Prescribing Guidelines for place in therapy. Benzoyl peroxide all strengths First-line for inflammatory acne in adults and children over 12. To be purchased over the-counter. Duac TM once daily aqueous gel - (Benzoyl peroxide 5%, clindamycin 1%) Reserved for use where compliance with twice daily application of separate products is an issue. Please note: This preparation is more expensive than the separate components. Azelaic acid for acne Please see 3Ts Acne Prescribing Guidelines for place in therapy. Azelaic acid Topical antibacterials for acne Please see 3Ts Acne Prescribing Guidelines for place in therapy. Clindamycin 1% aqueous lotion (Dalacin T ) Zineryt (Erythromycin/Zinc acetate) Second-line for inflammatory acne in adults and children over 12. Please note: safety for use in pregnancy has not been established. For inflammatory acne in children under 12. Second-line for inflammatory acne in adults and children over 12 who are allergic to, intolerant of or otherwise unable to use Clindamycin 1% aqueous lotion. Please note: this product has an 8- week expiry once reconstituted. Topical retinoids & related preparations for acne Please see 3Ts Acne Prescribing Guidelines for place in therapy. These preparations, as well as oral retinoids below, are contra-indicated in pregnancy; women of a childbearing age must use effective contraceptive precautions whilst using a retinoid. Avoid ultraviolet lamps and exposure to sunlight. Adapalene gel (Differin ) Epiduo gel (adapalene 0.1%, benzoyl peroxide 2.5%) First-line for comedomal acne and for a combination of inflammatory and comedomal acne. Isotrexin gel (contains Erythromycin) Second-line for comedomal acne and for a combination of inflammatory and comedomal acne. Treclin gel (tretinoin 0.025%, clindamycin 1%) 13.6.2 Oral preparations for acne
Chapter 13 page number 10 Antibacterials Please see 3Ts Acne Prescribing Guidelines for place in therapy. Treat for at least 12 weeks and review. If improving continue for another 3 months. Oxytetracycline 500mg BD on an empty stomach. Trimethoprim- unlicensed use in acne. Doxycycline 100mg daily. More likely to cause photosensitivity. Lymecycline 408mg OD. Erythromycin First line in children and pregnant women. Hormone treatment for acne Please see 3Ts Acne Prescribing Guidelines for place in therapy. Co-Cyprindiol (Clairette /Dianette ) Note: Prescription charges are payable unless also used as a contraceptive and the prescription is endorsed appropriately. Only suitable for use in female patients See MHRA Drug Safety Update (June 2013) Oral retinoids for acne Please see 3Ts Acne Prescribing Guidelines for place in therapy. Isotretinoin - Consultant dermatologist approval required. See MHRA Drug Safety Update Oct17 for further information and advice on rare reports of erectile dysfunction and decreased libido. 13.7 Preparations for warts & calluses Treat for a minimum of 12 weeks with filing. Patients should ALWAYS be prescribed branded products, ahead of unlicensed, special- order products, which are prohibitively expensive in primary care (on average 300 per item per prescription). A patient must have tried and failed to tolerate the combination of branded products equivalent to the ingredients of an unlicensed, special- order product, before a dermatology specialist may consider initiation of an unlicensed, special-order product. Salicylic acid as the following; Salatac (12%) Salactol Paint Occlusal (26%) Verrugon (50%) Silver nitrate sticks/pencils Salicylic acid 2% in aqueous cream Salicylic acid 5% and 10% in White soft paraffin Note high strength. Not used for the treatment of warts but for other indications. Unlicensed, special order medicine. Patient MUST have tried and failed to tolerate ALL appropriate combinations of branded products, before a dermatology specialist may consider initiation of this unlicensed special, which may be prohibitively expensive in primary care. Unlicensed, special order medicine. Patient MUST have tried and failed to tolerate ALL appropriate combinations of branded products, before a dermatology specialist may consider initiation of this unlicensed special, which may be prohibitively expensive in primary care. Not routinely stocked within the Trust
Chapter 13 page number 11 Anogenital warts Other unlicensed preparations supplied as stock to clinic. Imiquimod ONLY for initiation by specialist in Sexual Health. Podophyllotoxin paint/cream various strengths (Warticon ) ONLY for initiation by specialist in Sexual Health. Catephen 10% ointment ONLY for initiation by specialist in Sexual Health. 13.8.1 Sun screen preparations Sunscreens are borderline substances prescribable only in very specific circumstances. Prescriptions should be endorsed ACBS. Only preparations of factor 30 and above are available on prescription. Sunsense ultra Dundee sun screen cream - consultant dermatologist approval required (5 day order). 13.8.2 Camouflages All cosmetic camouflage products should be considered to be amber drugs prescribeable by GPs on the advice of a specialist. The recommendation of cosmetic camouflage products by local Changing Faces clinics constitutes specialist advice. Existing patients should be referred to Skin Camouflage Practitioners for advice: Sue Bradbrooke Tel:01225 752825. Sue Bardwell Tel:01793 692225. In community, prescription must be endorsed ACBS as borderline substance. Products can take a considerable time for community pharmacists to obtain. Please note Dermablend currently withdrawn from prescription supply. Within the Acute Trust, the following will be ordered on receipt of prescription: Dermacolor camouflage cream Covermark classic foundation and finishing powder Within the Acute Trust these will be ordered on receipt of prescription. Veil covercream and finishing powder Keromask masking cream and finishing powder 13.8 Photodamage Actinic keratosis (incl. Bowens Disease) Please refer to Pathway and Guidelines for Management of Actinic (Solar) Keratoses
Chapter 13 page number 12 Diclofenac sodium 3% gel (Solaraze ) Actikerall (Fluorouracil 0.5% and Salicylic acid) Ingenol Mebutate (Picato ) Fluorouracil 5% cream (Efudix ) Imiquimod 5% cream (Aldara ) For small lesions and mild to moderate damage. For areas of thick, keratotic lesions. For widespread, ill-defined areas of solar damage. For widespread, ill-defined areas of solar damage. For widespread, ill-defined areas of solar damage. Metvix Cream Consultant dermatologist approval required within the trust. 13.9 Shampoos & some other scalp preparations For patients with scalp eczema a mild baby shampoo is a useful first treatment. Polytar liquid Ketoconazole 2% shampoo Capasal shampoo Ceanel concentrate shampoo Cocois scalp ointment Useful for treating pityriasis versicolor. Useful if thick scaly plaques present..
Chapter 13 page number 13 13.10.1.1 & 2 Antibacterial preparations Use with care because of the risk of bacterial resistance developing. The BNF suggests that choice should be limited to those not used systemically. In hospital,take swabs for microbiological testing before initiating topical treatment which should only be short term. Naseptin Contains arachis oil. See also section 12.2.3 Fusidic acid 2% cream/sodium fusidate 2% Narrow spectrum antibacterial for treatment of Staphylococcal skin infection. Does not influence telangiectasia or erythema. Metronidazole 0.75% (cream or gel) The most cost-effective brand licensed for inflammatory papules, pustules & rosacea is Rozex, whilst the most cost-effective brand licensed for malodorous fungating tumours is Anabact gel. Silver sulfadiazine cream Mupirocin 2% nasal ointment Mupirocin 2% ointment and cream Polyfax ointment Use only to treat MRSA and peanut allergic patients. Max duration 10 days. Use only to treat MRSA. Max duration 10 days. Avoid use on large areas, risk of ototoxicity. 13.10.2 Antifungal preparations To prevent relapse local antifungal treatment should be continued for 1-2 weeks after disappearance of signs of infection. See section 5.2 for other oral antifungals. See section 13.4 for topical antifungals with steroids. Nail clippings for mycology must be carried out before prescribing antifungals. Diagnosis should be confirmed by nail clippings (repeat up to 3 times) before initiating treatment. Refer to primary care antibiotic guidelines Clotrimazole Miconazole nitrate Nystatin Terbinafine cream See MHRA Drug Safety Update June 2016 for further information and advice on the potential for topical miconazole, including oral gel, to seriously interact with warfarin. Used mainly in infants with G.I candidiasis. Not effective for fungal nail infections. Terbinafine tablets Salicylic Acid (Phytex ) Paint Amorolfine nail laquer 13.10.3 Antiviral preparations see 5.3. for oral antivirals Aciclovir cream If only small amounts required prescribe 2g pack to minimise wastage
Chapter 13 page number 14 13.10.4 Parasiticidal preparations Treatment of head lice. No district policy. Rotate preparations for each individual patient if treatment fails. See DoH Prevention & Treatment of head Lice. See also MHRA Drug Safety Update Mar 18 for information and advice on the risk of serious burns if treated hair is exposed to open flames or a source of ignition. Treatment of scabies. The itch and eczema of scabies persists for some weeks after the infestation has been eliminated. Treatment for pruritus and eczema may be required. Head lice Aqueous based preparation preferable. Dimeticone (Linicin Lotion ) Dimeticone (Hedrin ) Malathion Scabies Permethrin (Lyclear dermal cream ) Ivermectin 3mg tablets - consultant dermatologist approval required for treatment of scabies. Malathion 13.10.5 Preparations for minor cuts & abrasions Magnesium sulfate paste Within hospital - A&E only. Liquiband 13.11 Disinfectants & cleansers - See antibiotics chapter Sodium chloride 0.9% sterile Dermol 500 Potassium permanganate (Permitabs ) Povidone iodine preparations Advise patients to follow the dilution instructions and make sure the tablets are completely dissolved. Avoid long-term use. 13.11.2 Chlorhexidine salts Chlorhexidine (Hibiscrub ) 13.11.7 Preparations for the promotion of wound healing Hydrogen peroxide cream (Crystacide ) 13.12 Antiperspirants Aluminium salts (Anhydrol Forte or ZeaSORB ) Propantheline Licensed for gustatory sweating Acute Trust Policy for Infection Control is available on the hospital intranet. Octenisan, CX powder and Bactroban nasal ointment are used within the hospital MRSA Decolonisation Regime see MRSA Policy on hospital intranet Hydrogen peroxide 3 and 6% Solution Glycopyrronium cream, tablets and solution Botulinum Toxin Type A For use by consultant specialists only. See CNS Chapter section 4.9.3
Chapter 13 page number 15 Miscellaneous Medicated bandages Please refer to the joint wound formulary for dressing choices. Consider in lichenified eczema and prurigo lesions on limbs. Avoid in heavily exuding wounds, infected wounds and arterial ulcers. Beware of sensitisation presenting initially as eczema under the bandage. Zinc paste (Viscopaste PB 7 ) Depigmenting agents Patch tests Not useful in urticaria or food allergy. Antihistamines: For general antihistamine, use see section in Chapter 3. Sedating antihistamines Chlorphenamine Kligmans - in Ung Merck in aqueous cream. Depigmenting Cream - hydrocortisone 1%, hydroquinone 5%, tretinoin 0.1% cream 50g. Specially prepared usually available within 1 week. Requires consultant dermatologist approval. Hydroxyzine See MHRA Drug Safety Update for information on risk of QT interval prolongation & Torsade de Pointes. Please note Alimemazine has been removed from 3Ts Formulary, as it is prohibitively expensive. Prescribers are asked to utilise other formulary options. Non-sedating antihistamines Cetirizine Loratadine Fexofenadine 180 mg Symptomatic relief of chronic idiopathic urticaria. Not recommended for children under 12 years. Dermatitis: The following items are specials available on receipt of prescription with a 2-3 day delivery, from the hospital pharmacy. Used for cradle cap/ seborrhoeic dermatitis. 2% sulphur and 2% salicylic acid in aqueous cream Miscellaneous Dapsone Hydroxychloroquine Mepacrine Used for painful fissures. To remove toenails 50% lassar's paste in 50% WSP 40% urea in WSP NHS Swindon, NHS Wiltshire and Great Western Hospitals NHS Foundation Trust in collaboration with Avon & Wilts Mental Healthcare Partnership Trust.
Chapter 13 page number 16 References: 1. BNF 63 Edition March 2012 2. NICE Technology Appraisal Guidance 81: Frequency of application of topical corticosteroids for atopic eczema. August 2004. 3. NICE Technology Appraisal Guidance 82: Tacrolimus and pimecrolimus for atopic eczema. August 2004. 4. The Treatment of Acne Vulgaris an update MeReC Bulletin 1999 Vol. 10 No 8 5. Skin Care: Practical Aspects. Nurse 2 Nurse: Volume 02 issue 11 6. Emollients: application of topical treatments to the skin. Gail Dunning: British Journal of Nursing 2007, Vol 16, No 21 7. Skin barrier breakdown; a renaissance in emollient therapy. Michael J Cork, Simon Danby; British Journal of Nursing 2009, Vol 18, No 14 8. Emollients: effective use and pump dispenser waste. Steve Chaplin MRPharmS; Prescriber, 5 October 2007 9. Emollient therapy for dry and inflammatory skin conditions. Green L; Nursing Standard, Sept 7, vol 26 no 1, 2011 10. Exploring the use of emollient therapy in dermatological nursing. Jill Peters, British Journal of Community Nursing. Vol 11, no 5 11. A guide to emollient therapy. Brown A, Butcher M. Nursing Standard, Feb 23, vol 19, no 24, 2005 12. Practical Issues for emollient therapy in dry and itchy skin. Sandra Lawton, British Journal of Nursing, 2009, Vol 18 no 16 13. Recommended use of emollients in inflammatory dermatoses. Alison Hepplewhite BSc (Hons), RGN. Prescriber 5 Dec 2006 14. Using emollients to maintain and restore skin integrity. Watkins P, Nursing Standard, June 18, vol 22 no 41, 2008 15. Us of emollients in the treatment of dry skin conditions. Tina Dyble, Jennifer Ashton, British Journal of Community Nursing. Vol 16, No 5 16. NHS Clinical Knowledge Summary, Itch Widespread Management 17. Choosing topical corticosteroids. Jonathan D Ference, Allen R Last, American Family Physician, January 15, 2009 Volume 79, Number 2 18. NHS Clinical Knowledge Summary, Corticosteroids topical (skin) nose, and eyes management 19. Topical Treatments for chronic plaque psoriasis. Cochrane Review 2009 20. NHS Clinical Knowledge Summary, Warts and Calluses 21. NICE: Psoriasis: The management of psoriasis. Draft Clinical Guideline Planned publication Oct 12 22. NHS Clinical Knowledge Summary, Psoriasis 23. NHS Clinical Knowledge Summary, Seborrhoeic dermatitis and scalp psoriasis