Drugs and preparations used for the treatment of the skin Skin - Emollients and barrier preparations Skin – Treatment of inflammatory skin conditions Skin - Preparations used to treat acne Skin – Treatment of infections and infestations – Please see the infections in primary care section

Skin - Emollients and barrier preparations Emollients Urea Containing Emollients Antimicrobial Containing Emollient Emollient Bath Preparations Topical local antipruritics Barrier Preparations

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Topical preparations for the management of skin conditions The active ingredient and vehicle are both important when deciding which treatment to use. The vehicle will affect the degree of hydration, may have anti-inflammatory effects or may aid the penetration of the drug. Excipients in topical preparations may also guide choice. Vehicles • Creams are emulsions of oil in water and are well absorbed and are suitable for moist / weeping lesions. • Ointments are greasy and suitable for chronic dry, llichenified or scaly lesions where a more occlusive effect is required. • Gels generally have high water content and are suitable for scalp application. • Lotions have a cooling effect and are suitable for hairy areas. Excipients Excipients in topical products rarely cause problems. If a patch test indicates allergy to an excipient, then products containing the substance should be avoided. Beeswax Benzyl alcohol Butylated hydroxyanisole Butylated hydroxytoluene Cetostearyl alcohol

Chlorocresol Edetic acid (EDTA) Ethylenediamine Fragrances Hydroxybenzoates (parabens)

Imidurea Isopropyl palmitate N-(3Chloroallyl)hexaminium chloride

Please refer to the current BNF for excipient contents of products. Skin - Emollients and barrier preparations

Polysorbates Propylene glycol Sodium metabisulphite Sorbic acid Wool fat and related substances including lanolin

Emollients hydrate the skin and are indicated for all dry skin disorders and their effects are short lives hence should be applied frequently even after improvement occurs. The choice of preparation will depend upon severity of the condition, patient preference and site of application. Emollients should be applied in the direction of hair growth. Further information can also be found in the following guidelines: THPCT Dermatology in Primary Care – Management Guidance. A guide to suitable quantities of emollients for adults and children 12 – 16 years for twice daily application for 2 weeks Area of Body Creams and Ointments Lotions Face 30 - 60g 200ml Both hands 50 - 100g 400ml Scalp 100 – 200g 400ml Both arms or both legs 200 – 400g 400ml Trunk 800g 1000ml Groins and genitalia 25 – 50g 200ml

Emollients NPSA safety alert – fire hazard with paraffin based emollients Emulsifying ointment or 50:50 liquid paraffin : white soft paraffin ointment in contact with dressings or clothing is easily ignited by a naked flame. The risk will be greater when these preparations are applied to large areas of the body, and clothing or dressings become soaked with the ointment. Patients should be told to keep away from fire or flames, and not to smoke when using these preparations. The risk of fire should be considered when using large quantities of any paraffin-based emollient. Preparations Indication Formulation Notes on prescribing For dry skin Very hydrous, evaporates quickly therefore requires more frequent conditions as application than greasier preparations. More useful as a soap Aqueous Cream Cream emollient or soap substitute. substitute. Non-greasy Emulsifying ointment Ointment Very greasy Hydrous ointment Ointment Greasy Liquid and white soft paraffin

Ointment

Very greasy

50:50 ointment White soft paraffin jelly

Ointment

[Aveeno®]

Cream

[Diprobase®] [Doublebase®]

For dry skin conditions as emollient or soap substitute.

[E45®] [Epaderm ®]

Cream, ointment Gel Cream, lotion, wash cream Ointment

Greasy ACBS Non-greasy Cream is Non-greasy Ointment is greasy Suitable for patients who need an emollient greasier than a lotion but not as greasy as an ointment. ACBS Non-greasy Greasy

Skin - Emollients and barrier preparations Urea Containing Emollients Drug [Balneum® Plus] [ Aquadrate ®]

Indication Dry skin conditions

Antimicrobial Containing Emollient Drug Indication Dry skin [Dermol® 500] conditions

Formulation 5% cream, 10% cream

Notes on prescribing

Formulation

Notes on prescribing

May be more irritant than the 5% preparation for some patients.

Lotion

Emollient Bath Preparations These preparations may make skin and surfaces slippery. Care is needed when bathing Preparations Indication Formulation Notes on prescribing [Oilatum ®] Dry skin Emulsion

[Dermol® 600] [Balneum® Plus Bath Oil]

conditions Dry skin conditions

Bath/Junior Bath additive Bath emollient Bath oil

Contains an antimicrobial Suitable for itchy skin

Barrier Preparations These preparations are unsuitable for atopic eczema. These have a limited role where the skin has broken down. Preparations Indication Formulation Notes on prescribing Zinc & Castor oil Nappy + urinary rash Ointment [Conotrane®] As above + pressure sores Cream [Sudocrem®] Nappy rash + pressure sore Cream Skin - Emollients and barrier preparations Topical local antipruritics Preparations Calamine

Crotamiton [Eurax®]

Indication Pruritus

Pruritus

Formulation Lotion, aqueous cream Cream

Notes on prescribing Dries on as a coloured paste. Crotamiton may be helpful for symptom control, but may modify the appearance of scabies making diagnosis more difficult. Exclude diagnosis of scabies before prescribing/recommending. More helpful in management of bites than dermatoses.

References: • Joint Formulary Committee. British National Formulary. 54th Ed. London: British Medical Association and Royal Pharmaceutical Society of Great Britain; 2007. • Clinical Knowledge Summaries. Eczema – atopic. SCHIN Ltd, Centre for Health Informatics at Newcastle. Available from: http://www.cks.library.nhs.uk/eczema_atopic Accessed 19/02/08 • Clinical Knowledge Summaries. Contact dermatitis. SCHIN Ltd, Centre for Health Informatics at Newcastle. Available from: http://www.cks.library.nhs.uk/dermatitis_contact/in_summary/scenario_dry_skin. Accessed 16/02/08. • MHRA. Fire Hazard with Paraffin Based Skin Products on Dressings and Clothing. November 2007. • National Institute for Clinical Excellence. Clinical Guidance: Management of atopic eczema in children from birth up to the age of 12 years. CG57. December 2007 Available from: www.nice.org.uk. Accessed 17/03/08. • PRODIGY. Quick Reference Guide: Emollient. Issued in June 2005 http://www.cks.library.nhs.uk/qrg/emollients.pdf • Tower Hamlets PCT. Dermatology in primary care management guidance. December 2007.

Skin - Emollients and barrier preparations Back to main index Skin – Treatment of inflammatory skin conditions Corticosteroids Corticosteroid scalp preparations Other scalp preparations Vitamin D analogue preparations Coal Tar Preparation Dithranol preparations Topical drugs affecting the immune system Oral Immunosuppressants

Camouflages Sunscreens

Corticosteroids Any corticosteroid more potent than hydrocortisone 1% should not be used on facial skin of children. Potent corticosteroids should generally be avoided on the face (keep away from eyes) and skin flexures unless advised by the specialist. Corticosteroids are not curative, and on discontinuation a rebound exacerbation may occur. Corticosteroids are contraindicated in rosacea, untreated bacterial, fungal or viral lesions and are not recommended for acne. For psoriasis, systemic or potent topical corticosteroids should only be prescribed under the supervision of a specialist. Application To minimise side effects, corticosteroids should be applied thinly and only to the affected areas. Once daily application is often sufficient; these should not be applied more frequently than twice daily. The least potent formulation which is fully effective should be used first. See current BNF for dosing of fingertip units. Mixing topical preparations should be avoided; at least 30 minutes should elapse between applications of different preparations. Further information can also be found in the following guidelines: THPCT Dermatology in Primary Care – Management Guidance. Drug compound Indication Formulation Notes on prescribing Potency Inflammatory Cream, Less potent Hydrocortisone 1% Can be used on the face for both children and adults. skin ointment disorders Betamethasone valerate Cream, Can be used on the face in adults only. 0.025% [Betnovate® RD] ointment Clobetasone butyrate 0.05% Cream, Can be used on the face in adults only. [Eumovate®] ointment

Betamethasone valerate 0.1% [Betnovate®]

Clobetasol propionate [Dermovate®]

Cream, ointment

For short term use only and use should be reviewed by prescribers regularly. Suitable for hands and feet. Should not be prescribed on the face.

Cream, ointment

Should not be prescribed on the face. Regularly review, not for long term use and if skin condition responding step down to next potency of topical steroid.

Very potent

Skin – Treatment of inflammatory skin conditions Corticosteroid scalp preparations Drug compound Indication

Formulation

Notes on prescribing

Betamethasone valerate 0.1% [Betacap®]

Scalp lotion

Aqueous base

Betamethasone valerate 0.05% + salicylic acid 3% [Diprosalic®]

Scalp application

Alcoholic base

Gel

Aqueous base

Mometasone furoate 0.1% [Elocon®]

Scalp application

Aqueous + Alcoholic base

Clobetasol proprionate 0.05% [Dermovate®]

Scalp application

Alcoholic base

Fluocinolone acetonide 0.025% [Synalar®]

Inflammatory scalp disorders

Aqueous preparations are the treatment choice for small children and those suffering from asthma.

Topical corticosteroids (amounts suitable for an adult for 2 weeks based on a single daily application Area of Body Creams and Ointments Lotions Face 30g 100ml Both hands 30g 100ml Scalp 30g 100ml Both arms 60g 200ml Both legs 100g 200ml

Potency Less potent

Very potent

Trunk Groins and genitalia

100g 15g

200ml 50ml

Skin – Treatment of inflammatory skin conditions Other scalp preparations Drug compound Ketoconazole 2% shampoo [Alphosyl 2 in 1 Shampoo] [Capasal ®] [Sebco® Scalp ointment] Selenium sulphide [Selsun®] [T/ Gel® Shampoo]

Indication Seborrhoeic dermatitis of the scalp Seborrhoeic dermatitis of the scalp

Formulation

Notes on prescribing

Shampoo

Contains an antifungal. Treatment of pityriasis versicolor apply once daily for max. 5 days. Leave on for 3–5mins before rinsing off.

Shampoo Shampoo Scalp ointment

Alcoholic coal tar extract Can be used for cradle cap Licensed in children over 6 years of age.

Shampoo

Does not contain coal tar.

Shampoo

Coal tar extract

Vitamin D analogue preparations Local skin reactions are common. Hands should be washed thoroughly after application to prevent inadvertent transfer to other body areas. Preparation Indication Formulation Notes on prescribing When scalp solution and ointment/cream are used together, the maximum Calcipotriol Cream, ointment total quantity of calcipotriol should not exceed 5mg in any one week. This Psoriasis [Dovonex®] scalp solution equates to either 60ml scalp solution + 30g of cream or ointment or 60g of cream or ointment + 30ml of scalp solution. Calcipotriol + Betamethasone Psoriasis Ointment Contains a potent topical steroid. [Dovobet®]

Coal Tar Preparations

Preparation [Psoriderm®] [Polytar ® emollient]

Indication Psoriasis Psoriasis

Formulation Cream Bath additive

Notes on prescribing Add 2-4 capfuls (15-30ml) in bath and soak for 20 minutes

Skin – Treatment of inflammatory skin conditions Dithranol preparations Drug Indication

Dithranol

Psoriasis

Formulation

Ointment, cream, scalp gel

Notes on prescribing Dithranol cream should be applied sparingly and only to the affected area(s) carefully avoiding normal skin. When applying dithranol, hands should be protected by gloves or washed thoroughly afterwards. Should be initiated under the advice of a specialist, at the lowest dose and increase every 3 days if no burning. Stop use if irritation / burning are experienced. May stain skin and clothing. Some preparation may also contain coal tar or salicylic acid

Topical drugs affecting the immune system MHRA – Potential risks of cancer occurring with topical tacrolimus: Tacrolimus 0.1% and 0.03% ointment will remain second line treatment for moderate or severe atopic dermatitis in patients who are not adequately responsive to or are intolerant to topical corticosteroids. Treatment with pimecrolimus cream and tacrolimus ointment should: • Not be given to patients with congenital or acquired immunodeficiencies, or to patients on therapy causing immunosuppression • Not be applied to malignant, or potentially malignant skin lesions • Tacrolimus 0.03% ointment are not recommended for children under 2 years of age

• Tacrolimus 0.1% ointment is not recommended for children under 16 years of age • The frequency of administration of tacrolimus 0.03% in children should be limited to once a day only • The lower strength (0.03%), should be used in adults wherever possible. Drug Indication Formulation Notes on prescribing Tacrolimus

Severe atopic eczema

Ointment

Initiation by dermatologist. Treatment can be transferred to primary care if agreed on a shared care arrangement. Avoid excessive exposure to sunlight and sunlamps. Do not apply other topical preparations within 2 hours of application.

Oral Immunosuppressants The EMIS High Risk Template must be used for patients receiving these drugs. Patient Monitoring Booklets are available from the Prescribing Team. Please see the Prescribing intranet site for, Shared Care Guidelines, Monitoring Summaries, HRD prescribing audit template and ‘The Patient Journey’ flowchart http://10.148.22.36:8080/thpct/Prescribing/default.aspx All oral immunosuppressants must be initiated by secondary / tertiary care specialists only. Prescribing to be continued only under agreed shared care guidance. Regular blood monitoring required as per shared care guidance.

Drug

Indication

Formulation

Notes on prescribing

Ciclosporin [Neoral®]

Psoriasis, eczema(Unlicensed)

Capsules

The brand [NEORAL®] should be specified as different brands have different bioavailabilities.

Dapsone

Psoriasis (unlicensed)

Tablets

Hydroxycarbamide

Psoriasis (unlicensed)

Tablets Methotrexate must be taken weekly.

Methotrexate

Psoriasis

2.5mg tablets

Methotrexate should be prescribed as 2.5mg tablets. If 10mg tablets are prescribed, this needs to be agreed in a documented discussion with the patient. Please specify the day methotrexate is to be taken and also the dose in milligrams and number of tablets e.g. “methotrexate 2.5mg tablets, Take (5mg) TWO tablets on Mondays”

Skin – Treatment of inflammatory skin conditions Sunscreens Sunscreens are only prescribable on the NHS for abnormal cutaneous photosensitivity from genetic disorders or photodermatoses. Prescriptions for these conditions must be endorsed ACBS by the prescriber. See current BNF Appendix 7.

Camouflages Camouflages are only prescribable on the NHS for postoperative scars and other deformities and as an adjunctive therapy in the relief of emotional disturbances due to disfiguring skin disease such as vitiligo. Prescriptions for these conditions must be endorsed ACBS by the prescriber. See current BNF Appendix 7.

References: th • Joint Formulary Committee. British National Formulary. 54 Ed. London: British Medical Association and Royal Pharmaceutical Society of Great Britain; 2007. • National Institute for Clinical Excellence. Atopic dermatitis (eczema) - pimecrolimus and tacrolimus for atopic dermatitis (eczema) Technology appraisal .TA82 .August 2004Available from: www.nice.org.uk. Accessed 17/03/08 • National Institute for Clinical Excellence. Atopic dermatitis (eczema) - topical steroids Frequency of application of topical corticosteriods for eczema. Technology appraisal. TA81. August 2004. Available from: www.nice.org.uk. Accessed 17/03/08 • National Institute for Clinical Excellence. Atopic eczema in children Management of atopic eczema in children from birth up to the age of 12 years. Clinical guideline CG57. December 2007. Available from: www.nice.org.uk. Accessed 17/03/08. • Summary of Product Characteristics. Dithranol, Ciclosporin [Neoral®], Methotrexate, Tacrolimus. Available from: www.medicines.org.uk. Accessed 19/02/08. • MHRA. Topical tacrolimus (Protopic) and pimecrolimus (Elidel): potential cancer risk. Current Problems in Pharmacovigilance: Volume 31 (pages 1-12) May 2006 • Tower Hamlets PCT. Dermatology in primary care management guidance. December 2007.

Skin – Treatment of inflammatory skin conditions Back to main index Skin - Preparations used to treat acne Topical preparations for acne Topical retinoids and related preparations for acne Oral antibacterials for acne Topical antibacterials for acne Hormone treatment for acne Oral retinoids for acne and psoriasis

• • •

Topical acne applications should be initiated with the lowest strength preparation and increased if necessary. If the acne does not respond after 2 months, consider a topical antibacterial. If topical preparations are inadequate, oral preparations maybe needed.

Topical preparations for acne Preparation Benzoyl Peroxide [Panoxyl®, Duac®] Azelaic acid [Finacea®, Skinoren®]

Indication Acne Acne

Formulation Aquagel, gel, cream

Notes on prescribing

Gel, cream

Please see current BNF for licensed indications of different preparations.

Please see current BNF for licensed indications of different preparations.

Topical retinoids and related preparations for acne Topical retinoids are contraindicated in pregnancy and in women of child bearing age not using effective contraception. The oral progesterone only contraceptive is not considered effective contraception. Topical retinoids should be avoided in severe acne involving large areas. Contact with eyes, nostrils, mouth and mucous membranes, eczematous, broken or sunburned skin should be avoided. These drugs should be used with caution in sensitive areas such as the neck, and accumulation in angles of the nose should be avoided. Exposure to UV light (including sunlight, solarium) should be avoided; if sun exposure is unavoidable appropriate sunscreen or protective clothing should be used. Preparation Indication Formulation Notes on prescribing Exposure to sunlight and artificial UV irradiation, including sunlamps, should be minimised during use. Use of sunscreen products and protective clothing over treated areas is recommended when exposure cannot be Adapalene Acne Cream , gel avoided. Do not apply to broken (cuts and abrasions) /sunburnt / eczematous skin, or acne involving large areas of the body. Can cause redness and skin peeling (more than adalapene) but usually Isotretinoin Gel passes. Acne Tretinoin Cream, gel

Skin - Preparations used to treat acne

Oral antibacterials for acne If no benefit is obtained after 3 months of treatment, another antibacterial should be used. Treatment may be continued for 2 years or longer. Drug Formulation Dosing information and Notes 500mg BD Oxytetracycline Tablets Needs to be taken on an empty stomach. Contraindicated in pregnancy. 408mg OD Suitable if adherence is likely to be a problem (can be taken with food). Lymecycline Capsules TNDG: Lymecycline has been approved for initiation in primary care. Contraindicated in pregnancy. 500mg BD Tablets, An alternative if a tetracycline is contraindicated or otherwise unsuitable. Erythromycin suspension There are significant problems with resistance associated with erythromycin use, and gastrointestinal adverse effects may restrict its use.

Topical antibacterials for acne Drug Formulation Clindamycin Solution, [DalacinT®] lotion [Duac®]

Hormone treatment for acne

Dosing information and Notes Apply to the affected area(s) BD

Duration of treatment Treatment should be continued for at least 6 months. After that however regular reviews are necessary.

Drug Co-cyprindiol cyproterone acetate and ethinylestradiol [Clairette®]

Indication

Acne

Formulation

Notes on prescribing

Tablets

CSM: Venous thromboembolism occurs MORE frequently than those taking low dose combined oral contraceptive. It is licensed in severe acne not responding to oral antibiotics and moderately severe hirutism and NOT SOLELY for contraception.

Skin - Preparations used to treat acne Oral retinoids for acne and psoriasis TNDG: Oral retinoid preparations- isotretinoin (generic or [Roaccutane®]) and acitretin [Neotigason®] are for hospital only prescribing.

References: th • Joint Formulary Committee. British National Formulary. 54 Ed. London: British Medical Association and Royal Pharmaceutical Society of Great Britain; 2007. • Summary of Product Characteristics. Adalapene, Isotretinoin, Tretinoin. Available from: www.medicines.org.uk. Accessed 16/02/08. • National Institute for Clinical Excellence. Guidance on the use of. Available from: www.nice.org.uk. Accessed 17/03/08. • MHRA. Isotretinoin for severe acne Drug Safety Update: Volume 1, Issue 1, August 2007 • Clinical Knowledge Summaries. Acne vulgaris. SCHIN Ltd, Centre for Health Informatics at Newcastle. Available from: http://www.cks.library.nhs.uk/clinical_knowledge/cks_drugs/clinical_topics/acne_vulgaris. Accessed 16/02/08. • Tower Hamlets PCT. Dermatology in primary care management guidance. December 2007.

Skin - Preparations used to treat acne Back to main index Skin – Treatment of infections and infestations – Please see the infections in primary care section