Trafford Dermatology Guidelines

Contents Introduction Trafford clinics, staff and contact details ............................ 2 Referral.............................................................................. 3

Acne .................................................................................. 4 Rosacea ............................................................................ 7 Hand eczema .................................................................... 9 Atopic eczema ................................................................. 11 Topical preparations – quantities ..................................... 15 Varicose eczema ............................................................. 18 Seborrhoeic dermatitis.......................................................20 Psoriasis .......................................................................... 22 Urticaria and angioedema ................................................ 26 Generalised pruritus ........................................................ 26 Viral warts ........................................................................ 28 Molluscum contagiosum .................................................. 31 Scabies........................................................................... .33 Onychodystrophy ............................................................. 36 Actinic/Solar keratosis ..................................................... 38 Seborrhoeic keratosis........................................................39 Skin cancer.... .................................................................. 40 Patient and self help groups............................................ . 42 Emollients Appendix........................................................ . 43 Galderma (UK) ltd has financially contributed to the production and publication of these guidelines.

Introduction These guidelines have been developed by a sub-group of the Trafford Dermatology Clinical Stakeholder panel, originally adapted from Medway NHS Trust guidelines. This document was made possible by Dr Farzana Nayeemuddin This document offers recommendations for the first line treatment of common skin conditions in primary care and defines the point at which referral to the relevant specialist community service or secondary care department should be made. This information is intended to be used as a source of reference by General Practitioners in order to become familiar with the most common skin diseases encountered in General Practice and to boost confidence in dealing with them. The treatments received in each section are not prescriptive and alternative comparable products can be used. These can be found within the relevant section of the B.N.F. It is impossible to define exactly the stage at which a referral to a specialist service should be made and frequently the problems at the edge of our definitions are the most challenging. These treatment recommendations should be followed prior to consideration of referral to the specialist service. Criteria for referral are clearly stated at the end of each section.

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Trafford Contact Information Trafford General Hospital Moorside Road Davyhulme Manchester M41 5SL Dermatology Consultant /Skin Cancer Lead- Dr Farzana Nayeemuddin Locum Consultant - Dr Jitendra Gupta Telephone: 0161 746 2856 Fax : 0161 746 2655 Altrincham General Hospital Market Street Altrincham Cheshire WA14 1PE Lead Clinician / Dermatology Consultant - Dr Jennifer Yell, Telephone: 0161 934 8376 Fax: 0161 934 8401 Trafford Commissioning Consortium (NHS Trafford) Third Floor Oakland House Talbot Road Old Trafford Manchester M16 0PQ GP Clinical Lead-Dr N MacDonald Lead Manager - Chris Valchero Tel: 0161 873 9572 (Direct)

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Referrals Urgent Referrals to Secondary Care All referrals will be assessed and prioritised by a Consultant/member of the Dermatology team. Urgent referrals may be faxed directly to your chosen hospital or via Choose and Book. If you wish to discuss a case with a Trafford Consultant, please telephone via the secretary’s direct line on 0161 746 2856. You can also discuss urgent cases (not skin cancer) with the on-call Dermatology Registrar at Salford Royal NHS Foundation Trust (Hope) via their switchboard on 0161-789 7373.

Skin cancer Referrals for suspected melanomas and squamous cell carcinomas must be made using the HSC 205 referral pathway. These patients will be assessed within two weeks of receipt. Referrals for other skin lesions, e.g. basal cell carcinoma, should be made via the non-urgent pathway.

Content of referral letter The following information should be included: 

Nature of condition and duration



Relevant past medical history



All medication currently and previously used for this condition including dose, duration of treatment and response, plus all other concurrent medication



Photographs (optional)

Referrals to Trafford Community Services Trafford Under 5s Community Eczema Clinic Chapel road clinic- 0161 973 1329 – Clinic runs Thursday mornings Referral letter to : Eczema Clinic, Chapel Road Clinic, 70 Chapel Road, Sale, M33 7EG

Community Children’s Nursing Team (0yrs to 16yrs for eczema & psoriasis) Trafford General Hospital Tel- 0161 934 8332 Fax -0161 934 8319

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Acne Treatment aims; 

To reduce the severity of the disease



To reduce the psychological impact on the individual

Mild to moderate acne should be managed in primary care. Several different agents may need to be tried alone or in combination e.g. topical benzoyl peroxide plus systemic antibiotics. Inform patient that response is usually slow and allow 12 weeks before review. Topical retinoids are also the preferred agent for maintenance therapy in place of antibiotics, which will lead to bacterial resistance. The goal is to minimise the use of antibiotics CLINICAL FEATURES MILD ACNE Un-inflamed lesions Open and closed comedones (Blackheads) (Sometimes with papules/pustules.)

TREATMENT ■ Topical preparations Benzoyl peroxide 2.5-10% ■ With antimicrobial Benzoyl peroxide, potassium hydroxyquinoline sulphate (Quinoderm) cream Clindamycin/ Benzoyl peroxide 5% (Duac) gel ■ Topical antibacterials

THERAPEUTIC TIPS Start at 2.5% and increase to 5 or 10% Lotion or gel preparations may reduce irritation Build slowly to daily use over 2-3 weeks. If irritation occurs, reduce frequency of application and possibly build up again. If skin becomes excessively dry, add a moisturiser.

Clinidamycin 1% lotion Clinidamycin 1% topical solution Erythromycin topical solution (Zineryt topical solution) ■ Topical Retinoids (avoid in pregnancy) Isotretinoin gel – (Isotrex) Adapalene cream – (Differin) Tretinoin – (Retin-A) ■ Topical Retinoid / benzoyl peroxide fixed dose combination Adapalene 0.1%/ benzoyl peroxide 2.5% (Epiduo)

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Anti-biotic resistance: Please see Trafford Anti-biotic guidance

Use topical retinoids at all stages of acne to help minimise formation of comedones. Should be applied to entire acne prone area. Build v slowly (2x per week) over 2-3 weeks. Then up to every other day or once daily (depending on patient). Use in the evening as a thin film, using only one pea shaped amount for the whole face. (If dryness occurs, stop for 1.5 weeks and then restart at less frequent intervals)

CLINICAL FEATURES MODERATE

TREATMENT Treat as for mild acne for 3 months

More extensive inflamed Lesions

■ Systemic antibiotics Lymecycline 408mg once daily Doxycycline 100mg once daily Oxytetracycline 500mg twice daily Erythromycin 500mg twice daily Minocycline MR100mg once daily NB (Minocycline should be prescribed as last option due to side effect profile)

THERAPEUTIC TIPS

Treat for 3 months and reassess Should be > 70% improved Stop at 6 months & continue with topicals Repeat if relapses Use alternative antibiotic if poor response Lymecycline should be considered 1st line due to cost and compliance (once daily) for patients >12 years old

■ Add topical retinoid for “Combination therapy” if no response to antibiotics alone

Minocycline - ANA/LFTs required pre treatment and at 6 months.(can induce Lupus) if treatment extended >6 months ANA/LFTs every 3 months thereafter

■ Consider hormone therapy (females only) alone or systemic antibiotics can be added if response is suboptimal

Treat for 4 - 6 months and reassess. (Slow onset of response).

Cocyprindiol -Ethinyloestradiol /Cyproterone acetate (Dianette) or Desogestrel/ethinyloestradiol (Marvelon )- not licensed for acne SEVERE ACNE

Commence systemic therapy and refer for assessment for treatment with oral Isotretinoin (Roaccutane).

Consider starting oral contraceptive pill for female patients of child bearing potential

MAINTENANCE

Topical retinoid therapy or topical benzoyl peroxide preparations

For 3-6 months after systemic treatment is completed.

CRITERIA FOR REFERRAL The main reason for referring a patient with acne is for oral Isotretinoin treatment. The indications for Isotretinoin treatment are as follows: Severe nodulo-cystic acne (refer immediately) Moderate acne that has failed to respond to 2 or more courses of the above treatments. Mild to moderate acne in patients who have extreme psychological distress despite prolonged courses of systemic antibiotics and topical retinoid/ benzoyl peroxide combination therapy. Do not refer female patients planning a pregnancy. Caution patients re sun exposure and photosensitivity as per BNF with all retinoids (topical and oral) and Doxycycline Page | 5

Mild

Moderate

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Mild/Moderate

Moderate/Severe

Rosacea CLINICAL FEATURES Papules on an erythematous background Pustules Telangiectasia Flushing often made worse by alcohol, spicy foods, hot drinks, temperature changes or emotion

TREATMENT

THERAPEUTIC TIPS Early treatment of rosacea is considered to be important as each exacerbation leads to further skin damage and increases the risk of more advanced disease. Intermittent therapy can be considered for those with very occasional flare-ups.

Rhinophyma –Please see severe section for advice.

Continuous therapy will be needed if there are frequent recurrences. Mild to moderate cases or where systemic treatment is contraindicated

■ Topical treatment Metronidazole 0.75% cream / gel twice daily Azelaic Acid 15% (Finacea Gel) twice daily

Moderate - Severe

Creams for dry/sensitive skin Gels for normal/oily skin Continue therapy for 6 – 8 weeks – response is usually rapid.

■ Systemic Treatments Oxytetracycline 500mg twice daily Lymecycline 408mg once daily (unlicensed for Rosacea) Doxycycline 50 - 100mg once daily (unlicensed for Rosacea) Erythromycin 500mg twice daily (not contraindicated in pregnancy) Minocycline 100mg once daily (unlicensed in Rosacea) Doxycycline 40 mg Modified Release once daily ( Efracea)

Ocular Rosacea

Continue for 6 - 8 weeks and reassess

Refer to Ophthalmologist - can lead to keratitis and blindness

NB Tetracyclines are contraindicated in pregnancy, lactation and renal disease.

NB All drugs apart from Lymecycline can cause photosensitivity.

ANA/LFTs required pre Minocycline and at 6 months. Minocycline can induce Lupus Anti Inflamatory dose. Will not kill bacteria or cause resistance. Advise patient on lid hygiene to manage blepharitis e.g. hot flannel scrubs twice daily

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CLINICAL FEATURES Telangiectasia with / without rhinophyma

TREATMENT Laser treatments

THERAPEUTIC TIPS Subject to funding approval from PCT

Patient Counselling

SPF15 worn daily April September Higher factors if abroad

Sunshine may exacerbate Rosacea

Sun protection

Reapply 1 - 2 hourly

CRITERIA FOR REFERRAL ■ ■ ■ ■

Doubt over diagnosis Poor response to systemic therapy Severe disease associated with the development of pyoderma faciale Severe Ocular Rosacea with keratitis or uveitis (refer to ophthalmologist)

Subtype I: Erythematotelangiectatic (ETR)

Subtype III: Phymatous rosacea

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Subtype II: Papulopustular rosacea (PPR)

Subtype IV: Ocular rosacea

Hand Eczema CLINICAL FEATURES Dry Hand Eczema Blistering Hand Eczema (Pompholyx) Both conditions may also affect feet

TREATMENT Avoidance of irritants eg soaps, shampoos, detergents, use of PVC gloves (Patient Advice Sheet provides further guidance) All patients should be given soap substitutes and emollients ■Soap substitutes (see emollient appendix) ■Emollients (see emollient appendix) ■Topical Steroids Moderate to potent strength ■Dry and scaly eczema Betamethasone valerate 0.1% (Betnovate) ointment twice daily for 4-6 weeks, review and reduce to clobetasone butyrate (Eumovate) 0.05% ointment / cream ■Wet, weeping or blisters/ burst blisters Potassium permanganate soaks 1:10,000 10-15 minutes twice daily for 5 - 7 days Flucloxacillin 250 mg four times daily for 7 days Clobetasol propionate 0.05% cream, (Dermovate) twice daily for 2 to 3 weeks. When dry switch to Betamethasone valerate 0.1% (Betnovate) ointment as per dry eczema ■For severe cases consider Prednisolone 30 mg once daily for 7 days, if patient is unable to complete topical treatments

Cracked/Splits on digits/heels

■ ■ ■

THERAPEUTIC TIPS Other skin conditions can mimic Eczema and should be kept in mind. Examine the skin all over as this can provide clues to other diagnoses e.g. plaques in extensor distribution in psoriasis, scabetic nodules. An occupational and social history should be taken. The patient may need Patch Tests. If eczema is present on only one hand fungal infection needs to be excluded by taking skin scrapings for mycology.

Dissolve tablet in bucket of water until colour is a light purple. Nb- If pink then the solution is too dilute.

■Fludroxycortide Tape (Haelan Tape) leave on for at least 12 hours daily Review at 4-6 weeks Regular review to ensure treatment is effective.

CRITERIA FOR REFERRAL If allergic contact dermatitis is suspected – patients may benefit from Patch Testing Patch Tests are of no value in type 1 reactions (e.g. food allergies, anaphylaxis or urticaria). Severe chronic hand dermatitis, which is unresponsive to standard treatment i.e. not significantly improved after 2 weeks

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“Wet” (Blistering and Weeping)

“Dry” (Hyperkeratotic and fissured eczma)

Splits and cracks “Dry” eczema

Lichenfied eczema

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Atopic Eczema CLINICAL FEATURES Atopic eczema is a common disease affecting up to 15% of children and 2 – 10% of adults. If it does not itch, it is unlikely to be eczema. There may also be personal / immediate family history of asthma / hayfever. Involvement of the face frequently occurs in infants. The characteristic flexural distribution is usually present by the age of 18 months.

TREATMENT Avoid irritants ■Emollients – see Appendix for emollient products Emollients should be prescribed in all cases. Bath Additives (see appendix) Shower preparations (see appendix)

THERAPEUTIC TIPS Soaps and detergents including bubble bath and shower gels should be avoided Choose cotton clothing Avoid wool next to the skin Fingernails should be kept short to reduce skin damage from scratching. Skin should be moisturised at least 4 x per day and best applied when skin is moist but can be applied at other times Aqueous Cream should NOT be used as an emollient; it is a soap substitute only. Ideally avoid in mod/severe Eczema as it can adversely affect skin barrier function.

Realistic treatment aims need to be discussed with the patient and parents/carers

NB Paraffin Products are flammable

CHILDREN

■Topical Steroids

Mild - Any site

Hydrocortisone 1% ointment twice daily for 1 week

Mild/Moderate -Flexural/Face

Hydrocortisone 1% ointment twice daily for 1-2 weeks

Moderate – Trunk / Limbs

Clobetasone Butyrate 0.05% ointment twice daily (Eumovate) use 1 - 2 weeks and reduce to hydrocortisone 1% ointment for 2 – 4 weeks

Severe

Start treatment as for moderate and refer

For moderate or severe eczema with a poor response to standard treatment

■Topical Immunodilators Should only be initiated by physicians with experience in dermatology

Tips Use body surface area charts to calculate correct quantities 1% Hydrocortisone containing preparations are safe for long term use. 1% Hydrocortisone is the only mild potency steroid

Pimecrolimus 1% cream twice daily. Tacrolimus 0.03% ointment twice daily for 6 weeks Can use maintenance treatment twice a week

Tacrolimus is very useful on the face, neck and flexures where potent steroids are contraindicated Burning and irritation may occur and wears off within 7 – 10 days Avoid in presence of viral infection eg herpes simplex

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CLINICAL FEATURES

ADULTS

TREATMENT

Mild – any site

Treatment as for children. See above

Moderate – Trunk / limbs

Betamethasone valerate 0.1% (Betnovate) ointment - use 2-4 weeks, review and reduce to clobetasone butyrate 0.05% (Eumovate) ointment

Moderate – Face / Flexures

Clobetasone butyrate 0.05% (Eumovate) ointment - use 2-4 weeks, review and reduce to Hydrocortisone 1%

Severe – Trunk / limbs

Clobetasol propionate 0.05% ointment (Dermovate) twice daily for 2 – 4 weeks, review and reduce to clobetasone butyrate 0.05% (Eumovate) ointment

Severe – Face

As for moderate Tapering Prednisolone 30mg once daily for 1 week, reducing by 5mg per week (total 6 weeks course) where topical treatments are not suitable

For eczema of any severity with a poor response to standard treatment

THERAPEUTIC TIPS Creams are preferable in flexural sites Ointment are preferable elsewhere

An ultra potent topical steroid

DO NOT prescribe more than one course per year

■Topical Immunodilators Should only be initiated by physicians with experience in dermatology

Moderate to severe Tacrolimus 0.1% ointment twice daily for 3 weeks then Tacrolimus 0.03% ointment twice daily until clearance Mild to moderate Pimecrolimus 1% cream

Eczema

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Infected Eczema

CLINICAL FEATURES Infected Eczema Suspect infection if: Poor response to topical steroid treatment Weepy, crusting, bleeding Sudden flare

TREATMENT Use topical steroid strength appropriate to site and severity of eczema

THERAPEUTIC TIPS Take nasal swabs from patient and family: Commonest pathogens:

1% Hydrocortisone containing preparations Hydrocortisone 1% Clotrimazole (Canestan HC) Hydrocortisone 1% Miconazole nitrate (Daktacort) Hydrocortisone 1% fusidic acid (Fucidin H)

Staphylococcus aureus Streptococcus pyogenes

Clobetasone butyrate 0.05% containing preparations (Trimovate cream) Betamethasone valerate 0.1% containing preparations Betamethasone valerate 0.1% + Clioquinol 3% (Betnovate C) Betamethasone valerate 0.1% + Neomycin sulphate 0.5% (Betnovate N) Betamethasone valerate 0.1% + Fusidic acid 2% (Fucibet) If extensive or severe infection - ADD oral antibiotics Flucloxacillin 500mg four times daily x 14 days or Children over 2 yrs 250mg four times daily x 14 days Erythromycin 500mg four times daily x 14 days Clarithromycin 500mg twice daily If recurrent infections occur, take nasal swabs from family members and if positive, eradicate nasal carriage of Staphylcoccus Aureus using: Naseptin twice daily for 10 days Bactroban nasal twice daily for 5 days ■Bandaging Zinc paste bandages (Zipzoc) on the limbs used alone or over topical corticosteroids can result in rapid improvement of lichenified eczema

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Bandaging techniques may be demonstrated by a suitably trained nurse or nurse specialist

CLINICAL FEATURES Allergies and allergy testing

TREATMENT Keep dust down and in severe cases try protective coverings to pillows and bedding

THERAPEUTIC TIPS House dust mites can aggravate eczema in some children. No tests are available to confirm or refute food allergy as a cause of worsening eczema. RAST tests and skin prick tests are not helpful. Patch testing is useful if patients report irritation with topical preparations.

Consider exclusion diets only in difficult cases and abandon if no improvement apparent after 2 wks

Food allergies, especially to eggs and dairy products only occasionally cause worsening of eczema. Dietetic advice is required if exclusion diets are used for more than 2-4 weeks. The commonest manifestation of food allergy is urticaria not eczema.

CRITERIA FOR REFERRAL - SPECIALIST NURSE CLINICS (Community Nurse Eczema Teams-See Contacts Page) ■

Known cases of eczema for:

■

Patient education / advice

■

Review of treatment

■

To learn techniques eg. Zinc based paste bandages etc CRITERIA FOR A REFERRAL- DERMATOLOGY

■

Only cases of severe or difficult eczema usually need to see a Dermatologist

■

For consideration of second line treatment e.g. phototherapy or cytotoxic drugs

■

Eczema herpeticum

■

If allergic contact dermatitis is suspected

■

For in-patient treatment

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Topical preparations – quantities General notes on prescribing dermatology products for patients The BNF recommended quantities of EMOLLIENTS to be given to ADULTS for twice daily application for one week are: EMOLLIENTS/TWICE DAILY Face Both hands Scalp Both arms or both legs Trunk Groin and genitalia

EMOLLIENTS/TWICE DAILY 15 – 30g 25 - 50g 50 - 100g 100 - 200g 400g 15 - 25g

LOTIONS 100ml 200ml 200ml 200ml 500ml 100ml

NB In some cases emollients will be required 4 - 6 times daily and quantities should be increased accordingly Patients with eczema should be prescribed 500- 1000g emollients a week. The recommended quantities of STEROIDS to be given to ADULTS for twice daily applications for one week are: STEROIDS/TWICE DAILY Face Both hands Scalp Both arms Both legs Trunk Groin and genitalia

CREAMS & OINTMENTS 15 - 30g 15 - 30g 15 - 30g 30 - 60g 100g 100g 15 - 30g

Prescribing topical steroids for children Children, especially babies, are particularly susceptible to side effects. The more potent steroids are contra-indicated in infants less than one year, and in general should be avoided or used with great care for short periods

Topical Steroid Ladder Ultra potent eg Potent eg Moderate eg Mild eg

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Dermovate/Nerisone Forte Betamethasone/Elocon/Synalar Eumovate Hydrocortisone 1%

How much topical treatment? How much to apply? AGE Face & Neck Arm & Hand Leg & Foot Trunk (front) Trunk (back)

3-6 MTHS 1

1-2 YRS 1½

3-5 YRS 1½

6-10 YRS 2

1

1½

2

2½

1½

2

3

4½

1

2

3

3½

1½

3

3½

5

How much to prescribe (extensive body rash) Children - dose depends on PROPORTIONAL SURFACE AREA (ref 2)

Adult 12yrs 3-4yrs Infant

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% ADULT DOSE 100% 75% 50% 25%

DAILY (B.D. USE) 35.0g 26.5g 17.5g 8.7g

WEEKLY (B.D. USE) 245g 183g 122g 61g

Skin Care Advice for Patients with Hand Eczema / Dermatitis Application of Treatment Apply prescribed steroid cream / ointments generously twice a day until much improved, then daily Use moisturisers to soften the skin frequently (at least twice daily) Use soap substitute (aqueous cream or emulsifying ointment) to wash

Hand washing Use lukewarm water and a soap substitute to wash. Rinse thoroughly and dry hands carefully. Apply a moisturiser afterwards.

Washing up Avoid skin contact with detergents, polishes, solvents (white spirit) and cleansers (eg Swarfega) Always wear gloves and use long handled brushes for washing pans Wear cotton gloves inside rubber or PVC gloves for increased comfort

Housework Wear cotton gloves for dry jobs such as polishing and rubber / PVC gloves for wet work

Cooking Avoid direct contact with lemons, oranges, grapefruits, garlic etc and raw meat and fish

Shampooing Hair Wear gloves and avoid direct contact with shampoos and hair care products

Skin protection and cold weather Use plenty of moisturising creams and wear gloves to avoid drying and chapping of skin REMEMBER Hand care should be continued after the skin appears normal because the resistance of the skin to soaps and detergents is low for up to six months after the skin has healed and looks normal

Varicose Eczema CLINICAL FEATURES Varicose eczema commonly co-exists with varicose ulcers

TREATMENT All patients need

THERAPEUTIC TIPS

■Emollients – see emollient appendix ■Soap substitutes - see emollient appendix ■Topical steroids – see below Below knee compression stockings

Mild

Clobetasone butyrate 0.05% (Eumovate) twice daily

Moderate - Severe or ‘Discoid’ eczema

Betamethasone valerate 0.1% (Betnovate) twice daily, use 2 - 4 weeks then reduce to lowest effective strength

These should only be worn during the day time. Available in Class I, II, III dependent upon severity – usually start with Class I stockings

↓

Betamethaone valerate 0.025% (Betnovate RD) twice daily

↓

1% Hydrocortisone ointment twice daily Infection Wet, weeping or Blisters

Burst blisters Potassium permanganate soaks 1:10,000 for 10-15 minutes twice a day Substitute - Steroid-antibiotic preparations – as for infected eczema

Dissolve tablet in bucket of water until colour is a light purple. Nb- If pink then the solution is too dilute. Use creams if wet/ weeping Use ointment if dry/scaly. See section on hand dermatitis

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CLINICAL FEATURES Severe infection

TREATMENT Treatment as for infected eczema

Cellulitis

Oral Antibiotics Flucloxacillin 500mg four times daily for 7 to 14 days Clarithromycin 500mg twice daily for 7 – 14 days and review regularly

THERAPEUTIC TIPS Take skin swabs for culture and sensitivity

CRITERIA FOR REFERRAL Acquired allergic sensitivity to topical medicants (ie allergic contact dermatitis) is a common cause of failure to respond to treatment. Refer patients who fail to respond to standard treatment. Refer urgently to medical team for rapidly extending cellulitis

Wet/weepy infected eczema and ulcers

Blisters/weeping eczema

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Dry/scaly eczema and ulcers

Dry/scaly eczema and ulcers

Seborrhoeic Dermatitis CLINICAL FEATURES Very common chronic dermatosis, characterised by redness and scaling affecting areas where sebaceous glands are most active i.e scalp, face, presternal area + body flexures. Newborns can present with cradle cap.

TREATMENT

Infants with cradle cap

Olive oil/emulsifying ointment under cap to soften scales and wash off with baby shampoo. Then apply Hydrocortisone 1% cream

Infants - face and body

1) Hydrocortisone 1% cream twice daily for 5– 7 days 2) Hydrocortisone 1% with miconazole nitrate 2% (Daktacort) cream – Twice daily for 5 -7 days. 3) Hydrocortisone 1% with clomitrazole 1% (Canestan hc) cream – Twice daily for 5 -7 days.

Older children and adults – face

1) Hydrocortisone 1% cream twice daily 2) Hydrocortisone 1% with miconazole nitrate 2% (Daktacort) cream – Twice daily for 5 -7 days. 3) Hydrocortisone 1% with clomitrazole 1% (Canestan HC) cream – Twice daily for 5 -7 days. 4) Ketoconazole 2% cream twice daily 5) Clobetasone Butyrate 0.05% (Eumovate) cream twice daily

Eyelids

■Wash with diluted baby shampoo and rub vigorously with a warm flannel

Scalp

■Tar based or anti-fungal shampoo eg. Ketoconazole/capasal shampoo once or twice a week

Pre-sternal area/flexures

■Ketoconazole 2% cream twice daily Clobetasone Butyrate 0.05% (Eumovate) cream twice daily ■Steroid sparing treatments:1) pimecrolimus 1% cream twice daily 2) tacrolimus 0.03% or 0.1% ointment twice daily 3) pulsed itraconazole 200mg twice daily for 7 days

THERAPEUTIC TIPS

Occlude with cap for 2-3 hours

Treat for 7 – 10 days

Consider these if using topical steroids frequently Usually improves with sunlight Consider HIV status in young patients presenting with severe rapid onset of symptoms

CRITERIA FOR REFERRAL 1. Failed suggested treatments

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2. Persistent or frequent episodes

3. Uncertainty in diagnosis

Seborrhoeic Dermatitis

Seborrhoeic Dermatitis

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Psoriasis Acknowledgements to Salford Royal NHS Foundation Trust

CLINICAL FEATURES TRUNK & LIMBS Mild to moderate Pink plaques with silvery white scales, commonest sites are elbows and knees. Aggravated by stress and infections. Improves with sunlight

TRUNK & LIMBS Severe

Plaque Psoriasis (limbs)

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TREATMENT ■Emollients for all patients Plus Calcipotriol & betamethasone (Dovobet) gel / ointment once daily ■Vitamin D analogues e.g Calcipotriol 50 µg/g (generic or Dovonex)

THERAPEUTIC TIPS Licensed for 18 and over

Calcipotriol is licensed for 6 yrs and over

Calcitriol 3µg/g (Silkis) twice daily

Calcitriol is licensed for 12yrs and over.

Tacalcitol 4 µg/g (Curatoderm) once daily

Tacalcitol is licensed for 12yrs and over Vitamin D preparations can cause skin irritation Vit D Analogues should be avoided in those with calcium metabolism disorders as they can cause hypercalcaemia

■Coal Tar Preparations Exorex Lotion twice or three times daily Or Alphosyl HC twice daily

Coal tar products are not to be used on broken/highly inflamed skin, sore /acute pustular psoriasis or infected skin

Start Calcipotriol & betamethasone (Dovobet) Ointment , once daily and REFER to secondary care

Licensed for 18 yrs and over.

CLINICAL FEATURES FLEXURES & GENITALIA

TREATMENT ■Emollients for all patients plus Clotrimazole Cream 1%+ Hydrocortisone 1%, (Canestan HC) cream twice daily. Miconazole Nitrate Hydrocortisone (Daktacort) cream twice daily 1% Hydrocortisone cream

THERAPEUTIC TIPS Try one preparation for two weeks

See above therapeutic tips regarding Vitamin D analogues

Calcitriol (Silkis) twice daily Or Tacalcitol (Curatoderm) once daily (unlicensed indication) If no improvement: Clobetasone, nystatin.(Trimovate) cream twice daily for 1-2 weeks Or Tacrolimus 0.1% ointment for 2 4 weeks. (Unlicensed indication) FACE & HAIRLINE

■Emollients for all patients plus Clobetasone butyrate, (Eumovate) twice daily. 1% Hydrocortisone twice daily. Miconazole Nitrate Hydrocortisone, (Daktacort) twice daily. Clotrimazole Cream 1% + Hyrocortizone 1%, (Canesten HC) cream twice daily. Or Calcitriol (Silkis) twice daily Tacalcitol (Curatoderm) once daily Tacrolimus 0.1% or 0.3% ( Unlicensed indication)

Flexural Psoriasis (Breast fold)

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Step down from moderately potent steroid once controlled to either mild steroid or vitamin D analogue Try one preparation for up to 2 weeks

Silkis is licensed for eyelids with caution

Psoriasis hairline

CLINICAL FEATURES Scalp Psoriasis Mild

TREATMENT ■Shampoos: Polytar, Alphosyl 2:1, Ceanel, Capasal, Nizoral, T-Gel

Moderate

Calcipotriol & betamethasone (Dovobet gel) once daily for 4 weeks Betamethasone diprop 0.05% + Salicylic acid 2% application (Diprosalic) twice daily. Or Fluocinolone acetonide 0.025% (Synalar gel) twice daily. Clobetasol Proprionate 500mg Shampoo. (Etrivex) Apply for 15 minutes, once daily for 4 weeks

THERAPEUTIC TIPS Always check patient preference to smell colour and application to ensure maximum compliance.

Apply to affected areas daily for 4 weeks. Apply to dry hair leave in overnight. To remove; apply shampoo to dry hair, then wait a few minutes before washing as normal. Repeat shampoo as needed.

After 15 minutes contact, add warm water to wash hair. Then rinse out as normal shampoo.

Betnovate scalp solution twice daily Severe

Palmar Plantar

Sebco to be applied every night for 7 days to descale and then treat with dovobet/ synalar gel

Add occlusion shower cap if required

Continue gel preparations as above thereafter ■Emollients for all patients plus Calcipotriol & betamethasone (Dovobet) once daily

Plus a shampoo of choice

Diprosalic ointment twice daily Betnovate ointment twice daily Scalp Psoriasis

Page | 24

Try one treatment for 2-4 weeks then review If no improvement include plastic occlusion overnight, i.e plastic gloves /cling film

Patient Review For each area – initial treatment period of 4 weeks, then review as required Check compliance / amount of treatment used etc

Improvement

No Improvement

If clear, stop treatment, if improved go to maintenance therapy i.e. initial treatment for mild/moderate disease

Change topical treatments as per protocol

Review every 8 weeks or as and when needed Improvement

Refer to Specialist Services ■ Erythroderma ■ Extensive >20% body surface area with disabling psoriasis ■ Failure to respond to treatment ■ Unstable/rapidly extending psoriasis

Page | 25

Try treatments for a further 4 weeks with review

Urticaria and Angioedema CLINICAL FEATURES Recurrent itchy wheals which resolve within 24 hours

TREATMENT ■Antihistamines Non-sedating – start with once daily dose and can increase to twice daily if required.

THERAPEUTIC TIPS Prick tests, RAST tests and Patch tests are of no value in urticaria.

Minimise: Overheating Stress

Should be used as required for sporadic attacks

Contact urticaria is rare and the cause is obvious from the history.

The following drugs are associated with Urticaria:aspirin,codeine, morphine, NSAIDs, ACE inhibitors and penicillin.

If there is no response after six weeks, double the dose or try a second and then a third agent.

Reassure the patient that it is benign and usually selflimiting.

Exclude: C1esterase Inhibitor Deficiency by blood test (if angioedema is the only sign) Insect bites

If sleep is disturbed, add a sedative antihistamine at night.

The cause of food allergy is usually obvious from the history.

Urticaria may follow non-specific infections, hepatitis, streptococcal infections, campylobacter and parasitic infestations. Rarely it may be a symptom of an underlying systemic disease such as thyroid disease or connective tissue disease eg Lupus.

Summary of non-sedating and low-sedating antihistamines Cetirizine

NAME

DRUG INTERACTIONS ■ None

COMMENTS Minimally sedating. Halve the dose in renal impairment.

Loratidine

■ None

Avoid in pregnancy

Acrivastine

■ None

Fexofenadine

■ None

Short acting. Avoid in renal impairment and pregnancy Avoid in pregnancy

More sedating antihistamines Hydroxyzine

NAME

DRUG INTERACTIONS Yes

Sedative

Chlorpheniramine maleate

Yes

Ok in pregnancy

Urticaria

Page | 26

COMMENTS

Generalised Pruritus CLINICAL FEATURES Dry skin, low grade eczema and scabies are the commonest cause of generalised pruritus.

TREATMENT Standard emollients and soap substitutes – see appendix

A full history and skin examination are required.

1% Menthol in aqueous cream as often as necessary to pruritic areas.

Crotamiton or Crotamiton combined with hydrocortisone cream (Eurax HC) twice daily / as needed to pruritic areas.

If symptoms are still uncontrolled consider: sedating antihistamines (nocte) Hydroxyzine 25-75mg or 10-30mg (elderly) Chlorpheniramine Maleate 2 - 4 mg

THERAPEUTIC TIPS If NO RASH can be seen other than excoriations consider the following: Iron deficiency anaemia Low serum iron Uraemia Obstructive jaundice Thyroid disease Lymphoma, especially in young adults Carcinoma, especially in middle age and elderly Psychological Investigations: FBC ESR Urea and electrolytes LFTs Thyroid function tests Iron studies Fe/TIBC/Ferritin Chest X-ray NB Pruritus may occasionally predate a lymphoma by several years. Regular follow-up is indicated for patients whose itching is unexplained.

Patients may be referred if:

CRITERIA FOR REFERRAL

■

Diagnosis uncertain

■

Persistent symptoms not responding to topical treatments.

Page | 27

Viral warts CLINICAL FEATURES Viral warts/verrucae There is no cure, can only clear > 70% resolve spontaneously in 2 years. Plantar warts are more persistent. Topical treatment is as effective as cryotherapy for hand warts.

TREATMENT ■Topical keratolytics Hand warts Use high concentrations of salicyclic acid. Use once daily for up to 3 months ■Adults e.g. Occlusal (25% Salicylic acid) ■Children e.g. Duofilm (16.7% Salicylic Acid) Salactol (16.7% Salicylic Acid)

THERAPEUTIC TIPS File warts daily before applying a fresh coat of paint solution

■Plantar warts Verrugon (50% Salicylic Acid) ■Cryotherapy Freeze times Face 5 - 7 seconds Hands 10 - 12 seconds Feet 1st freeze 15 seconds Thaw 1 - 2 minutes 2nd freeze 10 - 15 seconds

Up to 6 treatments 3-4 weeks apart.

Plane warts (face/ hands)

No treatment or trial of Tretinoin 0.025% cream/gel for 4 weeks (NB- unlicensed for this use)

Plane warts are notoriously resistant to treatment and usually get worse with cryotherapy/destructive treatments as a result of the Koebner Phenomenon

Filiform warts (face/ eyelids)

Cryotherapy Curettage & cautery

Avoid topical keratolytics which are too irritant for use on the face

CRITERIA FOR REFERRAL In general patients with viral warts/verrucae should not be referred; Patients may be referred if: ■

Severe disabling warts despite six months of topical salicylic acid treatment + cryotherapy.

■

Significant warts or mollusca in immunocompromised patients

■

Atypical appearance, difficult anatomical sites

■

It is unkind to treat very young children (< 10 yrs) with cryotherapy for warts

Page | 28

Viral Warts

Mosaic Warts on heal

Page | 29

Treatment Regime for Warts Soak – pare – paint Warts are caused by a viral infection. There is no ideal treatment for warts but approximately 70% will clear within three months if treated with a wart paint and pumice stone. If left untreated, 70% warts will clear within two years.

Instructions Soak the affected area in warm water (or bath) for 10 minutes Rub down hard skin with a pumice stone or emery board Apply wart paint and allow to dry Repeat steps 1-3 each evening on each wart Do not stop the treatment until one week after you think the wart is gone. If the wart starts to come back, then start treating again.

Molluscum Contagiosum CLINICAL FEATURES Most lesions spontaneously resolve in 6 - 12 months. Resolution is often preceded by inflammation, swelling and crusting. Patchy dry skin surrounding molluscum contagiosum is common.

TREATMENT ■No Treatment OR ■Trial of hydrogen peroxide 1% cream (Crystacide) twice daily for 3 weeks (unlicensed use)

THERAPEUTIC TIPS

Treat complications: ■Infection Topical fusidic acid cream ■Eczema Treat dry skin (if necessary) with emollients (see appendix) Mild topical steroids eg Hydrocortisone 1% Cryotherapy

CRITERIA FOR REFERRAL In general patients with Molluscum contagiosum should not be referred. Patients may be referred if: ■ Age >10, persistent lesions >2 years ■

Facial lesions

■

Giant molluscum

■

Immunocompromised

Page | 31

Cryotherapy is very poorly tolerated by very young children < 10 years. Risk of permanent scar/ pigmentation changes with cryotherapy

Molluscum contagioscum

Giant molluscum

Page | 32

Molluscum with dry skin

Scabies CLINICAL FEATURES Human scabies is an infestation caused by the mite Sarcoptes scabiei. Mites are transmitted from one person to another by close physical contact (in a warm atmosphere) eg. sharing a bed, children playing with each other or young people holding hands. An individual who has never had scabies before may not develop itching or a rash until 1 - 3 months after becoming infested. There are burrows on non hair bearing skin e.g. palms/ soles /wrists /ankles /sides of feet and often a widespread eczematous rash (sparing face in older children and adults) There may be inflammatory nodules on male genitalia, periareola areas, axilla/groin especially in long standing cases or impetiginisation due to secondary infection with Staph Aureus

TREATMENT Treat when there is a strong clinical suspicion of infestation.

THERAPEUTIC TIPS It is essential that all members of the household and any other close social contacts of an infested person should receive treatment at the same time as the patient.

Apply either: Malathion 0.5% Aqueous solution (Derbac-M) (apply with a paintbrush) Or Permethrin 5% (Lyclear Dermal cream)

All skin below the chin must be treated including the web spaces of the fingers/ toes, under the nails and all body folds.

Malathion should be left on the skin for 24 hours and Permethrin for 8 - 12 hours. Repeat treatment in 7 days

Disinfestation of clothing and bedding other than by ordinary laundering is not necessary.

Treat residual rash/itch with: Crotamiton/ hydrocortisone (Eurax HC) For impetiginised rash: Betamethasone ointment 0.025% twice daily +/- Flucloxacillin 250mg 4 times daily for 7 - 10 days Inflammatory nodules settle spontaneously though this can take months

Page | 33

Remind patients to re-apply the scabicide after washing their hands.

Mites are killed within 24 hrs but the pruritus and rash may take 3 - 6 weeks to settle. Do not allow repeated use of scabicides to pruritic areas as this may irritate the skin.

Scabies

Page | 34

Scabies

Instructions for Patients with Scabies Scabies is a skin disease caused by microscopic mites, which burrow into the skin. They are passed from person to person by close physical contact. For the first couple of weeks following infestation, the mites may cause no symptoms but the body then develops an allergic reaction to the mites and an itch rash appears. Because it takes some time for symptoms to appear an individual is capable of passing on the mite to someone else before they know that they have the condition. For this reason all household contacts and close friends of a person with scabies should be treated, even if they have no symptoms. Scabies is NOT due to poor hygiene. Infestation with the scabies mite is not transmitted by clothing, bedding, toilet seats etc and there is no need for any special cleaning of these.

Instructions Apply a thin layer of lotion or cream to every body surface from the chin downwards. Ensure that all nooks and crannies of the body, especially between the fingers and toes, underneath the nails and the genital area are adequately treated. Leave the lotion or cream on the skin overnight before washing. If the hands or other areas are washed sooner than this, reapply the lotion or cream to these sites. Repeat treatment after 7 days. IMPORTANT The treatment will kill all the mites. The mites do not survive in bedding etc and it is not necessary to treat these separately. Itching may persist for 4-6 weeks after treatment and is managed with mild topical steroid creams and antihistamines by mouth. Do not continue using the lotion or cream, unless advised. The body does not acquire immunity to scabies infestation and treatment does not prevent another attack. It is therefore very important that all close contacts are treated at the same time.

Onychodystrophy (Thickened and Dystrophic nails) CLINICAL FEATURES The thickness of nail plates is normally 0.5mm; this increases in manual workers and in certain disease states including:

TREATMENT If mycology is positive and dystrophy does not extend to nail matrix (Distal Onychomycosis) use: Amorolfine (Loceryl) lacquer once weekly continued for 6 - 12 months.

■Onychomycosis (fungal / yeast infection)

(trim and file down nails prior to application)

■Psoriasis

Topical Amorolfine can be used alongside systemic treatment.

■Chronic Eczema

THERAPEUTIC TIPS NB Asymptomatic patients may be advised to ‘leave well alone’ Examine all nails and all of the skin. Ask patient to grow nails to provide viable samples (large nail clippings including scrapings of thickened crumbly material from the underside of the nail if present) for mycology. (Nb-Poor samples = false negatives) Cultures take up to 6 weeks.

■Lichen Planus If negative mycology, arrange for regular chiropody to keep nails short and offer a trial of treatment

■Alopecia areata ■Norwegian scabies ■Darier’s Disease ■Old age ■Trauma e.g. from footwear

■Alternatively oral treatment for Fungal Infections; Terbinafine 250mg once daily 12-16 weeks for toenails, 6 - 12 weeks for fingernails

■Congenital ichthyosis Itraconazole (200mg twice daily for 7 days) repeated monthly 3 cycles for toenails, 2 for fingernails) or 200mg once daily for 8 - 12 weeks For Yeast Infections Itraconazole (regime as above)

Page | 36

LFTs required every 6 weeks with Terbinafine Terbinafine is not effective for yeast infections.

Caution: Itranconazole – drug interactions

Fungal nail

Page | 37

Actinic/Solar keratosis CLINICAL FEATURES Solar keratoses Also known as actinic keratoses, usually multiple, flat, pale or reddish-brown lesions with a dry adherent scale. Evidence suggests that the annual incidence of transformation from solar keratoses to SCC is less than 0.1%. The risk is higher in immunocompromised patients.

TREATMENT Topical Diclofenac Sodium (Solaraze) Apply twice daily to maximum of 10 lesions, for 12 weeks.

THERAPEUTIC TIPS Solaraze will produce much less inflammation than Efudix. Solaraze is less effective than Efudix for thicker lesions.

0.5% Fluorouracil & 10% Salicylic acid (Actikerall)- for superficial lesions only Applied daily to maximum of 10 lesions for 12weeks. Topical Fluorouracil 5% (Efudix) cream Apply sparingly once or twice daily for 2 - 4 weeks.

IT IS NOT NECESSARY TO REFER ALL PATIENTS WITH SOLAR KERATOSES.

Efudix is a treatment for multiple, illdefined solar keratoses. It is safe, efficacious, with little systemic absorption. Stop treatment once marked inflammation occurs. The patient must be warned to expect this. Inflammation will settle over the next few weeks. Hydrocortisone 1% cream can be used to treat inflammation Optimum effect 1 month post treatment.

Cryotherapy Freeze for 10 - 15 seconds each Preventative measures SP15 (Sunblock) April -September Apply to exposed areas (face, neck, hands) Hat with 3 inch brim for sunny days. CRITERIA FOR REFERRAL –(Lesions which have not responded to above treatment options) ■

If there is suspicion of malignancy

■

If the lesions have not responded to treatment

■

If the individual is on immunosuppressant’s (e.g. post renal transplant)

AK (scalp)

Page | 38

AK (nose)

AK

(leg)

Seborrhoeic Keratosis/Basal Cell Papilloma CLINICAL FEATURES Common benign warty lesions of variable size and pigmentation with a characteristic ‘stuck on’ appearance. Usually appear after age 30. Can be hereditary. They have no malignant potential.

TREATMENT 1) No treatment – the majority of lesions do not require treatment.

THERAPEUTIC TIPS

2) Cryotherapy – suitable for small troublesome lesions 3) Curettage & cautery – only for large troublesome lesions

CRITERIA FOR REFERRAL Large troublesome lesions on difficult anatomical sites Diagnostic uncertainty

Seborrhoeic Keratosis

Seborrhoeic Keratosis

Page | 39

Skin Cancer CLINICAL FEATURES

TREATMENT

Basal cell carcinoma

They are best managed by:

Common slow growing and locally invasive tumours. Most are easily recognised with a pearly rolled edge and later central ulceration.

1) Excision Biopsy OR 2) Radiotherapy

Pigmented and morphoeic (scarlike, poorly defined) BCCs are less common. Squamous cell carcinoma Much less common. They may be slow growing, well differentiated, keratinising or rapidly enlarging, poorly differentiated tumours. Up to 5% may metastasise to regional lymph nodes.

This is the most dangerous skin malignancy. Early detection and Treatment is vital for optimizing outcome. Melanoma subtypes ■ Superficial spreading ■ Nodular ■ Amelanotic ■ Lentigo Maligna ■ Acral lentiginous and Subungual

Page | 40

Radiotherapy may be the preferred option but in frail, elderly patients, MOHS surgery is the best option for removing BCCs from difficult facial sites eg nose, lips. BCC does not require a HSC 205 referral

Lesions with a high index of suspicion, especially if rapidly growing should be referred using the Skin Cancer proforma (HSC 205). Referrals should be directed to Dermatology or Plastics not General Surgery. Referrals through fax or choose and book should be within 24 hours and the patients will be seen within two weeks.

Malignant melanoma

THERAPEUTIC TIPS

All suspicious moles must be referred using the Skin Cancer pro forma (HSC 205) and will be seen within two weeks. Any lesion felt to be highly suspicious of melanoma will either be excised on the day of attendance or within 1 – 2 weeks

CRITERIA FOR PIGMENTED LESION REFERRAL The following seven point checklist may be useful in deciding whether to refer a changing pigmented lesion. Refer if at least one major or two minor criteria present. Major features ■ Change in size ■ Change in colour (variability of pigmentation) ■ Change in shape (irregularity of edge) Minor features ■ Size > 6mm diameter ■ Inflammation ■ Bleeding/crusting ■ Itch

Page | 41

Patient Support Groups The Acne Academy Dermatology Department, Harrogate & District Foundation Trust Lancaster Park Road, Harrogate HG2 7SX, North Yorkshire Tel. 01707 226023 www.acneacademy.org British Allergy Foundation Muriel A Simmons Deepdene House, 30 Bellegrove Road Welling , Kent DA16 3PY Tel: 020 8303 8525 Helpline: 020 8303 8583 (Mon-Fri 9 - 5pm) www.allergy.baf.com The Psoriasis Association Milton House Milton Street Northampton NN2 7JG Tel: 01604 711129 • Fax: 01604 792894 Herpes Viruses Association (SPHERE) And Shingles Support Society Miss Marion Nicholson, Director 41 North Road, London N7 9DP Tel: 020 7607 9661 (office and Minicom) Helpline: 020 7609 9061 www.astrabis.co.uk/sites/herpesviruses/ default.htm Cancer BACUP 3 Bath Place, Rivington Street London EC2A 3DR Tel: Freephone 0808 800 1234 (9am - 7pm) Fax: 020 7696 9002 www.cancerbacup.org.uk

Page | 42

National Eczema Society Hill House, Highgate Hill London N9 5NA Tel: 020 7281 3553 Eczema Information Line: 0870 241 3604 (Mon - Fri 9 - 5pm) www.eczema.org Hairline International Ms Elizabeth Steel Lyons Court, 1668 High Street Knowle, West Midlands B93 0LY Tel: 01564 775281 • Fax: 01564 782270 www.hairlineinternational.com Raynaud’s & Scleroderma Association Trust 112 Crewe Road Alsager, Cheshire ST7 2JA Tel: 01270 872776 • Fax: 01270 883556 www.raynauds.demon.co.uk Changing Faces 1 & 2 Junction Mews Paddington, London W2 1PN Tel: 020 7706 4232 Fax: 020 7706 4234 www.changingfaces.co.uk The Vitiligo Society 125 Kennington Road London SE11 6SF Tel: Freephone 0800 018 2631 Fax: 020 7840 0866 www.vitiligosociety.org.uk

Emollient Appendix Product type

Product names

Price

Nonproprietary emolients

Emulsifying oinment, BP

£2.03/500g

Hydrous ointment, BP*

£3.29/500g

Liquid and White Soft Paraffin Ointment, NPF

£6.09/500g

Paraffin, White Soft, BP

£2.47/500g

Paraffin, Yellow Soft, BP

£2.80/500g

Aquamol ®

£6.40/500g pump £1.22/50g

Aquadrate®

Aveeno®§

£6.80/300ml pump £3.97/100ml

Balneum® Cream

£9.80/500g £2.80/50g

Cetraben®

£11.11/1050g pump £5.61/500g pump £2.88/150g pump £1.17/50g pump

Balneum® Plus†

£14.99/500g pump £3.29/100g

Diprobase®

£6.32/500g pump £1.28/50g

Calmurid®

£27.42/500g £5.70/100g

E45®*(first choice option)

£4.89/500g pump £4.46/350g £2.55/125g £1.40/50g

E45® Itch Relief Cream†

£14.99/500g pump £3.47/100g £2.55/50g

Epaderm ®

£6.62/500g pump £1.62/50g pump

Eucerin® Intensive

£7.15/100ml

Hydromol Cream®

£12.60/500g £3.80/100g £2.04/50g

Nutraplus®

£4.37/100g

Linola® Gamma‡

£8.20/250g £2.83/50g

Lipobase®

£2.08/50g

Neutrogena®

£3.77/100g

Oilatum (first choice option)& Oilatum Junior(fragrance free)®

£9.98/1050ml pump £4.99/500ml pump £2.46/150g £1.30/40g

QV®

£11.60/1050g £5.60/500 £1.95/100g

Proprietary creams

Page | 43

Product names

Price

(with urea)

Produc ts with antisep tic

n/a

n/a

£4.37/100g

Dermol ®

(urea+ lactic acid)

Price

£6.63/500g pump £2.86/100g

Product type

Product names

Price

Proprietary creams (continued)

Ultrabase

£9.72/500g pump £1.14/50g

Unguentum ® M

£8.48/500g £5.50/200ml pump £2.78/100g £1.41/50g

Zerobase®

£5.26/500g pump £1.04/50g

Zerocream

£4.08/500g pump £1.17/50g

(first choice option) ® Zeroguent

£6.99/500g

Diprobase®

£1.28/50g

Epaderm®

£11.82/1000g £6.42/500g £3.78/125g

Hydromol Ointment®

£8.96/1000g £4.82/500g £2.84/125g

Kamillosan

£2.81/50g

Aveeno® lotion§

£6.42/400ml

Dermamist® spray application Doublebase ® gel

£5.97/250ml

E45® lotion*§ (first choice option) Emollin®

£4.50/500ml pump £2.40/200ml

QV® lotion

£5.00/500ml £3.00/250ml

Aqueous cream, BP(non proprietary) Aveeno® bath oil§

£1.57/500g

Aveeno Colloidal® bath additive§

£7.33/10x50g sachets £4.39/10x15g sachets (baby)

Balneum® bath oil

Balneum® Plus Bath Oil†

®

®

Proprietary ointments

®

Proprietary gels, lotions, and sprays

Non propietary and Proprietary washes and bath and shower additives

Page | 44

Products with urea

Price

Products with antiseptic

Price

£2.33/100g n/a

Eucerin® Intensive lotion

n/a

£7.93/250ml

Dermol® 500 lotion

£6.04/500ml

£5.83/500g £2.65/100g

£6.05/240ml £3.78/150ml

£1.08/100g

n/a

n/a

Dermol® 200 shower emollient Dermol® 600 bath emollient

£3.55/200ml

£10.39/1000ml £5.38/500ml £2.48/200ml

Emulsiderm® liquid emulsion

£12.00/1000ml £3.85/300ml

£6.66/500ml

Oilatum Plus ® bath addtive

£6.98/500ml

£4.28/250ml

£7.55/600ml

Product type

Product names

Price

Proprietary washes and bath and shower additives (continued)

Cetraben® emollient bath additive

£5.25/500ml

Dermalo® bath emollient

£3.60/500ml

Doublebase® emollient shower gel (first choice option)

£5.21/200g

Diprobath® bath additive

£5.70/500ml

E45® emollient bath oil§

£5.11/500ml £3.19/250ml

E45® emollient wash cream§ (first choice option) Hydromol Emollient® bath additive (first choice option)

£3.19/250ml

Imuderm® bath oil

£3.75/250ml

Oilatum® emollient bath additive*(first choice option) Oilatum® Junior emollient bath additive

£4.57/500ml £2.75/250ml

Oilatum® shower emollient (gel) (first choice option) QV® bath oil

£5.15/150g

QV® wash

£2.50/200ml

Products with urea

Price

£8.19/1000m l £4.11/500ml £3.61/350ml

£5.89/600ml £5.10/300ml £3.25/250ml £2.82/150ml

£4.50/500ml £2.20/200ml

n/a — Not available. * Contains lanolin or lanolin derivatives. † Contains lauromacrogols. ‡ Contains Evening Primrose oil. § Advisory Committee on Borderline Substances (ACBS) — state this on FP10 form. Prices correct as of October 2011

Page | 45

Products with antiseptic

Price