CHAPTER 13 SKIN - NHS Devon

CHAPTER 13 SKIN 

Produced: April 2008 

Page 

13.1 Management of skin conditions 13-3 

13.1.2 Suitable quantities for prescribing 13-3 

13.1.3 Excipients and sensitisation 13-4 

13.2 Emollient and barrier preparations 13-4 

13.2.1 Emollients 13-4 

13.2.1.1 Emollient bath additives 13-7 

13.2.2 Barrier preparations 13-8 

13.3 Topical local anaesthetics and antipruritics 13-8 

13.4 Topical corticosteroids 13-9 

13.5 Preparations for eczema and psoriasis 13-15 

13.5.1 Preparations for eczema 13-15 

13.5.2 Preparations for psoriasis 13-17 

13.5.3 Drugs affecting the immune response 13-23 

13.6 Acne and Rosacea 13.23 

13.6.1 Topical preparations for Acne 13.23 

13.6.2 Oral preparations for acne 13-24 

13.7 Preparations for warts and calluses 13-26 

13.8 Sunscreens and camouflagers 13-27 

13.8.1 Sunscreening preparations 13-27 

13.9 Shampoos and preparations for scalp and hair conditions 13-28 

13.10 Anti-infective skin preparations 13-29 

13.10.1 Antibacterial preparations 13-29 

13.10.1.1 Antibacterial preparations only used topically 13-29 

13.10.1.2 Antibacterial preparations also used systemically 13-30 

13.10.2 Antifungal preparations 13-30 

13.10.3 Antiviral preparations 13-31 

13.10.4 Parasiticidal preparations 13-31 

13.10.5 Preparations for minor cuts and abrasions 13-33 

13.11 Skin cleansers and antiseptics 13-33 

13.11.1 Alcohols and saline 13-33 

13.11.2 Chlorhexidine salts 13-33 

13.11.4 Iodine 13-34 

13.11.5 Phenolics 13-34 

13.11.6 Astringents, oxidisers and dyes 13-34 

13.11.7 Preparations for promotion of wound healing 13-34 

13.12 Antiperspirants 13-34 

13.13 Wound management products and elastic hosiery 13-35 

13.14 Others 13-35 

First line drugs Second line drugs Specialist drugs Hospital only drugs 

13-1

Appendices 

Appendix 1 – The Dermatology Referral Process 13 - 36 

Appendix 2 – Excipients that may cause sensitisation 13 - 37 

Appendix 3 – Urticaria Care Pathway 13 - 38 

Appendix 4 – NICE referral Advice for Atopic Eczema in Children, December 

2001 13 - 39 

– NICE referral Advice for Psoriasis, December 2001 

Appendix 5 – Care Pathway for Atopic Eczema 13 - 41 

Appendix 6 – Detailed Instructions on the Use of Topical Tacrolimus 13 - 42 

and Pimecrolimus 

Appendix 7 – Psoriasis Care Pathway 13 - 44 

Appendix 8 – Acne Care Pathway 13 - 45 

Appendix 9 – Sun Damaged Skin Pathway 13 - 46 

Appendix 10 –NPSA Alert No 4: Fire Hazard with Paraffin Based Skin Products 

on Dressings and Clothing 13 - 47 



13.1 Management of skin conditions 

Correct diagnosis of skin conditions is essential to effective treatment. The local 

dermatologists have recommended the following websites which give useful information for 

GPs and their patients to assist diagnosis and treatment. 

♦ British Association of Dermatologists: www.bad.org.uk 

♦ New Zealand Dermatological Society: www.dermnetnz.org 

♦ Clinical Knowledge Summaries (PRODIGY guidance): www.cks.library.nhs.uk 

♦ National Library for Health: www.library.nhs.uk 

The Dermatology department has also produced a number of care pathways as 

appendices to the chapter on the topics listed below. 

♦ The Dermatology Referral Process Appendix 1 

♦ Urticaria Appendix 3 

♦ Atopic Eczema Appendix 5 

♦ Psoriasis Appendix 7 

♦ Acne Appendix 8 

♦ Sun Damaged Skin Lesions Appendix 9 

IMPORTANT NOTE: 

♦ It is extremely important to consider patient acceptability of a skin product to maximise 

compliance. A wide range of products is available and patient acceptance of individual 

preparations is variable. 

♦ The aim of this formulary is to provide guidance on initial choice and sequence of 

treatments and to include sufficient agents to cover the vast majority of patient needs. 

♦ We recognise that in specific circumstances, dermatologists may need to use a nonformulary 

product. In such cases, the GP will be given sufficient information to 

continue prescribing where appropriate. 

13.1.2 Suitable quantities for prescribing 

The table below shows suitable quantities of dermatological preparations to be prescribed 

for specific areas of the body based on twice daily application for 1 week. 

This does not apply to corticosteroid preparations - See section 13.4 for suitable 

quantities for corticosteroid preparations. 

Ointments and Creams Lotions 

Face 15 – 30g 100ml 

Both hands 25 – 50g 200ml 

Scalp 50 – 100g 200ml 

Both arms or both legs 100 – 200g 200ml 

Trunk 400g 500ml 

Groins and genitalia 15-25g 100ml 



13.1.3 Excipients and sensitisation 

CSM Advice: In 2003 the CSM advised that medicinal products containing arachis oil 

should not be used in patients known to be peanut allergic because of a slight risk of the 

presence of some peanut protein in pharmaceutical grade arachis oil. They also advised 

that patients allergic to soya should also avoid products containing arachis oil because of a 

risk of cross-sensitivity. 

A table of excipients in topical preparations that may rarely be associated with sensitisation 

is provided in Appendix 2. Throughout this formulary, the presence of these possible 

sensitisers in products is indicated to aid product selection. 

If a patient is not responding to treatment and getting worse, consider the effect of 

sensitisers in topical preparations and refer for patch testing. 

Extemporaneous (‘specials’) preparation 

• A product should only be extemporaneously prepared when there is no product with a 

marketing authorisation available. 

• A pharmacy or specials manufacturer may do this, depending on the formulation. 

Where a specials manufacturer prepares the product, additional charges will be 

incurred. 

• Typically a special will cost in excess of £100 regardless of quantity and will have a 

shelf life of less than 28 days. 

Only prescribe commercially available products, unless otherwise advised by a 

dermatologist. 

13.2 Emollient and barrier preparations 

13.2.1 Emollients 

General information: 

• Emollients are essential in the management of dry skin conditions, but are underused 

in general practice. They reduce water loss from the epidermis resulting in softer, 

suppler skin. Used regularly, emollients may reduce flare-ups of eczema and the need 

for topical corticosteroids. 

• Greasy preparations (ointments) are preferable to creams in most circumstances 

because: 

♦ They contain fewer skin sensitisers. 

♦ They are more moisturising (i.e. water retaining). 

♦ They facilitate better penetration of active ingredients. 

• Patients should use the cheapest effective emollient that they are prepared to use 

regularly and is cosmetically acceptable. 

• Emollients should be smoothed on in the direction of hair growth. They should not be 

rubbed in. 

• Urea, salicylic acid and lactic acid are added to some products and may help hydrate 

thickened, keratinised skin. 



First Choice Emollients 

Note: All paraffin based and other greasy moisturisers are flammable. Patients supplied 

with an emollient, particularly those containing paraffin should be counselled that these 

products on dressings, clothing or skin are easily ignited on exposure to naked flame or 

cigarettes. Please see Appendix 10 – NPSA Alert 4. 

Greasy 

3 

Less 

greasy 

Preparation Comments 

50:50 Liquid and 

White Soft Paraffin 

Ointment 

2 Diprobase® Cream 

(contains cetostearyl alcohol, 

chlorocresol) 

1 

Aqueous Cream BP 

(contains cetostearyl alcohol) 

• Greasy but messy. 

• Good for dry skin eczema or 

acutely inflamed eczema or 

psoriasis. 

• Useful as a soap substitute and 

moisturiser. 

• Useful soap substitute. 

• Not moisturising enough for 

childhood or active eczema. 

• May irritate infant skins. 

Second Choice Emollients 


Greasy 

3 

2 

1 

Less 

greasy 

Emulsifying Ointment 


Hydrous Ointment BP 

(oily cream) 

(contains lanolin) 

• Good for hands and feet. 

• Good soap substitute. 

• Can be stiff and difficult to apply if 

cold; therefore warm in a jug of 

warm water. 

• Useful general moisturiser. 

Doublebase ® gel • Quickly dries on the skin so 

convenient for frequent use during 

the day. 



Alternatives 

Notes: 

Patients may experience stinging or irritation of the skin when using emollients. If further 

options are required, consider the following preparations: 

Greasy 

3 

2 

Less 

greasy 

1 


Epaderm ® Ointment 


E45 ® Cream 

(contains cetyl alcohol, cetostearyl 

alcohol, hydroxybenzoates 

(parabens), lanolin) 

Aveeno ® Lotion 

ACBS 

(contains benzyl alcohol, cetyl 

alcohol, isopropyl palmitate) 

Dermol ® 500 lotion 


• Good soap substitute. 

• Easier to apply when warm and 

soft. 

• Can feel ‘sticky’ to apply. 

• Soothing and cooling. 

• Based on oatmeal. 

• Also available OTC. 

• Contains antimicrobial agent- 

useful for weeping, mildly infected 

eczema. 

• Use alternative moisturiser when 

infection has cleared. 

Dermamist ® spray • Expensive. 

• A pressurised aerosol. 

• Occasionally useful for elderly 

patients or children with delicate 

skin. 

• Flammable. 

Neutrogena ® 

Dermatological 

Cream 

• Sometimes useful for hand 

eczema. 

• Encourage patients to buy over 

the counter. 



Emollient Preparations Containing Urea 

Urea, added to some products, may help hydrate thickened, keratinised skin. 


Aquadrate ® Cream 

Balneum ® Plus Cream 

(contains benzyl alcohol, polysorbates) 

13.2.1.1 Emollient bath additives 

Contains 10 % urea. 

• For dry scaling and itching skin. 

• May help hands and feet 

• Apply generously and smooth into area 

as required. 

Contains 5 % urea and soya oil. 

• Has antipruritic properties. 

• Useful in elderly patients as bath oils 

often unsuitable. 

• Apply generously twice a day. 

Notes: 

1. Soap substitutes, aqueous cream or emulsifying ointment are safer than bath oils as 

they are less likely to make the bath slippery compared with bath oils. 

2. Soap substitutes are necessary in inflammatory skin disease. 

3. A bath mat may help reduce the risk of slipping where bath oils are used. 


Hydromol Emollient ® Bath 

additive 

Oilatum ® Emollient bath 

additive 

(contains isopropyl palmitate, fragrance) 

Oilatum ® Shower 

emollient gel (contains fragrance) 

• Less expensive per ml than Oilatum ® . 

• Adults add 1-3 capfuls to the bath; 

infants: ½-2 capfuls 

• Adults add 1-3 capfuls to the bath; 

infants: ½-2 capfuls 

• Expensive but can be applied directly to 

skin as a moisturiser. 

• Gel formulation less likely to cause 

slipping compared with oils. 



Antimicrobial / emollient combination products 

Notes: 

1. Routine prophylactic use of antiseptic / emollient combinations is not recommended. 

2. A short course of a suitable oral antibiotic may be appropriate in patients with physical 

signs of infection and proven on skin swab. 

3. In recurrent staphylococcal infection please do a nasal swab. 

4. If not responding to the above preparations, the addition of an antimicrobial may be 

warranted. 


Oilatum ® Plus 

bath additive 

(contains wool fat, isopropyl palmitate) 

Dermol ® 500 lotion 


• Contains benzalkonium chloride 6%, 

triclosan 2% and liquid paraffin 52.5%. 

• May sting. 

• Add 1-2 capfuls to the bath (infant over 

6 months 1ml added to the bath) 

• Contains benzalkonium chloride and 

chlorhexidine. 

• Apply to skin or use as a soap 

substitute. 

13.2.2 Barrier preparations 


Zinc and castor oil 

ointment BP 

Zinc oxide 7.5%, castor oil 50% 

(contains beeswax, cetostearyl alcohol, 

peanut oil) 

Conotrane ® Cream 

(contains cetostearyl alcohol, fragrance) 

• For nappy and urinary rash 

• For nappy and urinary rash and 

pressure sores 

Metanium ® Ointment • For nappy rash and related disorders 

13.3 Topical local anaesthetics and antipruritics 

Notes on treatment of pruritus: 

1. An emollient may be of value in pruritus associated with dry skin. 

2. Antihistamines can prove valuable in treating generalised itching. (see Chapter 3) 

3. We cannot recommend the use of doxepin cream, which is sometimes used for pruritis 

ani. It is very expensive and current evidence shows that it is little more effective than 

vehicle cream alone. 

4. Calamine preparations are often ineffective and have little proven benefit. If necessary 

it is best to buy calamine in aqueous cream OTC. 

A DETAILED CARE PATHWAY FOR URTICARIA IS PROVIDED - SEE APPENDIX 3 




Eurax ® (Crotamiton) 

Cream 

(contains beeswax, fragrance, 

hydroxybenzoates (parabens), stearyl 

alcohol) 

Eurax ® (Crotamiton) 

Lotion 

(contains cetyl alcohol, fragrance, propylene 

glycol, sorbic acid, stearyl alcohol) 

• Contains antipruritic agent crotamiton. 

• More soothing than cream 

• Contains antipruritic agent crotamiton. 

• Dries skin, so not suitable for eczema. 

13.4 Topical corticosteroids 

Many patients are reluctant to use topical corticosteroids because of the fear of local and 

systemic effects. Patients should be reassured that side-effects are rarely seen when mild 

or moderately potent steroids are used in short or intermittent courses. 

Emollients can reduce the need to use topical steroids in atopic eczema and psoriasis. 

All patients with dry skin conditions should be using an effective emollient regimen. Soaps 

and detergents should be avoided by using substitutes such as aqueous cream. (See 

section 13.2.1.1) 

When topical steroids are prescribed for eczema, the following should be explained: 

The incurable and chronic nature of the disease 

That we aim to manage the disease 

The different potencies of each steroid preparation 

The area(s) of the body where each product should be used 

How much to apply 

How long to apply them for and when to restart 

How often to apply them in relation to other treatments 

As with all topical preparations, topical corticosteroids should be smoothed 

onto the skin in the direction of hair growth. Do not rub in. 



AGE 

ONE Adult 

finger tip unit 

(FTU) * 

Face & 

Neck 

Number of Finger Tip Units (FTUs) 

Arm & 

Hand 

Leg & 

Foot 

Trunk 

(front) 

Trunk 

(back incl. 

buttocks) 

Adult 2 ½ 4 8 7 7 

Children: 

3-6 months 1 1 1 ½ 1 1 ½ 

1-2 years 1 ½ 1 ½ 2 2 3 

3-5 years 1 ½ 2 3 3 3 ½ 

6-10 years 2 2 ½ 4 ½ 3 ½ 5 

* One adult finger tip unit (FTU) is the amount of ointment or cream expressed from a tube 

with a standard 5mm diameter nozzle, applied from the distal crease to the tip of the index 

finger. If preferred the patient can be counselled to use a ruler to measure the amount i.e. 

2cm (or 1inch) = 1 FTU. 

How much to prescribe? 

The table below shows suitable quantities of dermatological preparations to be prescribed 

for specific areas of the body based on twice daily application for 1 week. It is important 

to prescribe sufficient quantities to last 1-2 weeks. 

Ointments and creams 

Face and neck 15 – 30 g 

Both hands 15 - 30 g 

Scalp 15 - 30 g 

Both arms 30 - 60 g 

Both legs 100 g 

Trunk 100 g 

Groins and genitalia 15 - 30 g 

“To be spread thinly” is a cautionary warning which can be misleading and worry some 

patients. It is therefore vital to counsel patients on the correct application by 

fingertip units and ensure adequate coverage of affected areas. 



NICE TAG81: Frequency of application of topical corticosteroids for atopic eczema, 

August 2004 

It is recommended that 

• Topical corticosteroids for atopic eczema should be prescribed for application only once 

or twice daily. 

• Where more than one alternative topical corticosteroid is considered clinically 

appropriate within a potency class, the drug with the lowest acquisition cost should be 

prescribed, taking into account pack size and frequency of application.” 

Choice of Preparation 

• CAUTION MUST BE USED WHEN SELECTING CORTICOSTEROIDS FOR 

DIFFERENT PARTS OF THE BODY. 

♦ Use lower potency corticosteroids for the face and other sensitive areas. 

♦ Use the least potent steroid to control symptoms. 

• Ointments are preferable to creams in most circumstances because: 

♦ They contain fewer skin sensitisers. 

♦ They are more moisturising (i.e. water retaining). 

♦ They facilitate better penetration of steroid. 

• Creams can be useful for: 

♦ Application to the face. 

♦ Moist or weeping lesions. 

♦ Daytime use with an ointment at night. 

Topical Corticosteroid Use 

1. Flare-ups can be treated initially with a potent steroid and then stepped down to a lower 

potency or an emollient. 

2. Topical steroids should normally be used for short periods (3-7 days) to treat 

exacerbations. 

3. Topical steroids should not be used regularly for more than 4 weeks without review. 

4. Review patients requiring steroid maintenance therapy at least every 3 months. 

5. Long-term use of potent and very potent steroids should be supervised by a 

dermatologist / nurse specialist. 

6. Topical steroids should not be used routinely on infected skin, unless the infection is 

being treated. A short course of a suitable oral antibiotic may be indicated. 

7. Remind patients to dispose of unwanted or out of date medicines as reuse of a 

microbially contaminated steroid product could be harmful. 



Topical Corticosteroid preparations 


Mild Potency 

Moderate Potency 

Potent 

Very Potent 

Hydrocortisone: 

Efcortelan ® 

(excipients may differ depending on 

brand see BNF) 

Ointment: 0.5%, 1%, 2.5% 

Cream: 0.5%, 1%,2.5% 

Betamethasone 

valerate: 

Betnovate RD ® 0.025% 

ointment or cream (cream contains: 

cetostearyl alcohol, chlorocresol) 

Clobetasone butyrate: 

Eumovate ® 0.05% ointment or 

cream (cream contains: beeswax 

substitute, cetostearyl alcohol, 

chlorocresol 

Betamethasone 

valerate Betnovate ® 

Ointment or cream: 0.1% (excipients 

for cream vary depending on brand, 

see BNF) 

Mometasone furoate 

Elocon ® 0.1% ointment or cream 

(cream contains: stearyl alcohol) 

Clobetasol propionate 

Dermovate ® 0.05% ointment 

or cream (cream contains: beeswax 

(or beeswax substitute), cetostearyl 

alcohol, chlorocresol, propylene 

glycol) 

• Please prescribe as Efcortelan ® it 

is much cheaper. 

• 1% ointment and cream is sold OTC 

for treatment (max 1 week) of 

allergic contact dermatitis, irritant 

dermatitis, insect bite reactions and 

mild to moderate eczema. It can’t be 

sold for use on eyes/face, anogenital 

region, broken or infected skin. 

• Cream is sold OTC for short-term 

treatment and control of patches of 

eczema and dermatitis (not 

seborrhoeic dermatitis) for adults 

and children over 12 years. 

• Of similar potency to Betnovate 

RD ® 

• Some patients are intolerant to the 

ointment as it sometimes stings. 

• Do not use unless 

a potent steroid is 

not sufficient 



Corticosteroid Preparations for the Scalp 


Potent 

Very Potent 

Betamethasone 

valerate 

Betnovate ® Scalp 

Application: 0.1% (watermiscible 

base) 

Betacap ® Scalp 

Application: 0.1% (watermiscible 

base contains coconut oil) 

Fluocinolone 

acetonide 

Synalar ® 0.025% gel 

Use on scalp (gel contains parabens 

and propylene glycol) 

Dermovate ® Scalp 

Application: 0.05%, in a 

thickened alcoholic basis 

• Contains no alcohol – less likely 

to irritate scalp. 

• Some patients find this more 

acceptable than Betnovate ® 

application which may sting. 

• Penetrates better to the scalp 

than Betnovate ® . 

• Gel for scalp can be easier to 

control and is less likely to dribble 

onto face. 

• Has an alcoholic base. It is very 

useful for some patients with 

psoriasis. 


13-13

Antimicrobial / steroid combination products 

• Topical steroid preparations that include an antibacterial or antifungal may 

occasionally have a place where there is associated bacterial or fungal infection. 

• Antibacterials that are used for other purposes should not be used for “possibly” 

infected skin – i.e. SODIUM FUSIDATE AS FUCIDIN, FUCIDIN HC OR FUCIBET. 

• The use of Betnovate-C ® or Daktacort ® is preferable. 

Mild Potency 

Moderate 

Potency 

Potent 


Vioform- 

Hydrocortisone ® 

Hydrocortisone 1%, clioquinol 3%; 

ointment or cream 

Daktacort ® 

Hydrocortisone 1%, miconazole 

nitrate 2% Ointment / Cream 

(contains: butylated hydroxyanisole, 

disodium edetate) 

Trimovate ® 

Clobetasone butyrate 0.05%, 

oxytetracycline 3%, nystatin 

100,000 units/g; cream (contains: 

cetostearyl alcohol, chlorocresol, 

sodium metabisulphite) 

Betnovate-C ® 

Betamethasone 0.1%, clioquinol 

3%; ointment or cream (cream 

contains: cetostearyl alcohol, 

chlorocresol) 

Note: Stains clothing 

• Useful for seborrheic dermatitis. 

• Has both antifungal and 

antibacterial properties 

• 15g cream can be sold over the 

counter for short-term treatment 

of athlete’s foot and candidal 

intertrigo. 

Note: Stains clothing 

Note: stains clothing 



13.5 Preparations for eczema and psoriasis 

13.5.1 Preparations for eczema 

NICE Referral Advice for Atopic Eczema in Children, 2001 is provided 

- See Appendix 4 

A DETAILED CARE PATHWAY FOR ECZEMA IS PROVIDED - APPENDIX 5 

Treatment of eczema 

The main treatments for eczema are broadly outlined below 

1. Emollients and soap substitutes (See Section 13.2.1 for more info): 

• Emollients should be the mainstay of eczema treatment. 

• Must be used frequently, at least twice daily, on all areas of the skin even where 

there is no visible sign of eczema. They should be used every 2 hours when the 

condition is florid. 

2. Topical steroids (See Section 13.4 for more info): 

• Useful for reducing inflammation and itching. 

• Choice of steroid prescribed should depend upon patient age, site affected, 

severity of the eczema and whether or not infection is present. 

3. Drugs affecting the immune system: Please see below for NICE guidance on 

tacrolimus/pimecrolimus. 

4. Antihistamine treatment: 

• Sedating antihistamines can be useful for itching at night, but are not advisable in 

the day time. 

5. Treatment of infection: 

• Infection of broken skin is common making the patient feel unwell and limiting 

movement. 

• Staph. aureus infection is the commonest cause of acute flare up of atopic eczema 

and should be treated accordingly, e.g. flucloxacillin. 

6. Other treatments: 

• Dry tubular bandages applied over topical treatments or wet/paste bandages 

applied to severe eczema can help soothe discomfort. These methods should be 

demonstrated to the patient/carer by a health professional trained to do this. 

• This will increase absorption of the topical steroids, therefore use only mild and 

moderate potency steroids for this purpose. 

• Ichthammol is a specialist (amber) drug and should only be used in ENT. 

Please refer to Chapter 12. 

• There is no evidence to support the use of gamolenic acid in eczema. 

Prescribers are recommended not to prescribe unlicensed gamolenic acid or 

evening primrose oil. 



Eczema Treatment: 

Drugs affecting the immune response (from BNF section 13.5.3) 


Azathioprine 

Tablets (25mg and 50mg tablets) 

Ciclosporin 

Capsules (25mg, 50mg and 100mg tablets) 

Can only be prescribed by 

GPs 

under Shared Care agreement- 

See Chapter 20. 

Used for severe refractory eczema 

(unlicensed indication) 


GPs 



Can be used for severe atopic eczema 

unresponsive to conventional treatments 

Alitretinoin ♦ Capsules 10mg, 30mg 

NICE Guidance (TAG 177) Alitretinoin for the treatment of severe chronic hand 

eczema (August 2009) 

Alitretinoin is recommended as a possible treatment for people with severe chronic hand 

eczema if: 

• their eczema has not improved with treatments called potent topical corticosteroids 

and: 

• standard assessments show their eczema is severe and is affecting their quality of life. 

See http://guidance.nice.org.uk/TA177 for full guidance. 

Topical Immunomodulators 

Tacrolimus 

Ointment 0.1% 

Ointment 0.03% 

Pimecrolimus 

Cream 1% 


Guideline For use only in accordance with 

NICE guideline below. For detailed usage 

instructions see Appendix 4 

Guideline For use only in accordance with 

NICE guideline below. 

Summarised NICE TA082 (August 2004) guidelines: Tacrolimus and Pimecrolimus 

for Atopic Eczema 

• Topical tacrolimus and pimecrolimus are not recommended for the treatment of mild 

atopic eczema or as first-line treatments for atopic eczema of any severity. 

• These preparations are only recommended by NICE under the circumstances detailed 

in the table below provided the skin is free from infection AND WHEN: 

(a) Eczema is resistant to adequate use of topical corticosteroids at maximum 

strength and potency appropriate for patient’s age and area being treated AND 

(b) There is a serious risk of important adverse effects from further topical 

corticosteroid use, particularly irreversible skin atrophy. 

The table below summarises the NICE recommendations for each product. 



Product Strength NICE 

Recommended 

age group 

Tacrolimus 

Ointment 

Tacrolimus 

Ointment 

Pimecrolimus 

Cream 

NICE 

Recommended 

0.1% Adults ≥ 16yrs Any area of the 

body including 

face, neck and 

flexures. 

0.03% Adults and 

Children ≥ 

2yrs 

1% * Children aged 2- 

16yrs ONLY 

Any area of the 

body including 

face, neck and 

flexures. 

Face and neck 

ONLY for 

patients 

intolerant to 

tacrolimus 

Severity of 

Eczema 

licensed for 

Moderate to 

severe 

Moderate to 

severe 

Moderate ONLY 

* Weak evidence for efficacy of pimecrolimus 1% compared with tacrolimus 0.1% in 

adults. 

Because the effect of long term use of immunomodulators is unclear NICE recommends 

that topical tacrolimus and pimecrolimus is ONLY initiated by physicians (including GPs) 

with a special interest and experience in dermatology, and only after careful discussion with 

the patient of the potential risks and benefits of all appropriate second-line treatment 

options. Advice is available from the dermatology department (01803 654837). 

DETAILED COUNSELLING POINTS AND USAGE INSTRUCTIONS FOR TOPICAL 

TACROLIMUS AND PIMECROLIMUS ARE PROVIDED IN APPENDIX 6 

13.5.2 Preparations for psoriasis 

NICE Referral Advice for Psoriasis, December 2001 is Provided – See Appendix 4 

DETAILED CARE PATHWAY FOR PSORIASIS IS PROVIDED - APPENDIX 7 

Treatment of Psoriasis 

Treatment is usually effective; the skin becomes less scaly and may even look completely 

normal. Topical treatment may include the following: 

1. Emollients – used as frequently as needed 

2. Vitamin D derivatives – more expensive than other topical treatments, but equally or 

slightly more effective than the alternatives (other than for guttate psoriasis when 

vitamin D derivatives are generally less effective). 

3. Tar preparations – can help, but many find them “messy” and can stain clothing 



4. Topical steroids – can be very useful for limited psoriasis, flexural psoriasis or 

extremely unstable erythrodermic psoriasis. The weaker steroids often do not work 

very well on thick patches, but may work better on the face or in the skin folds. 

5. Salicylic acid – can be used on heavily scaled plaques, but irritation may occur 

6. Dithranol – can cause severe skin irritation and should only be prescribed by those 

experienced in its use. It should only be used for short contact periods of 30-60 

minutes. 

7. Drugs affecting the immune system: Reserved for patients with severe psoriasis 

unresponsive to conventional therapies. 

8. For additional scalp preparations see section 13.9 

Topical Preparations for Treating Psoriasis: 

N.B. Avoid irritant preparations (tar, dithranol, vitamin D derivatives) in flexure psoriasis. A 

mild steroid, with or without an antiseptic, is more appropriate. 

Vitamin D and Analogues 


Calcipotriol 

Dovonex ® cream 50micrograms/g; 

120g (contains: cetostearyl alcohol, 

disodium edetate) 

Calcipotriol 

Oint 50micrograms/g; (contains: cetostearyl 

alcohol, disodium edetate) 

Dovonex ® Scalp solution 

50micrograms / ml; 60ml, 120ml (contains: 

propylene glycol) 

Calcitriol Silkis ® 

Ointment 3mcg/g 100g 

• Apply once or twice daily maximum 

100g/week, children12-16 yrs max 

75g/wk, children 6-12 years 50g/wk. 

• Dovonex ® oint discontinued- Generic 

ointment only available as 120g tube. 

• Apply twice weekly- less when cream 

also being used. 

• When preparations used together 

ensure total weekly dose calcipotriol 

is ≤ 5mg 

• Well tolerated. 

• Can be used on face and flexures 

where steroid use is not ideal. 

• Not recommended in children 

• Apply twice daily 

• Treat maximum 35% body surface area 

/day 

• Use max 30g/day 



Vitamin D Analogue/Steroid Combinations 


Dovobet ® Ointment: calcipotriol 50 

micrograms/g and betamethasone 500 

micrograms/g; 60g 

• For stable plaque psoriasis 

• Apply once daily to max 30% body 

surface area for max 4 weeks. 

• Alternate with plain calcipotriol. 

• Daily max = 15g, weekly max = 100g 

• Not recommended in children under 

18 yrs 

Coal Tar Preparations 


Exorex ® Lotion: contains: 

hydroxybenzoates (parabens), polysorbate 

80) 

• Prepared coal tar 1% 

• Apply to skin or scalp 2-3 times/day 

• Dilute with a few drops of water before 

applying to children or elderly patients. 

Coal Tar Preparations with Corticosteroids 


Alphosyl HC ® Cream Coal Tar 

Extract 5%, Hydrocortisone 0.5%, Allantoin 

2% 

• For psoriasis in patients over 5 years old 

• Apply once or twice daily 

• Can be particularly useful for children 

• Well tolerated 

Dithranol Preparations 


Dithranol 

Micanol ®: 1% or 3% Dithranol Cream 

Dithranol in Lassar’s 

Paste, BP: usual strengths 0.1-5% of 

dithranol 

• Apply 1% to skin / scalp for up to 30 

minutes. At end of contact time use 

plenty of lukewarm (NOT HOT) water to 

rinse off. DO NOT USE SOAP 

• If necessary increase to 3% under 

medical supervision. 

• Stains skin and clothing 

• Lassar’s Paste – zinc oxide 24%, 

salicylic acid 2%, starch 24%, white soft 

paraffin 50% 

• Stains skin and clothing 

• Start at low strength, gradually increase 



Psoralen 


puvasoralen 8 emulsion 

Emulsion 0.15% 50ml 

• Used in combination with exposure to 

long wave UVA radiation. 

• Enhances the effect of irradiation 

Oral Preparations for Treating Psoriasis: 

For severe resistant psoriasis, oral treatments may be used. These must be initiated and 

supervised by a consultant. 

Psoralen 


8-methoxypsoralen 

Tablets 10mg 

Retinoids 

Acitretin 

Capsules, 10mg, 25mg 

(Neotigason ® ) 

– hospital pharmacy only 

• Used in combination with exposure to 

long wave UVA radiation. 

• Enhances the effect of irradiation 

• Solution used for bath PUVA. 


• Teratogenic Risk: Female patients 

must avoid pregnancy for at least 1 

month before, during and for 2 years 

after treatment. 

• Avoid concomitant use of 

methotrexate or tetracyclines or high 

doses of vitamin A. 

• Avoid concomitant use of 

keratiolytics 

Psoriasis Treatment: Drugs affecting the immune response 

(from BNF section 13.5.3) 


Azathioprine 

Tablets (25mg and 50mg tablets) 

Ciclosporin 

Neoral ® 

Capsules (25mg,50mg and 100mg 

capsules) 


GPs 



Used for severe refractory psoriasis 

(unlicensed indication) 


GPs 

under Shared Care 

agreement- 


Always prescribe as Neoral ® as other 

brands are not bioequivalvent. 

Used for severe psoriasis unresponsive to 

conventional treatments. 



Hydroxycarbamide 

500mg Capsules 

Previously known as hydroxyurea 

Methotrexate 

2.5mg Tablets 

Ustekinumab 

90 mg/ml, 0.5-mL (45-mg) vial 

Cytokine inhibitors (from BNF section 10.1.3): 

Used for severe psoriasis uncontrolled by 

other treatments (unlicensed indication) 

(Refer to chapter 8 for more information on 

prescribing of hydroxycarbamide) 


GPs under Shared Care 

agreement- See Chapter 20. 

Used for severe psoriasis uncontrolled by 

other treatments. 

Treatment of moderate to severe plaque 

psoriasis in adults who failed to respond to, 

or who have a contraindication to, or are 

intolerant to other systemic therapies 

including ciclosporin, methotrexate and 

PUVA 

Included as per NICE guideline TAG 180 

See below. 


Etanercept s/c Injection 

Infliximab i.v. infusion 

Adalimumab s/c 

• First choice. 

• For systemically unwell patients where 

a rapid response is required only. 

• Subcutaneous Injection 40mg 

Inhibitors of T-Cell Activation: 


Efalizumab s/c injection 

• For patients unresponsive to 

etanercept. 

N.B. These drugs should only be prescribed for psoriasis by consultant dermatologists and 

administered by staff experienced in their use. 

Summarised NICE Guidance: Etanercept and efalizumab for the treatment of adults 

with psoriasis (TAG 103, July 2006) 

1.1 Etanercept, within its licensed indications, administered at a dose not exceeding 25 

mg twice weekly is recommended for the treatment of adults with plaque psoriasis only 

when the following criteria are met. 

The disease is severe as defined by a total Psoriasis Area Severity Index (PASI) 

of 10 or more and a Dermatology Life Quality Index (DLQI) of more than 10. 

The psoriasis has failed to respond to standard systemic therapies including 

ciclosporin, methotrexate and PUVA (psoralen and long-wave ultraviolet 

radiation); or the person is intolerant to, or has a contraindication to these 

treatments. 

1.2 Etanercept treatment should be discontinued in patients whose psoriasis has not 

responded adequately at 12 weeks. Further treatment cycles are not recommended in 

these patients. An adequate response is defined as either: 

a 75% reduction in the PASI score from when treatment started (PASI 75) or 

a 50% reduction in the PASI score (PASI 50) and a five-point reduction in DLQI 

from when treatment started. 



1.3 Efalizumab, within its licensed indications, is recommended for treatment of adults with 

plaque psoriasis under the circumstances detailed in section 1.1 only if their psoriasis 

has failed to respond to etanercept or they are shown to be intolerant of, or have 

contraindications to, treatment with etanercept. 

1.4 Further treatment with efalizumab is not recommended in patients unless their 

psoriasis has responded adequately at 12 weeks as defined in section 1.2. 

1.5 Use of etanercept and efalizumab for psoriasis should be initiated and supervised by a 

dermatologist experienced in the diagnosis and treatment of psoriasis. If a person has 

psoriasis and psoriatic arthritis their treatment should be managed by collaboration 

between a rheumatologist and a dermatologist. 

Summarised NICE Guidance: Infliximab for the treatment of adults with psoriasis 

(TAG 134, January 2008) 

1.1 Infliximab, within its licensed indications, is recommended as a treatment option for 

adults with plaque psoriasis only when the following criteria are met. 

♦ The disease is very severe as defined by a total Psoriasis Area Severity Index 

(PASI) of 20 or more and a Dermatology Life Quality Index (DLQI) of more than 

18. 

♦ The psoriasis has failed to respond to standard systemic therapies such as 

ciclosporin, methotrexate or PUVA (psoralen and long-wave ultraviolet radiation), 

or the person is intolerant to or has a contraindication to these treatments. 

1.2 Infliximab treatment should only be continued beyond 10 weeks in people whose 

psoriasis has shown an adequate response to treatment within 10 weeks. An 

adequate response is defined as either: 

♦ a 75% reduction in the PASI score from when treatment started (PASI 75) or 

♦ a 50% reduction in the PASI score (PASI 50) and a five-point reduction in the 

DLQI from when treatment started. 

1.3 When using the DLQI healthcare professionals should take care to ensure that 

they take account of a patient’s disabilities (such as physical impairments) or 

linguistic or other communication difficulties, in reaching conclusions on the 

severity of plaque psoriasis. In such cases healthcare professionals should 

ensure that their use of the DLQI continues to be a sufficiently accurate 

measure. The same approach should apply in the context of a decision about 

whether to continue the use of the drug. 

NICE TAG 146: Adalimumab for the treatment of psoriasis 

(July 2008) 

Adalimumab is recommended as a possible treatment for adults with plaque psoriasis only 

if: 

♦ their condition is severe and 

♦ their condition has not improved with other treatments such as ciclosporin, 

methotrexate and PUVA (psoralen and long-wave ultraviolet radiation), or they have 

had side effects with these in the past or there is a medical reason why they should 

not be given these treatments. 

NICE guidance (TAG 180) Ustekinumab for the treatment of adults with moderate to 

severe psoriasis (September 2009) 

Ustekinumab is recommended as a possible treatment for people with plaque psoriasis if: 

♦ standard assessments show that their psoriasis is severe and is affecting their quality 

of life and 

♦ their psoriasis has not improved with other treatments such as ciclosporin, 



methotrexate or PUVA (psoralen and long-wave ultraviolet radiation), or they have had 

side effects with these treatments in the past or there is a medical reason why they 

should not be given them. 

13.5.3 Drugs affecting the immune response 

The drugs relevant to this BNF section have been placed under the skin conditions for 

which they are used. 

13.6 Acne and rosacea 

NICE Referral Advice for Acne, December 2001 is provided – Appendix 4 

A DETAILED CARE PATHWAY FOR ACNE IS PROVIDED - SEE APPENDIX 8 

13.6.1 Topical preparations for acne 

Notes: 

1. Mild acne can generally be treated with topical agents alone. 

2. Moderate to severe acne requires the use of both systemic and topical agents. 

3. Benzoyl peroxide or topical retinoids are first choice agents for mild comedonal acne. 

4. Benzoyl peroxide is the agent of choice for mild inflammatory acne. 

Topical benzoyl peroxide and azelaic acid 


Benzoyl peroxide 

PanOxyl ® 

Aquagel: 2.5%, 5%, 10% (contains: 


Cream: 5% (contains: isopropyl palmitate, 


Gel: 5%, 10% (contains: fragrance) 

Wash: 10% (contains: imidurea) 

Azelaic acid 

Skinoren ® cream, 20% (contains: 

proplyene glycol 

Topical antibiotics for acne 

DO NOT use topical and systemic antibiotics at the same time. 

• Effective in mild to moderate acne. 

• Comedones and inflamed lesions 

respond well. 

• Start with a low strength increase 

gradually. 

• May bleach clothing and bed covers. 

• If no response after 2 months then 

consider a topical antibiotic. 

• A possible alternative to benzoyl 

peroxide where skin irritation is a 

problem. 

• If no response after 2 months then 

consider using a topical antibiotic. 


Zineryt ® 

Erythromycin 40mg/ml 

Topical solution, powder for reconstitution 

Clindamycin 1% 

Topical solution (alcoholic basis) 

(contains: propylene glycol) Lotion 

(aqueous basis) (contains: cetostearyl 

alcohol, hydroxybenzoates (parabens)) 

• Lasts 5 weeks once reconstituted. 

For most cases 30ml should be prescribed. 

Only prescribe 90ml if treatment area is 

very large. 

• Lotion is less drying. 



Topical retinoids and related preparations for acne 

• Redness and skin peeling may occur for several days, but usually settles with time. 

• Acne may worsen for the first few weeks. 

• Several months treatment may be needed- use until no new lesions appear. 

• Advise to avoid ultraviolet lamps and minimise exposure to sunlight. 

• Advise to allow peeling (e.g. from benzoyl peroxide) to subside before using a topical 

retinoid. 

• Avoid concomitant use of abrasive cleaners or astringent cosmetics. 

• Topical retinoids must not be used in pregnancy. 

• WOMEN OF CHILDBEARING AGE MUST USE ADEQUATE CONTRACEPTION 

WHILE USING A RETINOID. 

• DO NOT USE ON SEVERE ACNE COVERING LARGE AREAS. 

Tretinoin 

Retin-A ® 

Cream, 0.025% 

Gel, 0.01%, 0.025% 


Isotretinoin 

Isotrex ® 

Gel, 0.05% (contains: butylated 

hydroxytoluene) 

• Licensed for acne vulgaris. 

• Apply thinly once or twice a day. 

• Cream better for dry or fair skin. 

• Cream contains: butylated 

hydroxytoluene, sorbic acid, stearyl 

alcohol 

• Gel contains: butylated hydroxytoluene 

• Licensed for mild to moderate acne. 

• Can sometimes be better tolerated than 

Retin-A ® . 

• Apply thinly once or twice a day. 

Other topical preparations for acne 

Notes: 

1. The BNF states that these products are considered less suitable for prescribing. 

2. Salicylic acid is available for sale to the public for the treatment of mild acne. 

3. Preparations containing sulphur and abrasive agents are not considered beneficial for 

acne. 

13.6.2 Oral preparations for acne 

Oral antibiotics for acne 

Notes: 

1. An adequate dose of an oral antibiotic should be given for at least 3 months before 

deciding a patient has failed to respond. 

2. Treatment should not be used for longer than necessary (usually between 6 and 12 

months). 

3. If acne returns, reuse the same drug if the previous response was satisfactory with 

that agent. 

DO NOT use topical and systemic antibiotics at the same time. 



Oxytetracycline 

Tablets 

Lymecycline 

Capsules 

Erythromycin 

Tablets 

Trimethoprim 

Tablets 

Minocycline 

Tablets 


• 500mg twice a day 

• 408mg daily 

• 500mg twice a day 

• Reserved for situations where other 

antibiotics are unsuitable. 

• Proprionibacterial resistance to this 

drug is quite common. 

• 300mg BD 

• For consultant initiation. 

• Sometimes useful for resistant acne 

• 3 rd Line Treatment. 

• If given for > 6months monitor for 

hepatotoxicity, unusual skin pigmentation 

and SLE. Discontinue if these develop. 

Hormone Treatment for acne 


Co-cyprindiol 

tablets 

• Cheaper to prescribe generically 

rather than as Dianette ® . 

• Licensed for women with severe acne 

unresponsive to oral antibiotics, or 

moderately severe hirsutism. . 

• If prescribed as a contraceptive as well 

as for acne, mark the prescription “♀” 

otherwise a prescription charge must be 

paid by the patient 

It is vital that patients taking co-cyprindiol are regularly reviewed to ensure that it is still 

appropriate for the patient. 

CSM Advice 

1. Co-cyprindiol is not licensed solely for contraceptive purposes . 

2. Withdraw co-cyprindiol 3 to 4 cycles after the treated condition has resolved. 

3. VTE incidence in co-cyprindiol users is higher than that in women who use low-dose 

oestrogens combined oral contraceptives. 

4. Co-cyprindiol is contra-indicated in women with a personal or close family history of 

confirmed, idiopathic VTE and in those with known current venous thrombotic or 

embolic disorders. 

5. Women who have severe acne or hirsutism may have an inherently increased 

cardiovascular risk. 

N.B. Always counsel patients when prescribing co-cyprindiol, as with other oral 

contraceptives. Please refer to Chapter 7. 



Oral Retinoids for acne 


Isotretinoin 

Capsules 5mg, 20mg 

• Should only be prescribed by, or under 

the supervision of a consultant 

dermatologist. 

• Usually given for a minimum of 16 

weeks; repeat courses are not normally 

required. 

• Do not take vitamin preparations 

containing more than 4000-5000 i.u. of 

vitamin A. 

• Teratogenic Risk: Female patients must 

avoid pregnancy for at least 1 month 

before, during and for 2 months after 

treatment. 

• Side effects: severe dryness of skin and 

mucous membranes, nosebleeds and 

joint pains. 

13.7 Preparations for warts and calluses 


Salicylic acid Salactol ® 

Paint; 16.7% salicylic acid, 16.7% lactic acid 

Podophyllum 

Podophyllin Paint, 

Compound, BP 

Podophyllotoxin 

Warticon ® 0.15% Cream 5g 

Podophyllotoxin 

Warticon ® 0.5% Solution 3ml 

• For treatment of viral warts and verrucae 

on hands and feet. 

• Many products are available for 

purchase OTC. 

• For external genital warts 

• Applied weekly at genitourinary clinic (or 

at GP surgery by a trained nurse). 

• For self treatment of external genital 

warts in females. 

• Apply twice daily for 3 days followed by a 

4 day break. Repeat for maximum 4 

treatments. 

• For self treatment of external genital 

warts in females. 

• Apply twice daily for 3 days followed by a 

4 day break. Repeat for maximum 4 

treatments. 

Cryotherapy is not appropriate for viral warts on the hands and feet. There is evidence for 

a lack of efficacy in hand warts, it is painful, can cause significant scarring and may 

exacerbate the warts. Surgical treatment is also inappropriate for these lesions. 



13.8 Sunscreens and camouflagers 

13.8.1 Sunscreening preparations 

Can only be prescribed for the following indications (endorsed ACBS) for: 

• Skin protection against ultraviolet radiation in abnormal cutaneous photosensitivity 

resulting from genetic disorders; 

• Photodermatoses, including vitiligo and those resulting from radiotherapy; 

• Chronic or recurrent herpes simplex labialis. 


E45 Sun Block SPF30+ ® 

ACBS lotion 

Sunsense ® Sunblock 

ACBS 

• Tends to leave a white sheen on the 

skin. 

SPF 30+ (contains 

hydroxybenzoates (parabens), 

isopropyl palmitate) 

• Doesn’t leave a white sheen on the skin. 

Preparations to treat photodamage 

A DETAILED CARE PATHWAY FOR SUN DAMAGED SKIN LESIONS IS PROVIDED - 

APPENDIX 9 


Fluorouracil (Efudix ® ) 

5% Cream 

Solaraze ® Gel 

Diclofenac sodium 3% in sodium 

hyaluronate basis. (contains: benzyl alcohol) 

• See care pathway - Appendix 9 

• First choice for actinic keratosis because 

of stronger evidence base and likely to be 

cost effective. 

• Apply thinly to affected area once or twice 

daily. Cover with occlusive dressing in 

malignant conditions. 

• Max area of skin to be treated at one time 

is 500cm 2 

• Usual duration of initial therapy = 3-4 

weeks. 

• Produces a more marked inflammatory 

reaction than with diclofenac but lesions 

resolve more quickly. 

• See care pathway - Appendix 9 

• For actinic keratosis. 

• For use where fluorouracil is 

contraindicated, poorly tolerated or large 

areas need treatment. Can be particularly 

useful for superficial lesions but evidence 

not as robust as for fluorouracil. 

• Apply thinly twice daily for 60-90 days. 

Max 8g daily. 



Preparations to treat Basal Cell Carinoma and Bowens Disease 


Imiquimod 

Aldara ® 

5 % Cream 

• For superficial BCC when surgery or 

cryotherapy is contra-indicated. 

• Apply to the lesion and 1cm beyond it for 

5 days each week for a total of 6 weeks. 

Response should be assessed after a 

further 12 weeks. 

• Leave on BCC for 8 hours then wash off 

with mild soap and water. 

• Also used for Bowens Disease. 

13.9 Shampoos and preparations for scalp and hair conditions 


Polytar Plus ® 

Liquid (contains: fragrance, imidurea, 

polysorbate 80, peanut oil) 

Capasal ® 

Shampoo; coal tar 1%, coconut oil 1%, 

salicylic acid 0.5% 

Ceanel ® Concentrate 

Shampoo; cetrimide 10%, undecenoic acid 

1%, phenylethyl alcohol 7.5% 

Ketoconazole 

Shampoo; 2% (contains: imidurea) 

Cocois ® 

Scalp ointment; coal tar solution 12%, 

salicylic acid 2%, precipitated sulphur 4% in 

a coconut emollient basis (contains: 

cetostearyl alcohol) 

• For scalp disorders including psoriasis, 

seborrhoea, eczema, pruritis and 

dandruff. 

• Use once or twice weekly 

• For scaly scalp disorders including 

psoriasis, seborrheic dermatitis, dandruff 

and cradle cap. 

• Use daily as necessary. 

• For scalp psoriasis, seborrheic 

dermatitis and dandruff. 

• Apply three times in the first week then 

twice weekly. 

• Useful for seborrheic dermatitis. 

• Available for sale OTC to the public for 

seborrheic dermatitis of the scalp and 

dandruff 

• Used to treat pityriasis versicolor – if 

extensive or resistant may need oral 

antifungal (See Chapter 5) 

• Used for scalp psoriasis 

• Rub in, leave for 2 hours then comb out 

to remove loose scales, then shampoo 

out with Capasal® shampoo 



13.10 Anti-infective skin preparations 

13.10.1 Antibacterial preparations 

13.10.1.1 Antibacterial preparations only used topically 

SMAC Report: Topical antimicrobial agents and disinfectants (1998, The Path of 

Least resistance p64 – p65) 

The use of topical antimicrobial agents has long been discouraged, on the grounds that 

it carries a particular risk of selecting resistance. However, some topical antibacterial use is 

strongly defensible, for example: 

• the use of sulphonamides with silver nitrate (silver sulphadiazine) to prevent and 

treat infections in extensive burns 

• The use of mupirocin to eliminate colonisation and superficial infections caused by 

MRSA. Nevertheless, mupirocin can be abused, e.g. by being given as blanket 

treatment or prophylaxis. 

Preparation Comment 

Silver Sulphadiazine 

Flamazine ® 

Cream, 1% 20g, 50g, 250g, 500g 

Mupirocin 

Bactroban ® 

Ointment or cream, 2% 

and nasal cream 

Chlorhexidine 0.1% with 

Neomycin 0.5% 

Naseptin ® 

Nasal cream, 

(contains: arachis oil and cetostearyl 

alchohol) 

• Prescribe for single patient use only. 

• Use only for burns. 

• Prevents Gram negative sepsis in 

extensive burns patients 

• Caution with hepatic/ renal impairment. 

• Apply daily and cover area with dressing. 

• Discard tube (20g/50g) 7 days after 

opening. 

Discard jars (250g/500g) 24hrs after 

opening. 

• Useful in treating MRSA 

• Only use if organism is mupirocin 

sensitive and recommended by 

Infection Control or Microbiology to 

avoid resistance developing. 

• Ointment used for skin infections. 

• Cream is used for secondarily 

infected traumatic lesions. 

• Use for no longer than 10 days. 

Bactroban ® nasal ointment is of value when 

the carriage of Staphlococcus aureus in the 

nose or ears has to be cleared. See 

chapter 12.2.3. 

• Naseptin® is of value when the carriage 

of Staphlococcus aureus in the nose has 

to be cleared. See chapter 12.2.3. 

• SDHCFT infection control policy 

states that this should ONLY be used 

on advice from microbiology. 

• Use four times a day for 5 days then reswab 

3 days after completing treatment. 



13.10.1.2 Antibacterial preparations also used systemically 


Fusidic acid 

Ointment, 2% (contains: cetyl alcohol, 

wool fat) 

Cream, 2% (contains: butylated 

hydroxyanisole, cetyl alcohol) 

Metronidazole 

Rozex ® 

cream or gel, 0.75% (cream contains: 

benzyl alcohol, isopropyl palmitate gel 

contains: disodium edetate, 

hydroxybenzoates (parabens), propylene 

glycol) 

Metronidazole 

Metrotop ® gel 0.8% 

Only use for PROVEN staphylococcal 

skin infection. 

• Licensed for acne rosacea 

• Licensed for malodorous tumours and 

skin ulcers. 

13.10.2 Antifungal preparations 

Yeast infections 

Notes: 

1. Obtain a positive culture before prescribing a topical antifungal. Hair, nail 

clippings or scalp scrapings can be used to determine the presence of fungal infection. 

There is no urgency in diagnosing fungal infections. 

2. Oncomycosis should only be treated orally if there is a positive culture. If positive 

for microscopy but negative for culture, TAKE A FURTHER SPECIMEN. Please see 

Chapter 5. 


Clotrimazole Cream 1% 

Canesten ® spray, 1% in isopropyl 

alcohol (contains: propylene glycol 

Miconazole nitrate 

Daktarin ® 

Cream 2% (contains: butylated 

hydroxyanisole) 

• Spray included for treatment of pityriasis 

versicolor. 

• Spray also for chronic paronychia, which 

is associated with a secondary infection 

of Candida albicans. 

• Apply twice a day continuing for 10 

days after lesions have healed 



Dermatophyte infections 


Ketoconazole (Nizoral ® ) 

SLS 

Cream 2% (contains: cetyl alcohol, 

polysorbates, propylene glycol, stearyl 

alcohol) 

Terbinafine 

Cream 1% (contains: benzyl alcohol, cetyl 

alcohol, polysorbate 60, stearyl alcohol) 

• Can only prescribe for seborrhoeic 

dermatitis or pityriasis versicolor. FP10 

prescriptions - must be endorsed “SLS”. 

• For tinea corporis. Fungal infection of 

the scalp, hands and feet often require 

systemic treatment. 

13.10.3 Antiviral preparations 


Aciclovir 

Cream 5% 2g, 10 g 

(excipients may differ depending on generic 

or proprietary preparation) 

13.10.4 Parasiticidal preparations 

Suitable quantities of parasiticidal preparations 

• Licensed for initial and recurrent labial 

and genital herpes simplex infection. 

• Must begin using early during ‘tingling 

phase’ and a supply kept to hand for 

repeat breakouts. 

• Once a lesion appears, aciclovir is little 

more effective than a base cream. 

• Systemic treatment is needed for buccal 

or vaginal infections. See Chapter 5 

Skin creams Lotions Cream rinses 

Scalp (head lice) - 50-100ml 50-100ml 

Body (scabies) 30-60g 100ml - 

Body (crab lice) 30-60g 100ml - 

These amounts are usually suitable for an adult for single application. 

Scabies (Sarcoptes scabiei) 

• Once diagnosed, close household contacts (bed partners and children) also require 

treatment. It requires about 5 minutes skin to skin contact to acquire the infection. 

• Patients are contagious from a few days after acquiring the infection when no sign of the 

infection may be present. 

• Itching, particularly at night, is the main symptom of scabies. This is usually delayed for 

1-2 months after exposure except when the patient has been exposed before, in which 

case itching can start after 1 week. 

• Itching still occurs after treatment and this does not always imply treatment failure. 

Scabies Treatment: permethrin (Lyclear® Dermal Cream); malathion (Derbac M®) 

• Apply treatment before going to bed and leave on overnight. 

• Reapply to hands if they are washed and at least 4-6 times a day on the day of 

treatment. 



• In adults - apply treatment to cover the body from below the jaw line down and including 

the soles of feet and genitalia. 

• In elderly and young patients - apply from the head to toe. 

• Treat all household members at the same time. 

• Second application less than one week apart advised. 

N.B. Crusted or Norwegian scabies, affecting mainly immunosuppressed patients 

and nursing / residential home patients are more difficult to treat and require more 

applications of treatment. Seek advice from the Consultant in Communicable 

Diseases - mass treatment of staff and residents will be needed in a care home 

setting. 

Head lice (Pediculus capitis) 

• Lice eggs hatch within 7-10 days. The empty egg cases (nits) move further along the 

hair shaft as the hair grows out. 

• Lice take about 6-14 days to fully mature, then they are capable of reproduction. 

Head Lice Treatment: malathion (Quellada M ® ); permethrin (Lyclear ® Crème Rinse); 

phenothrin (Full Marks ® liquid) 

Treatment should only be considered when live lice are observed on the scalp. 

Treatment options: 

1) Wet combing every 3 days for 2 weeks 

2) Insecticide – 2 applications used 7 days apart to prevent lice re-emerging from any 

eggs that survive the first application. (Alternatively, wet combing can be used to check 

for immature lice before re-application at 3-5 and 10-12 days.) 

To overcome the development of resistance, if a course of treatment fails to cure, a 

different insecticide should be used for the next course. 

The value of head lice repellents and alternative remedies, which are on sale to the public, 

is uncertain and, therefore, NOT recommended. 

Crab lice (Pthirus pubis) 

Treatment: malathion (Quellada M ®) ; permethrin (Lyclear ® Dermal Cream) 

Crab lice (or pubic lice) can exist in eyelashes, beard hair, axillary hair and the hair on the 

trunk and limbs, as well as pubic hair. 

Preparation 

Malathion Quellada M ® liquid, 0.5% in an aqueous basis (contains: 

cetostearyl alcohol, fragrance, hydroxybenzoates (parabens) 

Derbac M ® liquid, 0.5% in an aqueous basis (contains: cetostearyl alcohol, 

fragrance, hydroxybenzoates (parabens) 

Permethrin 

Lyclear ® 

Crème Rinse, 1% in isopropyl alcohol base (contains: cetyl alcohol) 

Dermal Cream, 5% (contains: butylated hydroxytoluene, wool fat derivative) 

Phenothrin 

Full Marks ® liquid, 0.5% in aqueous basis (contains: cetostearyl alcohol, fragrance, 

hydroxybenzoates (parabens) 



Notes: 

1. Benzyl benzoate is not considered suitable for prescribing. It is an irritant and is less 

effective than malathion and permethrin in treating scabies. 

2. Experimental data in animals suggests that carbaryl could be a potential human 

carcinogen and is not included. 

3. Alcoholic lotions are not recommended for head lice in severe eczema, asthma or in 

small children, or for scabies or crab lice 

13.10.5 Preparations for minor cuts and abrasions 


Flexible collodion 

• May be used to seal partially healed 

minor cuts and wounds. 

• Can cause a lot of irritation. 

Surgical tissue adhesive 

Note: The range of surgical tissue adhesives required to cover the increasing spectrum of 

uses is considered beyond the scope of this formulary. 

13.11 Skin cleansers and antiseptics 

See chapter 5 (appendix 3) for details of MRSA screening, decolonisation and 

treatment protocols. 

13.11.1 Alcohols and saline 


Industrial methylated spirit 

Surgical spirit 

Sodium chloride 0.9% 

Normasol ® 

Irriclens ® 

• Drinking water can be used to irrigate the 

majority of wounds such as a chronic leg 

ulcer where a sterile product is not 

indicated. 

13.11.2 Chlorhexidine salts 


Hydrex ® 

Surgical Scrub, chlorhexidine gluconate 4% 

in an alcoholic solution 

• Used for pre-op hand and skin 

preparation and for general hand 

disinfection. 

• Chlorhexidine use not recommended in 

the community. 

CX powder ® • For use as a dusting powder to, 

perineum, groin and axillae as per MRSA 

decolonisation policy. 



13.11.4 Iodine 


Videne ® 

Antiseptic solution (Videne ® has replaced 

Betadine ® aqueous solution which has been 

discontinued) 

• Chlorinated solutions are considered less 

suitable for prescribing 

• Avoid regular use on patients with thyroid 

disease or those receiving lithium 

therapy. 

• It may also interfere with thyroid function 

tests. 

13.11.5 Phenolics 


Triclosan 

Aquasept ® (contains: chlorocresol, 

edetic acid (EDTA), propylene glycol, 

fragrance) 

• At the time of writing this formulary 

Aquasept® was not available in the 

community and so cannot be prescribed 

on a FP10 prescription. Please refer any 

requests to the Hospital pharmacy 

Department. 

13.11.6 Astringents, oxidisers and dyes 


Potassium permanganate 

Permitabs ® 

• Use a dilution of 1:10,000. 

• Soaks useful for pompholyx eczema and 

weeping leg ulcers. 

13.11.7 Preparations for promotion of wound healing 

Appropriate wound management requires the underlying cause to be treated rather than to 

use preparations to promote wound healing. Therefore, none of these agents have been 

included. See Chapter 17 – Wound management. 

13.12 Antiperspirants 


Aluminium salts 

Anhydrol Forte ® 

Driclor ® 

ZeaSORB ® dusting powder (contains: 

fragrance) 

Botulinum Clostridium 

Type A 

Botox ® 

• Aluminium chloride is a potent 

antiperspirant for severe hyperhidrosis. 

• Irritation reduced if applied to completely 

dry skin. i.e. apply with a hairdryer 

directed at the axillae or palms. 

• Included for severe hyperhidrosis of the 

axillae which does not respond to topical 

treatment with antiperspirants or 

antihidrotics. 

Note: Propantheline bromide is included in chapter 1.2 for use in accordance only with the 

local Map of Medicine pathway on dermatological treatments for local hyperhidrosis. 



13.13 Wound management products and elastic hosiery 

Please refer to Chapter 17 Wound Management 

13.14 Others 

Pure Lanolin 

(Lansinoh ® ) 

10g, 56g ointment 


• used by midwives to treat sore and 

cracked nipples. 

Lansinoh® may be obtained from several of the pharmacy wholesalers or direct from: 

Lansinoh Laboratories, 

First Floor, 

Alexandra House, 

Well Lane, 

Chapel Allerton, 

Leeds 

LS7 4PQ 



Appendix 1: The Dermatology Referral Process 



Appendix 2 

Excipients that may cause sensitisation 

The following excipients in topical preparations may rarely be associated with sensitisation. 

Throughout this formulary, the presence of these excipients in products is indicated to aid 

product selection. 

Beeswax Benzyl alcohol Butylated hydroxyanisole 

Butylated hydroxytoluene Cetostearyl alcohol 

(including cetyl and stearyl 

alcohol) 

Edetic acid (EDTA) 

Hydroxybenzoates 

(parabens) 

N-(3-Chloroallyl) 

hexaminium chloride 

(quaternium 15) 

Chlorocresol 

Ethylenediamine Fragrances 

Imidurea Isopropyl palmitate 

Polysorbates Propylene glycol 

Sodium metabisulphite Sorbic acid Wool fat and related 

substances incl. lanolin 1 

1. 

Purified versions of wool fat have reduced the problem 

It is difficult to ‘rank’ these agents in order of their potential to cause sensitisation 



Appendix 3: Urticaria Care Pathway 



Appendix 4 

NICE Referral Advice for Atopic Eczema in Children, December 2001 

Most children with atopic eczema can be managed in primary care. Referral to a specialist 

service, which may be prompted by features such as sleep disturbance and school 

absenteeism, is advised if: 

**** infection with disseminated herpes simplex (eczema herpeticum) is suspected 

*** the disease is severe and has not responded to appropriate therapy in primary 

care 

*** the rash becomes infected with bacteria (manifest as weeping, crusting, or 

development of pustules), and treatment with an oral antibiotic plus a topical 

corticosteroid has failed 

** the rash is giving rise to severe social or psychological problems 

** treatment requires the use of excessive amounts of potent topical corticosteroids 

* management in primary care has not controlled the rash satisfactorily. Utimately, 

failure to improve is probably best based upon subjective assessment by the 

child or parent 

* the patient or family might benefit from additional advice on application of 

treatments (e.g. bandaging techniques) 

* contact dermatitis is suspected and confirmation requires patch testing (this is 

rarely needed) 

* the child has uncontrolled eczema and dietary factors are suspected (refer 

directly to dietician) 

Key to referral timings: Arrangements should be made so that the patient: 

**** is seen immediately 1 

*** is seen urgently 2 

** is seen soon 2 

* has a routine appointment 2 

∆ is seen within an appropriate time depending on his or her clinical circumstances 

(discretionary) 

1. Within a day. 

2. Health authorities, trusts and primary care organisations should work to local 

definitions of maximum waiting times in each of these categories. The multidisciplinary 

advisory groups considered a maximum waiting time of 2 weeks to be appropriate for 

the urgent category. 

The adoption of this system should take place in the context of local strategies for 

achieving outpatient waiting times and inpatient waiting list targets. 



Appendix 4 (continued) 

NICE Referral Advice for Psoriasis, December 2001 

Most patients with psoriasis can be managed in primary care. Referral to specialist 

services, which may be prompted by features such as sleep disturbance, social exclusion, 

reduced quality of life or reduced self-esteem, is advised if: 

**** the patient has generalised pustular or erythrodermic psoriasis 

*** the patient’s psoriasis is acutely unstable 

*** the patient has widespread guttate psoriasis (so that he/she can benefit from 

early phototherapy) 

** the condition is causing severe social or psychological problems 

** the rash is sufficiently extensive to make self-management impractical 

** the rash is in a sensitive area (such as face, hands, feet, genitalia) and the 

symptoms particularly troublesome 

** the rash is leading to time off work or school which is interfering with employment 

or education 

** the patient requires assessment for the management of associated arthropathy 

* the rash fails to respond to management in general practice. Failure is probably 

best based on the subjective assessment of the patient. Sometimes failure 

occurs when patients are unable to apply the treatment themselves 

Refer to Atopic Eczema table for key to referral timing 

NICE Referral Advice for Acne, December 2001 

Most patients with acne can be managed in primary care. However, referral to a specilaist 

service is advised if they: 

*** have a very severe variant such as fulminating acne with systemic symptoms 

(acne fulminans) 

** have severe acne or painful, deep nodules or cysts (nodulocystic acne) and could 

benefit from oral isotretinoin 

** have severe social or psychological problems, including a morbid fear of 

deformity (dysmorphophobia) 

* are at risk of, or are developing, scarring despite primary care therapies 

* have moderate acne that has failed to respond to treatment which should 

generally include several courses of both topical and systemic treatment over a 

period of at least 6 months. Failure is probably best based upon a subjective 

assessment by the patient 

* are suspected of having an underlying endocrinological cause for the acne (such 

as polycystic ovary syndrome) that needs assessment 

Refer to Atopic Eczema table for key to referral timing 



Appendix 5: Care pathway for Atopic Eczema 



Appendix 6 

Detailed Instructions on The Use of Topical Tacrolimus and 

Pimecrolimus. 

Before commencing treatment the following MUST be discussed with every patient: 

1. There have been rare reports of lymphoma, skin cancers and other malignancies 

in a small number of patients using topical tacrolimus and pimecrolimus. 

• A link can’t be confirmed or refuted based on evidence so far. 

• The EMEA concluded that the benefits still outweigh the risks. 

• Skin exposure to sunlight should be minimised and the use of ultraviolet (UV) light 

from a solarium. Appropriate sun protection methods should be used. 

• UVB or UVA therapy combined with psoralens (PUVA) should be avoided during 

treatment with tacrolimus ointment. 

2. The effect of treatment on the developing immune system of children, especially 

the young, has not been established. 

3. Treatment may be associated with increased risk of herpes simplex virus 

infection (including herpes, cold sores and eczema herpeticum [Kaposi’s varicelliform 

eruption) 

4. Stinging and burning may occur when applied 

5. There is a risk of vaccination failure while using these products: 

• Vaccination should be administered prior to commencement of treatment or 

during a treatment-free interval. 

• Allow 14 days between the last application of the product and the vaccination. 

• Allow 28 days for live, attenuated vaccine. 

6. These products MUST NOT be used in the following circumstances: 

• In the presence of infection. 

• In immunocompromised patients. 

• On cancerous or pre-cancerous lesions. 

7. Tacrolimus or pimecrolimus should be stopped in the event of poor toleration, 

lack of efficacy or the development of infection. 

Experience of dermatologists: 

♦ Tacrolimus has been found to be generally well tolerated. 

♦ In practice tacrolimus ointment has been found to be useful in severe eczema 

particularly for those where ciclosporin is being considered. 

♦ Facial eczema (including eyelid eczema) and flexural eczema previously unresponsive 

to topical corticosteroids appears to respond very well to tacrolimus ointment. 


Detailed Instructions on The Use of Topical Tacrolimus and 

Pimecrolimus 



Tacrolimus Ointment Usage instructions 

• Avoid using on thickened, lichenified eczema where penetration seems to be poor. 

• It may be used on any part of the body, including face, neck and flexure areas, except 

on mucous membranes. 

• Affected regions should be treated until clearance occurs and then treatment should 

be discontinued. 

• Generally improvement is seen within one week of starting tacrolimus. If no 

improvement is seen after two weeks treatment the diagnosis should be re-evaluated 

and alternative options considered. 

• Tacrolimus ointment can be used for short term and intermittent long term treatment. 

• Do not apply tacrolimus at the same time as other topical preparations (e.g. 

emollients, sun screens) which should be applied 2 hours or more afterwards. 

• If a patient has lymphadenopathy (enlarged lymph nodes or ‘glands’) at the start of 

treatment, the doctor should investigate it and keep it under review. 

Dosage instructions 

Adults (16 years of age and above) 

• Start with tacrolimus ointment 0.1% - apply a thin layer twice daily for up to 3 weeks. 

• Then reduce to tacrolimus ointment 0.03% twice daily. 

• Attempt to reduce the frequency of application if the condition allows. 

• Treatment should be continued until clearance of the lesion. 

Children (2 years of age and above) 

• Start with tacrolimus ointment 0.03% twice daily for up to 3 weeks. 

• Reduce frequency of application to once a day until clearance of lesion. 

Pimecrolimus Cream Usage instructions 

• Pimecrolimus should only be used in patients who cannot tolerate the side effects 

from tacrolimus. 

• Do not apply under occlusion. 

• It may only be used on the face and neck. 

• If no improvement is seen after 6 weeks, or in case of disease exacerbation, 

treatment should be stopped and further options considered. 

• It may be used for intermittent long term treatment. 

• Emollients may be applied immediately after using pimecrolimus. 



Appendix 7: Psoriasis Care Pathway 



Appendix 8: Acne Care Pathway 



Appendix 9: Sun Damaged Skin Pathway 



Appendix 10: Fire Hazard with Paraffin Based Skin Products on 

Dressings and Clothing 

NPSA Alert 4: Fire Hazard with Paraffin Based Skin Products on Dressings and 

Clothing 

On 26/11/2007 the National Patient Safety Agency (NPSA) alerted all healthcare staff 

involved in the prescribing, dispensing or administration of paraffin based skin products of 

a potential fire hazard. Bandages, dressings and clothing in contact with paraffin based 

products, for example White Soft Paraffin, White Soft Paraffin plus 50% Liquid Paraffin or 

Emulsifying ointment are easily ignited with a naked flame or cigarette. 

Further information and supporting materials (poster, patient information leaflet and videos 

of fire hazard testing) concerning are available at: www.npsa.nhs.uk/health/alerts 

The NPSA has directed the NHS to undertake the following actions for all patients in all 

settings being dispensed, or treated with, large quantities (100g or more) of paraffin based 

products: 

• Information should be given about the potential fire risks of smoking (or being near to 

people who are smoking), or exposure to any open flame or other potential cause of 

ignition during treatment; and about regularly changing clothing or bedding impregnated 

with paraffin based products (preferably on a daily basis) as the paraffin soaks into the 

fabrics and can potentially be a fire hazard. 

• This information should be given on the first occasion that such treatment is prescribed, 

dispensed or administered by a healthcare professional and a record kept confirming 

that such advice has been given. A check should be made on subsequent occasions 

that the advice has been received previously and understood. 

• Fire safety information should be displayed prominently in every clinical area where 

patients may be treated with large quantities of paraffin based products. If, against 

advice, a hospitalised patient intends to leave the ward to smoke, they should be 

informed of the risk and advised to wear a thick outer covering that has not been 

contaminated with paraffin based products. 

• Relatives or carers should be informed if a patient does not comply with safety advice. 




NPSA Alert 4: Fire Hazard with Paraffin Based Skin Products on Dressings and 

Clothing: Examples of products containing paraffin 

Examples of products containing paraffin 

Following a patient safety incident, the NPSA commissioned the Health and Safety 

Executive to undertake fire hazard testing with White Soft Paraffin at concentrations of 

over 50% on a variety of bandages, dressings and clothing. The results showed the ability 

to reproduce the fire hazard in a controlled environment. The following commonly 

prescribed products contain White Soft Paraffin (WSP) at concentrations of over 50%: 

Product Concentration of 

Product Concentration of WSP 

Diprobase Ointment 

95 % 

Emulsifying Ointment 

Liquid Paraffin 50%/White Soft Paraffin 

50% 

White Soft Paraffin 

Zinc And Salicylic Acid Paste BP 

Zinc Ointment BP 

50 % 

50% 

100 % 

50 % 

72.25 % 

Paraffin products can also be found as constituents in some commonly prescribed 

‘specials’ creams and ointment, for example emulsifying ointment is often used as a 

diluent to lower the strength of a ready prepared ointment. 

The evidence currently only relates to White Soft Paraffin and there is currently no 

evidence of a risk of fire hazard with preparations containing concentrations of WSP 

lower than 50%, however the NPSA has taken the view that this risk could apply to any 

paraffin ‘based’ product. In this respect the guidance should also apply to the following 

products. Dithranol Ointment (YSP), Epaderm (Emulsifying Wax, LP & YSP) and 

Hydromol Ointment (Emulsifying Wax, LP & YSP). 

LP = Liquid Paraffin; YSP = Yellow Soft Paraffin 

NB: These lists are not exhaustive and practitioners should make a professional 

judgement and risk assess whether the guidance should apply to other products.

CHAPTER 13 SKIN - NHS Devon

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