BNF for Children 2011-2012

BNFC 2011–2012 13.10 Anti-infective skin preparations 585T/Gel c (J&J)Shampoo, coal tar extract 2%, net price 125 mL =£3.18, 250 mL = £4.78Excipients include fragrance, hydroxybenzoates (parabens), imidurea,tetrasodium edetateDoseScalp psoriasis, seborrhoeic dermatitis, dandruffApply 2–3 times weeklyOther scalp preparationsCocois cSection 13.5.2Polytar c (Stiefel)Liquid, arachis (peanut) oil extract of coal tar 0.3%,cade oil 0.3%, coal tar solution 0.1%, oleyl alcohol 1%,tar 0.3%, net price 250 mL = £2.23Excipients include fragrance, imidurea, polysorbate 80DoseScalp disorders including psoriasis, seborrhoea,eczema, pruritus, and dandruffApply 1–2 times weeklyPolytar Plus c (Stiefel)Liquid, ingredients as Polytar c liquid with hydrolysedanimal protein 3%, net price 500 mL = £3.91Excipients include fragrance, imidurea, polysorbate 80DoseScalp disorders including psoriasis, seborrhoea,eczema, pruritus, and dandruffApply 1–2 times weekly13.10 Anti-infective skinpreparations13.10.1 Antibacterial preparations13.10.2 Antifungal preparations13.10.3 Antiviral preparations13.10.4 Parasiticidal preparations13.10.5 Preparations for minor cuts andabrasions13.10.1 AntibacterialpreparationsTopical antibacterial preparations are used to treatlocalised bacterial skin infections caused by Gram-positiveorganisms (particularly by staphylococci or streptococci).Systemic antibacterial treatment (Table 1, section5.1) is more appropriate for deep-seated skininfections.Problems associated with the use of topical antibacterialsinclude bacterial resistance, contact sensitisation,and superinfection. In order to minimise the developmentof resistance, antibacterials used systemically (e.g.fusidic acid) should not generally be chosen for topicaluse. Resistant organisms are more common in hospitals,and whenever possible swabs should be taken for bacteriologicalexamination before beginning treatment.Neomycin applied topically may cause sensitisationand cross-sensitivity with other aminoglycoside antibacterialssuch as gentamicin may occur. Topical antibacterialsapplied over large areas can cause systemictoxicity; ototoxicity with neomycin and with polymyxinsis a particular risk for neonates and children withrenal impairment.Superficial bacterial infection of the skin may be treatedwith a topical antiseptic such as povidine–iodine (section13.11.4) which also softens crusts, or hydrogenperoxide 1% cream (section 13.11.6).Bacterial infections such as impetigo and folliculitis canbe treated with a short course of topical fusidic acid;mupirocin should be used only to treat meticillin-resistantStaphylococcus aureus.For extensive or long-standing impetigo, an oral antibacterialsuch as flucloxacillin (or clarithromycin inchildren with penicillin-allergy), Table 1, section 5.1,should be used. A mild antiseptic may help to softencrusts. Mild antiseptics may be useful in reducing thespread of infection, but there is little evidence to supportthe use of topical antiseptics alone in the treatment ofimpetigo.Cellulitis, a rapidly spreading deeply seated inflammationof the skin and subcutaneous tissue, requires systemicantibacterial treatment (see Table 1, section 5.1).Lower leg infections or infections spreading aroundwounds are almost always cellulitis. Erysipelas, a superficialinfection with clearly defined edges (and oftenaffecting the face), is also treated with a systemic antibacterial(see Table 1, section 5.1).Staphylococcal scalded-skin syndrome requires urgenttreatment with a systemic antibacterial, such as flucloxacillin(see Table 1, section 5.1).Mupirocin is not related to any other antibacterial inuse; it is effective for skin infections, particularly thosedue to Gram-positive organisms but it is not indicatedfor pseudomonal infection. Although Staphylococcusaureus strains with low-level resistance to mupirocinare emerging, it is generally useful in infections resistantto other antibacterials. To avoid the development ofresistance, mupirocin or fusidic acid should not beused for longer than 10 days and local microbiologyadvice should be sought before using it in hospital. Inthe presence of mupirocin-resistant MRSA infection, atopical antiseptic, such as povidone–iodine, chlorhexidine,or alcohol, can be used (section 13.11); their useshould be discussed with the local microbiologist.Mupirocin ointment contains macrogols; extensiveabsorption of macrogols through the mucous membranesor through application to thin or damaged skinmay result in renal toxicity, especially in neonates.Mupirocin nasal ointment is formulated in a paraffinbase and may be more suitable for the treatment ofMRSA-infected open wound in neonates.Metronidazole gel is used topically in children toreduce the odour associated with anaerobic infectionsand for the treatment of periorificial rosacea (section13.6); oral metronidazole (section 5.1.11) is used to treatwounds infected with anaerobic bacteria.Retapamulin can be used for impetigo and other superficialbacterial skin infections caused by Staphylococcusaureus and Streptococcus pyogenes that are resistant tofirst-line topical antibacterials. However, it is not effectiveagainst MRSA. The Scottish Medicines Consortium13 Skin