13: Skin

Please select a topic:

13.2 Emollient and barrier preparations / 13.3 Topical local anaesthetics and antipruritics
13.4 Topical corticosteroids / 13.5 Preparations for eczema and psoriasis
13.6 Acne and rosacea / 13.7 Preparations for warts and calluses
13.8 Sunscreens and camouflagers / 13.9 Shampoos and some other scalp preparations
13.10 Anti-infective skin preparations / 13.11a Disinfectants and skin cleansers
13.11b Other preparations / 13.13 Wound management products and elastic hosiery

13.1 Management of skin conditions

  • The vehicle used in topical preparations influences skin hydration, has a mild anti-inflammatory effect and facilitates penetration of the active component.
  • Creams are more cosmetically acceptable than ointments. Gels are suitable for application to the face and scalp while lotions are used for moist conditions and hairy areas. Ointments are much less likely to sensitise and are suitable for chronic dry lesions.
  • Possible contact sensitivity to preservatives or antiseptics is the reason for the range of topical agents.

Body area / Non-corticosteroid cream/ointment
(Qty based on twice daily application for 1 week in adults) /
Corticosteroid cream/ointment
(Qty based on single daily application for 2 weeks in adults)
Face / 15 to 30g
Face and neck / 15 to 30g
Both hands / 25 to 50g / 15 to 30g
Scalp / 50 to 100g / 15 to 30g
Both arms / 100 to 200g / 30 to 60g
Both legs / 100 to 200g / 100g
Trunk / 400g / 100g
Groins and genitalia / 15 to 25g / 15 to 30g

Fire Hazard with Paraffin-based Emollients

Emulsifying ointment or 50% liquid paraffin and 50% white soft paraffin ointment in contact with dressings and clothing is easily ignited by a naked flame. The risk will be greater when these preparations are applied to large areas of the body, and clothing or ointment become soaked with the ointment. Patients should be told to keep away from fire or flames and not to smoke when using these preparations. The risk of fire should be considered when using large quantities of any paraffin-based emollient.

For further information refer to NPSA Rapid Response Report 4 dated 26.November 2007

The following products are known to be paraffin based:

STEROIDS

/

EMOLLIENTS

Betnovate ointment

/

Cetreban Cream & bath additive

Betnovate RD ointment

/

Dermol Cream, 500 lotion & 600 Bath Additive

Diprobase and Diprobath

Doublebase

E45 Cream and Bath Oil

Emulsifying Ointment

Epaderm

Hydromol Ointment and Bath additive

Oilatum Cream and Bath additive

Yellow soft paraffin

13.2 Emollient and barrier preparations

Emollients (moisturisers)

  • Aqueous cream 100g & 500g
  • Aveeno cream 100g
  • Balneum Plus cream 100g
  • Calmurid cream 100g
  • Cetraben emollient cream 500g
  • Dermol cream 500g
  • Diprobase cream 500g
  • Diprobase ointment 500g
  • E45 cream 50g & 100g
  • Emulsifying ointment 500g
  • Epaderm ointment 500g
  • Eucerin Intensive 10%w/w Urea Treatment Lotion 250ml
  • Hand cream 50g (STAFF USE ONLY)
  • Hydromol Ointment 125g & 500g
  • Oilatum cream 40g
  • Oilatum emollient 250ml
  • Oilatum Junior Cream 500ml & 1050ml
  • Yellow soft paraffin 15g

Dose

- Aqueous cream BP(emulsifying ointment 30%, phenoxyethanol 1% in freshly boiled and cooled purified water) (100g): massage into skin 2-3 times daily; may be used as a soap substitute.
- Aveeno® cream(colloidal oatmeal in emollient basis) (100mL): apply as often as required.

- Balneum® Plus cream(urea 5%, lauromacrogols 3%): apply as often as required.

- Calmurid cream(urea 10%, lactic acid 5%): apply twice a day.

- Cetraben emollient cream(white soft paraffin 13.2%, light liquid paraffin 10.5%): apply twice a day.

- Dermol cream (Benzalkonium Chloride 0.1% w/w; Chlorhexidine Hydrochloride 0.1% w/w; Liquid Paraffin 105% w/w; Isopropyl Myristate 10% w/w): apply as often as required

- Diprobase® cream(cetomacrogol 2.25%, cetostearyl alcohol 7.2%, liquid paraffin 6%, white soft paraffin 15%) (50g tube, 500g dispenser): apply as often as required.

- Diprobase® ointment(liquid paraffin 5%, white soft paraffin 95%) (50g tube, 500g dispenser): apply as often as required.

- E45 Cream (light liquid paraffin 12.6%, white soft paraffin 14.5%, hypoallergenic anhydrous wool fat 1% in self-emulsifying monostearin): apply as often as required.

- Epaderm® ointment(emulsifying wax 30%, yellow soft paraffin 30%, liquid paraffin 40%) (125g, 500g): massage into skin as often as required; may be used as a soap substitute.

- Eucerin® Intensive cream(urea 10%): apply thinly and rub into area twice a day.

- Hydromol® ointment (yellow soft paraffin 30%, emulsifying wax 30%): apply as often as required; may be used as a soap substitute.
- Oilatum emollient (light liquid paraffin 63.4%): apply as often as required.

- Oilatum cream (light liquid paraffin 6%, white soft paraffin 15%): apply as often as required.

- Oilatum Junior Cream (light liquid paraffin 6%, white soft paraffin 15%)

- Yellow soft paraffin (yellow petroleum jelly): apply as often as required.

Prescribing notes

  • Choice is guided by individual patient tolerance, preference and ease of use. It is dependent on previous use and adverse skin reactions (some may cause irritation or burning so advise testing on a small area of skin first and stop if a reaction occurs).
  • Emollients soothe, smooth and hydrate the skin and are indicated for all dry scaling disorders.
  • Emollients should be applied regularly to maintain improvement; most are best applied after a shower or bath.
  • Use an oil-based emollient at night and during the day if skin is very dry/flaky.
  • Use a cream which is easier to apply and less greasy throughout the day to aid compliance.
  • These products, apart from white soft paraffin 50%/liquid paraffin 50%, may be used as soap substitutes by firstly wetting the skin, washing with the cream or ointment, then rinsing off.
  • If emollients are being applied to the whole body twice daily, children may need 250g – 500g per week and adults 500g per week.
  • It is most cost effective to prescribe emollients in very large quantities
  • Hydromol contains less additives that Epaderm.
  • Aqueous cream and emulsifying ointment should be used for washing only.
  • Preparations that come in a pump dispenser presentation are good when product needed for use at school as more hygienic.
  • Ointments should be used for dry skin and chronic eczema. Creams should be sued for acute inflammatory eczema.

Emollient bath additives

  • Aveeno bath oil 250ml
  • Balneum bath oil 200ml
  • Diprobath 500ml
  • Dermol 600 600ml
  • E45 emollient bath oil 500ml
  • Hydromol emollient bath additive 500ml
  • Oilatum emollient bath additive 500ml
  • Oilatum Plus bath additive 500ml
  • Cetraban emollient bath additive 500ml

Dose

- Cetraban Emollient bath additive(light liquid paraffin 82.8%) (500mL): add 1-2 capfuls to bath (1/2 to 1 capful if child).
- Oilatum® Emollient bath additive(acetylated wool alcohols 5%, liquid paraffin 63.4%) (250mL, 500mL): add 5-15 mL/bath (2.5-10mL if an infant).
- Balneum® bath oil(soya oil 84.75%) (200mL, 500mL, 1L): add 20mL/bath (5mL, if an infant).
- Aveeno® bath oil(colloidal oatmeal, white oat fraction in emollient basis (250mL): up to 30mL/bath (child, up to 30mL).
- Oilatum® Plus bath additive(benzalkonium chloride 6%, triclosan 2%, light liquid paraffin 52.5%) (500mL, 1L): 1-2 capfuls/bath (infant over 6 months, 1mL).
- Dermol® 600 Bath Emollient(benzalkonium chloride 0.5%, liquid paraffin 25%, isopropyl myristate 25%) (600mL): up to 30mL/bath (infant up to 15mL).

- Hydromol® Emollient Bath Additive (isopropyl myristate 13%, light liquid paraffin 37.8%) (500ml): up to 1-3 capfuls/bath.

- Diprobath® Bath Additive (isopropyl myristate 39%, light liquid paraffin 46%) (500ml): up to 25-50ml/bath.

- E45® Emollient Bath Oil (cetyl dimeticone 5%, liquid paraffin 95%) (500ml): up to 15ml/bath.

Prescribing notes

  • Bath additives with antiseptic should be used in patients with infected eczema.
  • Oilatum® Plus bath additive is not suitable for use in the shower.
  • Preparations containing benzalkonium chloride can cause skin irritation with continued use.
  • E45® Emollient Bath Oil contains no irritants or allergens.

Soap substitutes

  • Aqueous cream 100g & 500g
  • Emulsifying ointment 500g
  • Epaderm ointment 500g
  • Hydromol ointment 500g
  • Dermol 500 lotion 500ml
  • Dermol 200 shower emollient 200ml
  • Oilatum shower emollient gel 150g

Dose

- Emulsifying Ointment (emulsifying wax 30%, white soft paraffin 50%, liquid paraffin 20%)

- Aqueous cream BP(emulsifying ointment 30%, phenoxyethanol 1% in freshly boiled and cooled purified water) (100g)
- Epaderm® ointment(emulsifying wax 30%, yellow soft paraffin 30%, liquid paraffin 40%)

(500g)

- Hydromol® ointment (yellow soft paraffin 30%, emulsifying wax 30%) (500g)

- Dermol 500 lotion (Benzalkonium Chloride 0.1% w/w; Chlorhexidine Hydrochloride 0.1% w/w; Liquid Paraffin 2.5% w/w; Isopropyl Myristate 2.5% w/w): apply as often as required; may be used as a soap substitute.

- Dermol 200 shower emollient (Benzalkonium Chloride 0.1% w/w; Chlorhexidine Hydrochloride 0.1% w/w; Liquid Paraffin 2.5% w/w; Isopropyl Myristate 2.5% w/w): apply as often as required; may be used as a soap substitute.

- Oilatum shower emollient gel (light liquid paraffin 70%): apply as often as required.

Prescribing notes

  • Most emollients may be used as soap substitutes by firstly wetting the skin, washing with the cream or ointment, then rinsing off.
  • Doublebase® Emollient Wash Gel and E45® Emollient Wash Cream come in pump dispensers so are more hygiengic to use a school and home particularly if Dermol products are not tolerated. They are available on a non-formulary basis.
  • White soft paraffin 50%/liquid paraffin 50% is not suitable as a soap substitute.
  • Hydromol contains less additives than Epaderm®
  • Preparations containing benzalkonium chloride can cause skin irritation with continued use.
  • A convenient way to apply emulsifying ointment and Hydromol® ointment is as "soap balls", which are made by putting a scoop of the ointment into tubinette or stockinette.

Barrier preparations

  • Vasogen cream 50g
  • Drapolene cream 100g
  • Metanium ointment 30g

Dose

- Vasogen Cream (dimeticone 20%, calamine 1.5%, zinc oxide 7.5%)): for nappy and urinary rash and eczematous conditions, apply several times daily as necessary or after each nappy change.

- Drapolene Cream (benzalkonium chloride 0.01%, cetrimide 0.2% in a basis containing white soft paraffin, cetyl alcohol and wool fat): for nappy and urinary rash and eczematous conditions, apply several times daily as necessary or after each nappy change.

- Metanium Ointment (titanium dioxide 20%, titanium peroxide 5%, titanium salicylate 3% in basis containing dimeticone, light liquid paraffin, white soft paraffin, and benzoin tincture): for nappy and urinary rash and eczematous conditions, apply several times daily as necessary or after each nappy change.

Prescribing notes

  • Urinary (nappy) rash may clear if skin is left exposed to air; if associated with yeast (candida) infection, an antifungal cream such as clotrimazole cream is useful.
  • For information on the use of Cavilon® please consult the separate Trust Wound Care Formulary.

13.3 Topical local anaesthetics and antipruritics

a)Topical antipruritics

  • Calamine lotion 200ml

Dose

- Calaminelotion: apply 2-3 times daily.

Prescribing notes

  • Emollient preparations may be useful for pruritus due to dry skin; sedating oral antihistamines may also be helpful for itch

(b) Topical local anaesthetics

  • LMX 4® cream

Dose

- LMX 4® cream (lidocaine 4%) (5g): for children & adults over 1 month, anaesthesia before e.g. venepuncture, apply a thick layer under an occlusive dressing 30 minutes before procedure

Prescribing notes

  • Topical local anaesthetics may be absorbed through mucosal surfaces.
  • Local anaesthetics may occasionally cause sensitisation.
  • For information on the use of Ethyl Chloride Spray please consult the Anaesthetics Chapter of the formulary.

13.4 Topical corticosteroids

  • Hydrocortisone 0.5% and 1% cream
  • Hydrocortisone 0.5% and 1% ointment
  • Hydrocortisone 1% plus clotrimazole 1% cream (Canesten HC)
  • Hydrocortisone 0.5% plus nystatin and chlorhexidine cream (Nystaform HC)
  • Hydrocortisone 0.5% plus nystatin and chlorhexidine ointment (Nystaform HC)
  • Hydrocortisone 0.5% plus nystatin, benzalkonium and dimeticone (Timodene)
  • Hydrocortisone 1% plus miconazole 2% (Daktacort)
  • Betamethasone valerate 0.1% cream (Betnovate) 100g & 30g
  • Betamethasone valerate 0.1% ointment (Betnovate) 100g & 30g
  • Betamethasone valerate 0.1% scalp application (Betnovate)
  • Betamethasone valerate 0.025% cream (Betnovate RD) 100g
  • Betamethasone valerate 0.025% ointment (Betnovate RD) 100g
  • Betamethasone valerate 0.1% plus clioquinol 3% ointment (Betnovate C)30g
  • Betamethasone valerate 0.1% plus neomycin 0.5% cream (Betnovate N) 30g
  • Betamethasone valerate 0.1% plus neomycin 0.5% ointment (Betnovate N) 30g
  • Clobetasol propionate 0.05% cream (Dermovate) 30g
  • Clobetasol propionate 0.05% ointment (Dermovate) 30g
  • Clobetasone butyrate 0.05% cream (Eumovate) 30g & 100g
  • Clobetasone butyrate 0.05% ointment (Eumovate) 30g & 100g
  • Clobetasone butyrate 0.05%, oxytetracycline and nystatin 0.05% ointment (Trimovate) 30g
  • Fluocinolone 0.025% ointment (Synalar) 30g

Dose

- Topical corticosteroids should be applied thinly as follows:

Mild steroids = 1-2 times daily.

Moderate, Potent & Very potent steroids = 1 x daily.

Prescribing notes

  • Topical corticosteroids are divided into four groups according to potency (see table) below). Mild or moderately potent corticosteroids should control most cases of eczema. Therapy should be stepped-down once control achieved.

Potency / Examples / Trade Name
Mild / Hydrocortisone 0.5% and 1%
Hydrocortisone with antimicrobials
Fluocinolone acetonide 0.0025% / Non-proprietary
Canesten HC, Timodene, Dakatacort, Vioform-HC
Synalar 1 in 10
Moderate / Betamethasone 0.025%
Clobetasone butyrate 0.5%
Clobetasone with antimicrobials
Fluocinolone acetonide 0.00625% / Betnovate RD
Eumovate
Trimovate
Synalar 1 in 4
Potent / Betamethasone 0.1%
Fluocinolone acetonide 0.025%
Betamethasone 0.1% with antimicrobials / Betnovate
Synalar
Betnovate C, Betnovate N
Very Potent / Clobetasol propionate 0.05% / Dermovate
  • Topical corticosteroids are not recommended in urticaria, rosacea, acne or undiagnosed, possibly infective, disorders.
  • Topical corticosteroids must not be applied more than twice a day.
  • To minimise the risk of side-effects, the smallest effective amount should be used, reducing strength and frequency of application as the condition settles. The risk of systemic side-effects increases with prolonged use on thin, inflamed or raw skin surfaces, use in flexures, or use of more potent corticosteroids. Occlusion increases efficacy and side-effects. Only mild corticosteroids should be used on the face.
  • Gloves should be worn during, or hands washed after, application of large quantities of steroid preparations.
  • The occlusive effect of ointments increases penetration of the corticosteroid.
  • Cream based preparations contain preservatives.
  • Topical corticosteroids should not be used on infected skin unless the infection is being treated.
  • Antibacterials and antifungals with corticosteroids may have a role if there is associated infection.
  • Palms and soles may require potent or very potent steroids.

13.5 Preparations for eczema and psoriasis

Preparations for eczema

  • PB7 Viscopaste bandages

Prescribing notes

  • Medicated bandages are flammable
  • All patients with eczema should use an emollient and soap substitute and/or bath oil.
  • Emollients with antiseptics should be used to in patients with infected eczema.
  • Exacerbation of eczema may represent secondary bacterial or viral infection. Appropriate swabs should be taken, and topical antibacterials applied. Systemic antibiotics may be required in widespread infected eczema.
  • Ciclosporin, azathioprine or systemic corticosteroids should be initiated on specialist advice only, with responsibility for monitoring agreed.
  • Topical corticosteroids should be reduced and withdrawn as the condition settles.
  • Sedating antihistamines may be used short-term for pruritus.

Preparations for psoriasis

  • Acitretin 10mg and 25mg capsules
  • Exorex lotion 100ml (prepared coal tar 1% in an emollient basis)
  • Calcipotriol 50microgram/gram cream 60g (Dovenex®)

Prescribing notes

  • Treatment choice depends on site, extent of psoriasis and patient preference and tolerance.
  • Potent and very potent topical corticosteroids should be used on specialist advice only; they may precipitate unstable and pustular psoriasis after stopping.
  • Phototherapy, methotrexate, ciclosporin, acitretin should be initiated on specialist advice only, with responsibility for monitoring agreed.

Drugs affecting the immune response

  • Ciclosporin 25mg, 50mg and 100mg capsules
  • Methotrexate 2.5mg tablets
  • Tacroliumus 0.03% ointment

13.6 Acne and rosacea

Preparations for acne

  • Isotretinoin 5mg and 20mg capsules (on advice on specialist only)
  • Dianette tablets

Prescribing notes

  • Topical treatment takes at least 30 days to become effective.
  • Benzoyl Peroxide is available to prescribe by GPs or for sale over the counter.
  • Topical antibiotics are as effective as oral antibiotics but encourage resistance and are more expensive.
  • Topical retinoids are recommended for comedonal acne; they may initially cause redness of the skin.
  • Oxytetracycline may take up to 6 months of compliant use to achieve maximum benefit.
  • Dianette® (cyproterone acetate with ethinylestradiol) is a treatment for severe acne and only in those patients may it also be used as an oral contraceptive. In those who do not require contraception, Dianette® should be withdrawn 3-4 cycles after the treated condition has completely resolved. If ongoing contraception is required, substitution with another COC is likely to maintain the improvement.
  • Some drugs, including enzyme-inducers and antibiotics, may impair the efficacy of oral contraceptives; see BNF for details.
  • Doxycycline can cause photosensitivity in some patients. Minocycline may be an alternative but prolonged use should be avoided due to the rare risk of liver damage; liver function tests should be monitored 3 monthly.
  • Tetracyclines and retinoids (systemic or topical) must be avoided in pregnancy.

Severe acne requires oral antibiotics and referral for consideration of isotretinoin for treatment failures. Oral isotretinoin (Roaccutane®) is a toxic and teratogenic drug that is only prescribable by a consultant dermatologist.

  • There is no effective treatment for redness of the skin due to rosacea; camouflagers may be required.
  • Mild rosacea is best treated with a topical agent.

Pustular rosacea is best treated with systemic antibiotics.

13.7 Preparations for warts and calluses

  • Cuplex gel 5g (salicylic acid 11%, lactic acid 4% in collodion basis)
  • Silver nitrate caustic pencil 95%
  • Salicyclic acid 10% in colloidion solution (chiropody)
  • Imiquimod 5% cream 5g

Prescribing notes

  • These preparations are contra-indicated in facial or genital warts.
  • The wart surface should be rubbed with a file or pumice stone, and the surrounding skin protected, before each application. If application becomes painful, treatment should be withheld for a few days then recommenced.

13.8 Sunscreens and camouflagers

  • Uvistat SPF 30 125g
  • Uvistat SPF 50 125g

Prescribing notes

  • Sunscreens with SPF > 15 are prescribable for photosensitive skin disorders including genetic disorders, vitiligo, following radio-therapy, photo-aggravated rosacea, or recurrent herpes simplex labialis.
  • Prescriptions should be endorsed "ACBS".
  • The choice of sunscreens depends on individual patient need, tolerance and evidence of sensitivity to excipients.

13.9 Shampoos and some other scalp preparations

  • Polytar shampoo 250ml
  • Ketoconazole 2% shampoo 120ml
  • Cocois scalp ointment 40g
  • Oilatum shampoo
  • Eucerin Dry Scalp Relief shampoo with 5% urea

Dose

- Ketoconazole2% shampoo (120mL): for seborrhoeic dermatitis and dandruff apply twice weekly for 2-4 weeks; for pityriasis versicolor, once daily for up to 5 days.