Position Statement on Emollients/Use of Sunscreens

Position Statement on Emollients/Use of Sunscreens

Practitioners are encouraged to adopt the cost-effective emollients in the BCCG formulary
Bath emollients/washes and shower gels not to be routinely available on prescription
Prescribers are requested to consider these products when initiating treatment in the absence of a recommendation from a specialist or specific patient requirements
Aqueous cream is no longer recommended as an emollient
Sunscreens should not be routinely prescribed for other than the conditions detailed in the current BNF

BACKGROUND

Evidence to inform the use of bath and shower emollients is lacking: there is no good evidence to recommend a particular emollient over another and no published randomised controlled trials have assessed the efficacy of bath and shower emollients in atopic eczema. Product selection is mostly based on patient preference which is important to maximise adherence and minimise wastage.

The proposed emollient formulary is a guide to prescribing the most cost effective product and should not override clinical judgement.

NHS guidance is that sunscreens should ONLY be prescribed on an FP10 for sun protection against UV radiation in abnormal cutaneous photosensitivity resulting from genetic disorders or photodermatoses.

COST & PRESCRIBING DATA

For the financial year of 2014/15Blackpool CCG spent £351,396,295(60,284 items) on emollients and on £7,803.44 (678 items) on sunscreens.

REFERENCES

Hoare C, Li Wan Po A, Williams H. Systematic review of treatments for atopic eczema. Health Technology Assessment 2000;4: (37)National Institute for Health and Clinical Excellence (NICE): Atopic eczema in children – Management of atopic eczema in children from birth up to the age of 12 years (CG57) London: National Collaborating Centre for Women’s and Children’s Health; 2007.Accessed via Accessed 15/7/15

Scottish Intercollegiate Guidelines Network (SIGN). Management of atopic eczema in primary care SIGN no.125 March 2011. Accessed via Accessed 15/7/15.

Eczema – atopic, Clinical Knowledge Summary, last revised March 2013.Accessed via Accessed 15/7/15.

With acknowledgment to Midlands and Lancashire CSU Medicines Commissioning

Cost-Effective Emollients/Use of Sunscreens

Executive Summary

Introduction

Evidence to inform the use of bath and shower emollients is lacking. There is no good evidence to recommend a particular emollient over another and no published randomised controlled trials have assessed the efficacy of bath and shower emollients in atopic eczema. Product selection is mostly based on patient preference which is important to maximise adherence and minimise wastage. Appendix 1 details products suitable for an initial, cost-effective first choice.

The proposed emollient formulary is a guide to prescribing the most cost effective product and should not override clinical judgement.

Background

In line with NICE guidance emollients should be prescribed according to the dryness of the skin, and individual preference. The preparations in Appendix 1 are formulated as comparable products to commonly prescribed emollients but are more cost effective. In addition, innovations in packaging used in the pumps and ‘top down’ bottles of these products can help to reduce waste.

The quantities of emollients deposited on the skin from bath and shower emollients are likely to be lower than emollients used as soap substitutes applied directly to the skin before bathing then rinsing. However, NICE CG 57 does state that the additional use of bath emollients for some children may be appropriate in order to ensure that adequate amounts of emollient are absorbed into the skin. If emollient bath additives are prescribed, the BNF No.15 recommends that in order to improve hydration, patients should soak in the bath for 10-20 minutes.

NHS guidance is that sunscreens should only be prescribed for sun protection against UV radiation in abnormal cutaneous photosensitivity resulting from genetic disorders or photodermatoses, including vitiligo and those resulting from radiotherapy; chronic or recurrent herpes simplex labialis. Photosensitive dermatoses are made up of the following conditions: polymorphic light eruption (PLE), actinic prurigo, chronic actinic dermatitis, solar urticaria, hydroa vacciniforme, xeroderma pigmentosum, porphyria, drug-induced photosensitivity, photocontact allergic reactions and phytophoto dermatitis.

Key Points in Emollient Product Selection

Patient will not use a product if they think it does not work or unpleasant to apply

Correct hydration potency is a factor in selection: oily based products retain skin moisture and are better moisturisers whereas high water based products are more pleasant to use but not as effective at retaining moisture

Severity of affected skin: understanding severity will govern product selection

Quantities: it is important to use appropriate amounts to ensure adequate hydration/application

Trial of cost effective emollient options should be used (small packs). Larger quantity can be prescribed if it suits the patient. They should be applied liberally and frequently, even when skin condition has improved, and known irritants avoided

Children:it is important to spend time educating children with atopic eczema and parents/carers which should cover how much treatment to use, how often to apply, when and how to stop treatment up or down, and how to treat infected atopic eczema

Recommendations

As emollients are the mainstay of treatment for mild flares of atopic eczema this recommendation is to bring to the attention of prescribers, cost effective alternatives to those products they are already familiar with. Prescribers are requested to consider these products when initiating treatment in the absence of a recommendation from a specialist or specific patient requirements.

N.B. Existing prescription recommendations from a dermatologist or specialist nurse should not be substituted

Consideration should also be given to advising patients on the correct application technique and prescribed in generous amounts and frequent and liberal use advised, even when the skin is clear. As the effectiveness and acceptability of a particular emollient may vary with time and that a patient feels that a particular product has become unsuitable for them (or if they have developed sensitivity to it), prescribing an alternative emollient should be considered.

Bath emollients/washes and shower gels not to be routinely available on prescription

Aqueous cream is no longer recommended as an emollient.

Sunscreens should not be routinely prescribed.

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Appendix 1

EMOLLIENT FORMULARY

Emollients reduce water loss from the skin and are first-line treatments in the management of dry skin conditions. They should be used liberally and at least 2-4 times a day. In general, the greasier the product, the more effective it is as an emollient.

N.B. Paraffin-based products are flammable – advise patients using these products to stay away from fire or flames and not to smoke.MHRA

Patient Advice on bath oils and shower gels for dry skin conditions

There are many bath oils and shower gels (also known as moisturisers or emollients) available for people to use to treat large areas of dry skin. We know that using moisturisers properly is a very important part of treating dry skin conditions such as eczema, dermatitis and psoriasis.

Do bath oils and shower gels work?

The amount of moisturiser left on the skin during bathing or showering is usually much less than if oils, moisturisers or ointments are put straight onto the skin.

By relying only on bath or shower oils, there is a real risk that people will under-treat the dry skin that is part of their skin condition.

Are there any risks in using bath oils and shower gels?

As well as being less effective at moisturising the skin, oils and shower gels coat the bath or shower and make it greasy and slippery, and so greatly increase the risk of falls. Using a bath mat or grab rails to reduce the risk of slipping is strongly advised, as well as cleaning the bath or shower properly after use. Other people who also use the bath or shower should be warned that it is likely to be very slippery.

What should you do to moisturise your skin when having a bath or shower if you don’t use bath oils/shower gels?

Don’t use soap as this strips the natural oils out of your skin. Use your moisturiser applied directly to the skin as a soap substitute to clean your skin. Massage the moisturiser between your hands and apply it to dry skin in a downward direction. Parents of young children may prefer to apply the moisturiser onto a flannel, if so a clean flannel should be used each time.

All moisturisers with the exception of Diprobase ointment, QV ointment and 50:50 LP:WSP, may be used as soap substitutes.

After a bath or shower it is best to dry off by patting the skin lightly with a towel rather than by rubbing. Rubbing can start the itch / scratch part of the eczema or dermatitis if that is causing the dry skin. Once the skin is almost dry but still moist, immediately apply an oil or moisturiser to seal the moisture into the skin.

Why BCCG has asked GPs to stop prescribing bath oils, shower gels and washes

Following discussion with local Dermatology Consultants, GPs and Specialists have agreed not to issue prescriptions for these products, because of concerns about the risk of falls and the evidence that these are less effective moisturisers than those applied directly to the skin. People who choose to continue to use them can buy them from their local community pharmacy (chemist) or supermarket.