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13: Skin

Approved: 1 Aug 2012. Last amended: 9 Oct 2023.

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13.1 Management of skin conditions

13.2 Emollient and barrier preparations

13.2.1 Emollients

For Emollients, please see the Gloucestershire Emollient Formulary

13.2.2 Barrier Preparations

For recommended barrier preparations, please see the Gloucestershire Woundcare Formulary

Specific Indication

  • Zinc and castor oil ointment

    Zinc preparations are restricted to use by the dermatologists

    • 13.3 Antipruritics

    For recommended topical antipruritics, please see the Gloucestershire Emollient Formulary

  • Doxepin Hydrochloride 5%

    Cream (Xepin®) – for small areas only. Restricted to dermatology. Doxepin cream can cause drowsiness that may affect skilled tasks and there may be a risk of sensitisation.

    • 13.4 Topical corticosteroids

    Frequency of application of topical corticosteroids for atopic eczema: NICE TA81

    Head and neck

    2.5 FTU/application, Approx 10g per week

    Each arm

    4 FTU/application, Approx 15g per week

    Trunk

    14 FTU/application, (7 FTU to front and 7 FTU to back), Approx 50g per week

    Each leg

    Each leg: 8 FTU/application, Approx 30g per week

    13.4.1 Topical Steroids

    13.4.1.1 Mild

  • Hydrocortisone 0.1, 0.5, 1.0 and 2.5%

    Cream/ointment

  • Synalar 1 in 10 Dilution®

    Cream (fluocinolone 0.0025%)

    • 13.4.1.2 Moderate

  • Eumovate®

    Cream/ointment (clobetasone butyrate 0.05%)

  • Betnovate RD®

    Cream/ointment (betamethasone valerate 0.025%)

  • Haelan®
    • Tape (fludroxycortide 4 micrograms/cm2)
    • Information leaflet
  • Synalar 1 in 4 Dilution®

    Cream/ointment (fluocinolone 0.00625%)

    • 13.4.1.3 Potent

  • Betamethasone valerate 0.1%

    Cream / Ointment / Lotion

  • Diprosalic®

    Ointment (betamethasone dipropionate 0.05% with salicylic acid 3%)

  • Elocon®

    Cream/ointment (mometasone furoate 0.1%)

    • 13.4.1.4 Very Potent

  • Dermovate®

    Cream/ointment (clobetasol propionate 0.05%)

  • Nerisone Forte®

    Oily cream (diflucortolone 0.3%)

    • 13.4.2 Topical Steroids with antimicrobials

    13.4.2.1 Mild

  • Canesten HC®

    Cream (hydrocortisone 1% and clotrimazole 1%)

  • Fucidin H®

    Cream/ointment (hydrocortisone 1% and fusidic acid 2%)

  • Daktacort®

    Cream/ointment (hydrocortisone 1% and miconazole 2%)

  • Timodine®

    Cream (hydrocortisone 0.5%, nystatin 100,000 units/g, benzalkonium chloride solution 0.2% and dimeticone ‘350’ 10%)

    • 13.4.2.2 Moderate

  • Trimovate®

    Cream (clobetasone butyrate 0.05%,oxytetracycline 3% & nystatin 100,000 units/g)

    • 13.4.2.3 Potent

  • Betnovate-C®

    Cream/ointment (betamethasone 0.1% and clioquinol 3%)

  • Lotriderm®

    Cream (betamethasone dipropionate 0.064% and clotrimazole 1%)

  • FuciBET®

    Cream (betamethasone 0.1% and fusidic acid 2%)

  • Betnovate N®

    Cream /ointment (betamethasone 0.1% and neomycin 0.5%)

  • Aureocort®

    Ointment (triamcinolone 0.1% and chlortetracycline 3%)

    • 13.4.3 Compound preparations

    13.4.3.1 Mild

  • Eurax-Hydrocortisone®

    Cream (hydrocortisone 0.25% and crotamiton 10%)

    • 13.4.3.2 Moderate

  • Alphaderm®

    Cream (hydrocortisone 1% and urea 10%)

  • Calmurid HC®

    Cream (hydrocortisone 1%, urea 10%, lactic acid 5%)

    • 13.4.4 Steroid scalp applications

    13.4.4.1 Potent

  • Betamethasone 0.1%

    (Betacap®) scalp application, (Betnovate®) scalp application, (Bettamousse®) foam scalp application

  • Diprosalic®

    Scalp application (betamethasone 0.05% and salicyclic acid 2%)

  • Synalar®

    Gel (fluocinolone acetonide 0.025%)

    • 13.4.4.2 Very Potent

  • Clobetasol propionate 0.05%
    • Dermovate® scalp application
    • Clarelux® foam
    • Etrivex® shampoo

    • 13.5 Preparations for Eczema and Psoriasis

    13.5.1 Preparations for eczema

    Please refer to section 13.2 (emollients) and 13.4 (topical corticosteroids).

    Specific Indication

  • Ichthopaste®

    (zinc paste and ichthammol) bandage – only to be applied by a Nurse skilled in paste bandage appplication

  • Steripaste®

    Zinc Bandages. Only to be applied by a Nurse skilled in paste bandage appplication

  • Zipzoc®

    (zinc paste) bandage

    • 13.5.1.1 Oral retinoid for eczema

  • Alitretinoin

    Severe chronic hand eczema: NICE TA177

    • 13.5.2 Preparations for psoriasis

    Topical preparations

    Please refer to the BNF for information regarding vitamin D and analogues.

    13.5.2.1 Vitamin D and analogues

  • Dovonex®

    Scalp solution (calcipotriol)

  • Dovobet®

    Gel (calcipotriol with betamethasone 0.05%) – body and scalp

  • Enstilar®

    Cutaneous foam (calcipotriol with betamethasone 0.05%)

  • Silkis®

    Ointment (calcitriol 3micrograms/g)

    • 13.5.2.2 Topical retinoid

  • Tazarotene

    0.05%, 0.1% gel

    • 13.5.2.3 Compound product

    Chelsea Day mix (Hospital Formula) is only available as a ‘special’ preparation (i.e. not a proprietary product).

    These preparations are not cost-effective in primary care and there may be a significant delay in obtaining such preparations.

  • Chelsea Day mix

    (Hospital Formula) possible price on FP10 prescription: up to £250 for 100g

    • 13.5.2.4 Coal tar

    Chelsea Night mix and Coal Tar 5% in Eumovate® ointments are only available as ‘special’ preparations (i.e. not proprietary products).

    These preparations are not cost-effective in primary care and there may be a significant delay in obtaining such preparations.

  • Cocois®

    Scalp ointment

  • Exorex®

    Lotion

  • Alphosyl HC®

    Cream (with hydrocortisone 0.5%)

  • Polytar Emollient®

    Bath additive (contains peanut oil)

  • Coal Tar 5% in Eumovate®

    Ointment possible price on FP10 prescription: up to £588 for 500g

  • Chelsea Night mix

    Possible price on FP10 prescription: up to £250 for 100g

    • 13.5.2.5 Dithranol

  • Dithrocream®

    0.1%, 0.25%, 0.5%, 1% and 2% - specialist use only

  • Micanol®
    • 1%, 3% cream.
    • Specialist use only
  • Dithranol in Lassar’s Paste
    • 0.1%, 0.25%, 0.5%, 1%, 2%, 4%
    • Specialist use only
  • Dithranol in Lassar's Paste

    GHNHSFT Local Guideline

  • Dithranol in Lassar's Paste

    Sample drug chart

    • 13.5.2.6 Salicylic Acid

    The 'amber' topical salicylic acid preparations below are only available as ‘special’ preparations (i.e. not proprietary products).

    These preparations are not cost-effective in primary care and there may be a significant delay in obtaining such preparations.

  • Salicylic acid 2% ointment

    Possible price on FP10 prescription: £1 for 100g

  • Salicylic acid 5% in white soft paraffin
    • Second-line to Flexitol® (see section 13.2.4.5)
    • Possible price on FP10 prescription: up to £100 for 100g
  • Salicylic acid 10% in white soft paraffin
    • Second-line to Flexitol® (see section 13.2.4.5)
    • Possible price on FP10 prescription: up to £100 for 100g

    • 13.5.2.7 Oral retinoids for psoriasis

  • Acitretin

    Specialist use only

    • 13.5.3 Drugs affecting the immune response

    13.5.3.1 Topical

  • Protopic®

    Ointment (tacrolimus 0.03% and 0.1%) – NICE TA82

  • Elidel®

    Cream (pimecrolimus 1%) – NICE TA82

    • 13.5.3.2 Systemic

    GHNHSFT Psoriasis Biologic Pathway

    GHNHSFT Psoriatic Arthritis Biologic Pathway

  • Ciclosporin

    Shared Care Guideline

  • Methotrexate

    Shared Care Guideline

  • Abrocitinib

    Atopic dermatitis: NICE TA814

  • Adalimumab

    Psoriasis: NICE TA146, NICE TA455

  • Apremilast

    Psoriasis: NICE TA419

  • Baricitinib

    Atopic dermatitis: NICE TA681

  • Bimekizumab

    Psoriasis: NICE TA723

  • Brodalumab

    Psoriasis: NICE TA511

  • Certolizumab

    Psoriasis: NICE TA574

  • Deucravacitinib

    Psoriasis: NICE TA907

  • Dimethyl fumarate

    Psoriasis:

  • Dupilumab

    Atopic dermatitis: NICE TA534

  • Etanercept

    Psoriasis: NICE TA103, NICE TA455

  • Guselkumab

    Psoriasis: NICE TA521

  • Infliximab

    Psoriasis: NICE TA134

  • Ixekizumab

    Psoriasis: NICE TA442

  • Risankizumab

    Psoriasis: NICE TA596

  • Secukinumab

    Psoriasis: NICE TA350, NICE TA734

  • Tildrakizumab

    Psoriais: NICE TA575

  • Tralokinumab

    Atopic dermatitis: NICE TA814

  • Upadacitinib

    Atopic dermatitis: NICE TA814

  • Ustekinumab

    Psoriasis: NICE TA180, NICE TA455

    • 13.6 Acne and rosacea

    13.6.1 Comedonal Acne

    Recommended

  • Brevoxyl®

    Cream (benzoyl peroxide 4%)

  • Differin®

    Cream / gel (adapalene 0.1%)

  • Skinoren®

    Cream (azelaic acid 20%)

    • 13.6.2 Mild to Moderate Papulopustular Acne

    Recommended

  • Aklief®

    Cream (trifarotene 50mcg/g)

    First-line for truncal acne

  • Duac®

    Gel (benzoyl peroxide 5% + clindamycin 1%)

  • Duac®

    Gel (benzoyl peroxide 3% + clindamycin 1%)

  • Epiduo®

    Gel (adapalene 0.1% + benzoyl peroxide 2.5%)

  • Treclin®

    Gel (tretinoin 0.025% + clindamycin 1%)

  • Oral antibiotics

    (see 13.6.2) PLUS above topical treatment – where topical treatment alone is ineffective

    • 13.6.3 Severe acne: Specialist initiation only

  • Isotretinoin

    Specialist use only

    • 13.6.4 Topical preparations for rosacea

    Recommended

  • Finacea®

    Gel (azelaic acid 15%)

  • Rozex®

    Gel/cream (metronidazole 0.75%)

    • Specific Indication

  • Soolantra®

    Cream (ivermectin 10mg/g) – where the recommended choices are ineffective or not tolerated

    • 13.6.5 Oral antibacterials for acne and rosacea

    Recommended

  • Doxycycline

    100mg

  • Lymecycline

    • Specific Indication

  • Doxycycline MR

    (Efracea®) 40mg od – Strictly reserved for patients wfho have demonstrated a definite intolerance to the recommended options

    • 13.7 Preparations for warts and calluses

  • Salactol®

    Paint (salicylic acid 16.7% and lactic acid 16.7%)

  • Posalfilin®

    Ointmefnt (salicylic acid 25% and podophyllum 20%)

  • Cantharone Plus®

    (cantharidin, podophyllum resin, salicylic acid) – unlicensed

    • 13.7.1 Anogenital warts

    Ideally all patients should first receive a full genito-urinary screen at GUM but there may be circumstances when Dermatologists may need to prescribe.

  • Warticon®

    Cream (podophyllotoxin)

  • Aldara®

    Cream (imiquimod 5%)

    • 13.8 Sunscreens and camouflagers

    13.8.1 Sunscreen preparations

    The following sunscreens may be prescribed for skin protection against ultraviolet radiation in abnormal cutaneous photosensitivity resulting from genetic disorders or photodermatoses, including vitiligo and those resulting from radiotherapy; chronic or recurrent herpes simplex labialis; patients taking photosensitising drugs and patients having PUVA.

  • RoC Total Sunblock® SPF 25
  • Sunsense® Ultra SPF 50
  • Sunsense® Ultra Sensitive SPF 50
  • Sunsense® Daily Face SPF 50

    • 13.8.2 Photodamage Actinic Keratosis

    Recommended

  • Efudix®

    Cream (fluorouracil 5%)

  • Klisyri®

    Ointment (tirbanibulin 10mg/g)

    • Specific Indication

  • Actikerall®

    Solution (Fluorouracil 0.5%, salycylic acid 10%) – Hypertrophic actinic keratosis. Lesion treatment where cryotherapy unavailable

  • Aldara® cream

    (imiquimod 5%) – patients who have failed to respond to other options

  • Metvix® cream

    (Methyl-5-Aminolevulinate). Treatment of actinic keratoses, superficial or nodular basal cell carcinoma and Bowen's Disease

    • 13.8.3 Miscellaneous

  • Pigmanorm®

    Cream (hydroquinone 5%, tretinoin 0.1%, hydrocortisone 1%) – melanin-induced hyperpigmentation of the skin (unlicensed)

    • 13.9 Shampoos and other preparations for scalp and hair conditions

    Please refer to the BNF for information regarding constituents.

  • Alphosyl 2 in 1®

    Shampoo

  • Capasal®

    Shampoo

  • Dermax®

    Shampoo

  • Ketoconazole 2%

    Shampoo

  • Polytar®

    Liquid

    • 13.10 Anti-infective skin preparations

    13.10.1 Antibacterial preparations

    13.10.1.1 Antibacterial preparations only used topically

  • Bactroban®

    Mupirocin 2% cream

  • Polyfax®

    Polymixin B sulphate and bacitracin zinc ointment

  • Flamazine®

    Silver sulfadiazine 1% cream

    • 13.10.1.2 Antibacterial preparations also used systemically

  • Fucidin®

    Ointment/cream (fusidic acid 2%)

  • Rozex®

    Gel/cream (metronidazole 0.75%) – For malodorous tumours and skin ulcers

    • 13.10.1.3 Rosacea

  • Rozex®

    Gel/cream (metronidazole 0.75%)

    • 13.10.2 Antifungal preparations

    Recommended

  • Clotrimazole 1%

    Cream/solution

    • Alternative

  • Miconazole 2%

    Cream

  • Terbinafine 1%

    Cream

  • Nystatin

    Cream/ointment

  • Nizoral®

    Cream (Ketoconazole 2%)

    • Specific Indication

  • Amorolfine 5%

    Nail laquer (prescribe generically) – nail infections, where oral therapy is contra-indicated.

    • 13.10.3 Antiviral preparations

  • Aciclovir 5%

    Cream - should only be started at first sign of attack.

    • 13.10.4 Parasiticidal preparations

  • Hedrin®

    Lotion (Dimeticone 4%)

  • Derbac M®

    Aqueous liquid (Malathion 0.5%)

  • Lyclear®

    Dermal cream (Permethrin 5%)

    • 13.10.5 Preparations for minor cuts and abrasions

    Skin tissue adhesive
  • LiquiBand®
  • Histoacryl®

    • 13.11 Skin cleansers and antiseptics

    GHNHSFT Local Guideline: Infection Control Policy

    13.11.1 Oxidisers and dyes

  • Permitabs®

    (Potassium permanganate) 400mg

    For external use only, toxic if swallowed. Only prescribe where use is absolutely necessary, and safe handling and storage have been clearly discussed.

  • Potassium permanganate application policy

    GHNHSFT Local Guideline: Potassium permanganate application policy (intranet)

    • 13.12 Antiperspirants

  • Driclor®

    (Aluminium chloride hexahydrate 20%)

    • 13.13 Wound management products and elastic hosiery

    Gloucestershire Wound Management Formulary

    13.13.1 Topical treatments for scar reduction

  • Dermatix®

    Gel

    • 13.14 Miscellaneous

  • Adalimumab

    Moderate to severe hidradenitis suppurativa as per NICE TA392

  • Secukinumab

    Moderate to severe hidradenitis suppurativa as per NICE TA935

  • Birch bark extract (Filsuvez® gel)

    Epidermolysis bullosa, as per NICE HST28

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    Key

    Hospital / Specialist only

    Specialist initiated / advised (with Shared Care Guideline)

    Specialist initiated / advised (without Shared Care Guideline)

    Non-specialist or Specialist

    Treatment Guidelines

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