If a Specials product is required Dermatologists in Fife have agreed to use only BAD approved Specials whenever possible.

Transcription

1 1 13 Skin Vehicles Both vehicle and active ingredients are important in the treatment of skin conditions. The vehicle affects the degree of hydration of the skin, has a mild anti-inflammatory effect, and aids the penetration of active drug. Creams are generally more cosmetically acceptable than ointments because they are less greasy and easier to apply. Gels are particularly suitable for application to the face and scalp. Lotions have a cooling effect and may be preferred for application over a hairy area. Lotions in alcoholic basis can sting if used on broken skin. Ointments are greasy preparations and are more occlusive than creams. They are particularly suitable for chronic, dry lesions. Pastes can be used to protect inflamed, lichenified, or excoriated skin. Unlicensed / Special Manufacture Preparations The British Association of Dermatologists (BAD) list of preferred unlicensed dermatological preparations ( Specials ) is available at Specially manufactured products can often be very expensive (often in excess of 100 per item). They should only be used when a suitable proprietary product is unavailable. If a Specials product is required Dermatologists in Fife have agreed to use only BAD approved Specials whenever possible Emollients Soap Substitutes (all choices below are fragrance free) 1st Choice Hydromol Ointment 2nd Choice Doublebase Emollient Wash Gel QV Gentle Wash R- Cetomacrogol Preparations containing Dermol Wash antimicrobials/antiseptics Soap substitutes can be used for hand washing and in the bath. The choice of emollient should be based on the severity of the condition, patient preference, site of application and preparation cost. Aqueous cream is no longer recommended as a soap substitute or emollient as it contains sodium lauryl sulphate which may damage the skin barrier. Fragrance free emollients are preferable in the management of eczema. R - Cetomacrogol may be used as soap substitute/leave on emollient in patients with genital dermatoses.

2 2 Preparations containing antimicrobials or antiseptics should only be used be used when treating patients with infected eczema or when antisepsis is required. Emollient Bath Additives (all choices below are fragrance free) 1st Choice 2nd Choice Preparations containing antimicrobials/antiseptics Hydromol Bath and Shower Emollient QV Bath Oil Oilatum Junior Dermol 600 Shower Preparations (all choices below are fragrance free) 1st Choice Hydromol Bath and Shower Emollient 2nd Choice Doublebase Emollient Shower Gel Oilatum Shower Emollient Gel Preparations containing Dermol 200 Shower Emollient antimicrobials/antiseptics Fragrance free emollients are preferable in the management of eczema. Preparations containing antimicrobials or antiseptics should only be used be used when treating patients with infected eczema or when antisepsis is required. Medium Weight Emollients preferable for use during the daytime 1st Choice Oilatum Cream QV Cream, Lotion 2nd Choice Aveeno Cream (ACBS) Cetraben Cream Doublebase Gel Doublebase Dayleve Gel E45 Cream R- Dermamist spray Heavy Weight Emollients - useful at night time or when using occlusive dressings 1st Choice Hydromol Ointment Hydrous Ointment Liquid Paraffin 50% and White Soft Paraffin 2nd Choice 50% Ointment QV Intensive Ointment White Soft Paraffin Yellow Soft Paraffin

3 3 Emollients soothe, smooth and hydrate the skin and are indicated for all dry or scaling disorders. They should be applied frequently (at least 3-4 times per day) even after improvement occurs. The choice of emollient should be based on the severity of the condition, patient preference, site of application and preparation cost. Aqueous cream is no longer recommended as a soap substitute or emollient as it contains sodium lauryl sulphate which may damage the skin barrier. Products that come in pump dispensers may be more suitable for long term use in order to reduce the risk of microbial contamination. Emollients should be applied in the direction of hair growth. Aveeno Cream should only be prescribed in line with ACBS recommendations (see BNF). R Dermamist Spray - Spray formulations of emollients are more expensive than creams / ointments but may be useful in patients unable to apply other formulations. Patients should be informed of the potential fire hazard when using paraffin based (See BNF). Preparations containing Urea Balneum Plus Cream (urea 5% + lauromacrogols 3%) Hydromol Intensive Cream (urea 10%) Dermatonics Once Heel Balm (urea 25%) Preparations containing urea are suitable for the treatment of dry, scaling conditions (including ichthyosis) Barrier preparations Dimeticone preparations 1st Choice Conotrane 2nd Choice Metanium Zinc preparations Sudocrem Zinc and castor oil ointment Nappy rash may clear if skin is left exposed to air. If fungal infection present then an antifungal preparation should be used Topical local anaesthetic and antipruritic preparations Crotamiton +/- hydrocortisone cream (Eurax, Eurax-HC ) Crotamiton lotion (Eurax )

4 4 Doxepin 5% cream (Xepin ) Further information on managing pruritus can be found at Dermatology Referral and Management Pathways. Medicines prescribed should be in line with Fife Formulary choices. Pruritus may be caused by systemic disease, skin disease or as a side-effect of medication. Where possible the underlying cause should be identified and treated. An emollient may be of value where the pruritus is associated with dry skin. Topical antihistamines and local anaesthetics are not recommended as they are only marginally effective and can cause sensitisation. Sedating oral antihistamines may be helpful in alleviating itch (see section ) Topical Corticosteroids For appropriate quantities of steroids to be prescribed for specific areas of the body see BNF. Topical corticosteroids are classified according to their potency: Mildly potent Moderately potent Potent Very Potent Hydrocortisone 1% Fluocinolone acetonide % (Synalar 1 in 10 ) Betamethasone (as valerate) 0.025% (Betnovate-RD ) Clobetasone butyrate 0.05% (Eumovate ) Fluocinolone acetonide % (Synalar 1 in 4 ) Betamethasone dipropionate 0.05% (Diprosone ) Betamethasone valerate 0.1% Betamethasone diproprionate 0.05% + Salicylic acid 3% (Diprosalic ) Fluocinolone acetonide 0.025% (Synalar ) Hydrocortisone butyrate 0.1% (Locoid ) Mometasone furoate 0.1% Clobetasol propionate 0.05% (Dermovate ) R- Diflucortolone vaerate 0.3% (Nerisone Forte )

5 5 The choice of steroid will depend on the nature of the inflammatory condition being treated, the age of the patient and the site of application. In order to minimise the side-effects of a topical corticosteroid, it is important to apply once or twice daily to the affected areas only. Use the least potent formulation which is fully effective for the shortest duration of treatment. There is no benefit in increasing the strength of hydrocortisone. Instead, patients should be moved up the steroid potency ladder i.e. to a moderately potent steroid. The potency of the steroid should be stepped up or stepped down depending on the severity of symptoms. Potent corticosteroids should generally be avoided on the face and skin flexures. In general, the most potent topical corticosteroids should be reserved for recalcitrant dermatoses such as chronic discoid lupus erythematosus, lichen simplex chronicus, hypertrophic lichen planus, and palmoplantar pustulosis. Topical use of potent corticosteroids on widespread psoriasis can lead to systemic as well as to local side-effects. It is reasonable, however, to prescribe a mild to moderate topical corticosteroid for a short period (2 4 weeks) for flexural and facial psoriasis and to use a more potent corticosteroid such as betamethasone for psoriasis of the scalp, palms, or soles. Potent topical corticosteroids should be avoided or used only under specialist supervision in psoriasis because, although they may suppress the psoriasis in the short term, relapse or vigorous rebound occurs on withdrawal. Patients prescribed very potent topical corticosteroids should be reviewed regularly (at least monthly) and the preparation should not be prescribed on repeat prescription except on specialist advice. R Nerisone Forte is approved for restricted use in the management of genital dermatosis. Specialist initiation. Choice of formulation Water-miscible corticosteroid creams are suitable for moist areas e.g. axillae or groin or for weeping lesions. Ointments are generally chosen for dry, lichenified or scaly lesions or where a more occlusive effect is required. Gels / Lotions may be useful when minimal application to a large or hair-bearing area is required or for the treatment of exudative lesions. The inclusion of urea or salicylic acid increases the penetration of the corticosteroid. Mixing topical preparations (e.g. steroid, emollient) on the skin should be avoided where possible; several minutes should elapse between application of different preparations. Topical Corticosteroids with Antimicrobials/Antifungals Mildly potent Canesten HC

6 6 (hydrocortisone 1% + Clotrimazole 1%) Daktacort (hydrocortisone 1% + miconazole 2%) Fucidin H (hydrocortisone 1% + Fusidic acid 2%) Terra-Cortril (hydrocortisone 1% + oxytetracycline 3%) Timodine (hydrocortisone 0.5% + nystatin units/g +benzalkonium chloride + dimeticone) Trimovate Moderately Potent (clobetasone 0.05% + oxytetracycline 3% + nystatin units/g) Potent Betamethasone 0.1% and clioquinol 3% FuciBet (betametasone valerate 0.1% + fusidic acid 2%) Synalar C (fluocinolone 0.025% + clioquinol 3%) Very Potent Clobetasol with neomycin and nysytatin The advantages of including antibacterials or antifungals with corticosteroids in topical preparations are uncertain, but such combinations may have a place where inflammatory skin conditions are associated with bacterial or fungal infection, such as infected eczema. Long term use of products containing antibacterials and antifungals increases the likelihood of resistance and sensitisation. Normally products should be used on a regular basis but for a short period only, usually 7 days. Terra Cortril contains oxytetracycline and is therefore contraindicated for use in children aged under 12 years Preparations for Psoriasis and Eczema Preparations for eczema Also see SIGN 125 Management of Atopic Eczema in Primary Care (March 2011) Emollients see section Topical corticosteroids see section 13.4 Ichthammol preparations (for chronic lichenified eczema) - Systemic drugs Methotrexate, Ciclosporin, Azathioprine (off label use) H - Alitretinoin (Toctino )

7 7 Further information on managing atopic eczema can be found at Dermatology Referral and Management Pathways. Medicines prescribed should be in line with Fife Formulary choices. The use of emollients should continue even if the eczema improves or if other treatment is being used. Bandages (including those containing zinc and ichthammol) are sometimes applied over topical corticosteroids or emollients to treat eczema of the limbs. Bacterial infection (commonly with Staphylococcus aureus) can exacerbate eczema and may require treatment with topical or systemic antibacterial drugs. See section and NHS Fife Guidance on Management of Common Infections Antihistamines (see section 3.4.1) may be helpful short-term for the management of itch. In severe refractory eczema, systemic immunosupressants e.g. methotrexate, ciclosporin, azathioprine may be prescribed after specialist initiation. Alitretinoin is accepted for use in adults with severe hand eczema unresponsive to treatment with potent topical corticosteroids. It should be prescribed only by, or under the supervision of, a consultant dermatologist and be dispensed by a hospital-based pharmacy. Topical immunomodulator preparations - Pimecrolimus 1% Cream (Elidel ) - Tacrolimus 0.03%, 0.1% ointment (Protopic ) Topical pimecrolimus and tacrolimus are options for atopic dermatitis not controlled by maximal topical corticosteroid treatment or if there is a risk of important corticosteroid side-effects (particularly skin atrophy). They can cause a transient sensation of warmth or burning. Pimecrolimus is recommended for moderate atopic eczema on the face and neck of children aged 2 16 years. Tacrolimus is recommended for moderate to severe atopic eczema in adults and children over 2 years. The 0.03% strength should be used in children aged 2-16 years. The 0.1% strength in those over 16 years of age. Tacrolimus ointment may be used twice weekly for the maintenance treatment of moderate to severe atopic dermatitis in adult patients experiencing a high frequency of disease exacerbations (i.e. occurring 4 or more times per year) who have had an initial response to a maximum of 6 weeks treatment of twice daily tacrolimus ointment (lesions cleared, almost cleared or mildly affected).

8 Preparations for Psoriasis Also see SIGN 121 Diagnosis and Management of Psoriasis and Psoriatic Arthritis in Adults (Oct. 2010) Also see British Association of Dermatologists Guidelines for Biologic Interventions for Psoriasis 2009 Topical preparations Coal tar based preparations Dithranol Emollients see section Topical corticosteroids see section 13.4 Carbo-Dome (coal tar solution 10%) Exorex lotion (coal tar 1%) Psoriderm cream (coal tar 6%) Further information on managing psoriasis can be found at Dermatology Referral and Management Pathways. Medicines prescribed should be in line with Fife Formulary choices. Emollients are useful in softening scaling and reducing irritation in inflammatory / plaque psoriasis. It may be appropriate to treat psoriasis in specific sites, such as the face and flexures, usually with a mild corticosteroid, and psoriasis of the scalp, palms, and soles with a potent corticosteroid. Potent topical corticosteroids should be avoided or used only under specialist supervision in psoriasis because, although they may suppress the psoriasis in the short term, relapse or vigorous rebound occurs on withdrawal. Dithranol (Micanol, Dithrocream ) Dithranol is effective for chronic plaque psoriasis. Its major disadvantages are irritation (for which individual susceptibility varies) and staining of skin and of clothing. Dithranol should be applied to chronic extensor plaques only, carefully avoiding normal skin. Dithranol is not generally suitable for widespread small lesions nor should it be used in the flexures or on the face. Treatment should be started with a low concentration such as dithranol 0.1%, and the strength increased gradually every few days up to 3%, according to tolerance. Preparations are usually washed off after 30 to 60 minutes ( short contact ).

9 9 Vitamin D analogues Vitamin D analogue + steroid 1st Choice Calcipotriol ointment 2nd Choice Tacalcitol (Curatoderm ) ointment or lotion Calcitriol (Silkis ) Dovobet ointment or gel (calcipotriol 50mcg/g and betamethasone 0.05%) Vitamin D analogues are used as first-line treatment for plaque psoriasis; they do not smell or stain and they may be more acceptable than tar or dithranol products. Tacalcitol is less likely to irritate. Local skin reactions (itching, erythema, burning, paraesthesia, dermatitis) are common. Hands should be washed thoroughly after application to avoid inadvertent transfer to other body areas. Aggravation of psoriasis has also been reported. Dovobet contains betamethasone (a potent steroid). It should not be used on the face or flexures. Dovobet can be used once daily with a maximum 15g daily or 100g weekly. The recommended treatment period is 4 weeks. Treatment should only be continued beyond 4 weeks or repeated if recommended by a specialist. The use of Dovobet may lead to rebound exacerbation of the psoriasis when treatment is discontinued. When different preparations containing calcipotriol are used e.g. cream and scalp solution, the total maximum weekly dose should not be exceeded e.g. 60g cream or ointment with 30ml of scalp solution or 60ml of scalp solution with 30g of cream or ointment. Tacalcitol is of use for face and flexures. It should be used once daily with a maximum of 10g per day. Scalp Psoriasis Vitamin D analogues Calcipotriol scalp solution Vitamin D analogue + steroid Dovobet gel (calcipotriol 50mcg/g and betamethasone 0.05%) Topical Corticosteroid Preparations Potent Betamethasone valerate 0.1% lotion (Betacap, alcohol based) Betamethasone valerate 0.1% foam (Bettamousse, alcohol Based)

10 10 Very Potent Coal Tar preparations Shampoos "Leave on" products Betamethasone dipropionate 0.05%, salicylic acid 2% scalp application (Diprosalic, alcohol based) Hydrocortisone butyrate 0.1% liquid emulsion (Locoid Crelo, aqueous based) Fluocinolone acetonide 0.025% gel (Synalar Gel ) Clobetasol propionate 0.05% scalp application (Dermovate ) Clobetasol propionate 0.05% foam (Clarelux ), shampoo (Etrivex ) Alphosyl 2 in 1 shampoo (coal tar extract 5%) Capasal (coal tar 1%, coconut oil 1%, salicylic acid 0.5%) T/Gel (coal tar extract 2%) Mild scalp psoriasis should be treated with a tar based shampoo. Sebco (Coal tar solution 12 %, salicylic acid 2%, sulphur 4% in a coconut oil base) For moderate scalp psoriasis or for itchy scalps a steroid scalp application can be used shortterm. Normally applied in the morning. Mousse/foam formulations of steroids can be used in patients with sensitive skin or where there is local scalp irritation. Calcipotriol scalp application can provide a safe maintenance treatment when long-term therapy is required. Scalp psoriasis is usually scaly, and the scale may be thick and adherent. This requires softening with an ointment, cream, or oil and usually combined with salicylic acid as a keratolytic. Salicyclic acid preparations may be useful where there is a marked scaling of the skin or scalp. Sebco should be left on for at least an hour, often more conveniently overnight, before washing it off. Oral retinoids for psoriasis H - Acitretin (Neotigason )

11 11 Acitretin is teratogenic and must not be given to women of child-bearing age unless they practice effective contraception. Women must also be registered with a pregnancy prevention programme Drugs affecting immune response Also see Appendix 10B Guidance on the Safe Use Of Oral Methotrexate In Non- Malignant Conditions Also see British Association of Dermatologists Guidelines for Biologic Interventions for Psoriasis 2009 Systemic Drugs 1st Choice 2nd Choice Methotrexate 2.5mg tablets H Ciclosporin (Capimune ) ) H Apremilast (Otezla ) 3rd Choice H Adalimumab (Humira ) H Etanercept (Enbrel ) H Infliximab (Remicade ) H Secukinumab (Cosentyx ) H Ustekinumab (Stelara ) Methotrexate can be used for severe psoriasis. The usual dose is methotrexate 10 to 25 mg once weekly. To avoid prescribing, dispensing and administration errors only the 2.5mg strength of methotrexate should be prescribed and dispensed. The patient should be advised on the dose and frequency for taking methotrexate. The patient should be advised to report immediately any signs of methotrexate toxicity. Regular monitoring of full blood count, renal function and liver function should be undertaken in line with local protocols. Ciclosporin preparations should be prescribed by brand name only due to differences in bioavailability. The formulary choice for ciclosporin is Capimune (10mg capsules and liquid formulation must be prescribed as Neoral ). Patients on ciclosporin should be regularly monitored for adverse effects including hypertension and renal impairment. Apremilast is approved for the treatment of moderate to severe chronic plaque psoriasis when other systemic treatments e.g. methotrexate, ciclosporin, PUVA have failed or are unsuitable, prior to the use of biologics.

12 12 Adalimumab is recommended for the treatment of chronic plaque psoriasis in adults which has failed to respond to standard systemic treatments (including ciclosporin and methotrexate) or to PUVA therapy, or when standard treatments cannot be used because of intolerance or contraindications. Its use should be restricted to severe disease (PASI score > or equal to 10 and a DLQI score of >10). Adalimumab should be withdrawn if the response is not adequate after 16 weeks (PASI 75 response from baseline). Etanercept is recommended for the treatment of severe plaque psoriasis which has failed to respond to standard systemic treatments (including ciclosporin and methotrexate) or to PUVA therapy, or when standard treatments cannot be used because of intolerance or contraindications. Etanercept should be withdrawn if the response is not adequate after 12 weeks. Infliximab is recommended for the treatment of severe plaque psoriasis in adults which has failed to respond to standard systemic treatments (including ciclosporin and methotrexate) or to PUVA therapy, or when standard treatments cannot be used because of intolerance or contraindications. Infliximab should be withdrawn if the response is not adequate after 10 weeks (PASI 75 response from baseline or a 50% reduction and a 5 point reduction in DLQI from baseline). Secukinumab has a different mode of action to other biologics, approved for use in patients with moderate to severe plaque psoriasis when other biologics are ineffective or considered unsuitable. Ustekinumab is approved as a 3 rd choice treatment option for the treatment of severe plaque psoriasis (for treatment of psoriatic arthritis see section ) Acne and Rosacea Mild to moderate papulopustular rosacea prescribe a topical agent 1st Choice Metronidazole 0.75% cream or gel (Rozex ) 2nd Choice Azelaic Acid 15% gel (Finacea ) Moderate to severe papulopustular rosacea prescribe an oral agent 1st Choice Oxytetracycline or Tetracycline 2nd Choice Erythromycin Doxycycline (off label use) Lymecycline (off label use) Moderate to severe facial erythema predominant rosacea Brimonidine 0.3% gel (Mirvaso ) Acne Further information on managing rosacea can be found at Dermatology Referral and Management Pathways. Medicines prescribed should be in line with Fife Formulary choices. The pustules and papules of rosacea respond to topical metronidazole or to topical azelaic acid. Courses of oral antibiotics usually last for 12 weeks and are repeated intermittently. Brimonidine gel should only be used in patients with moderate severe erythema predominant rosacea. Patients should be reviewed after 1 month to determine benefits of ongoing treatment.

13 13 General Points The choice of treatment depends on whether the acne is predominantly inflammatory or comedonal and its severity. Acne can be broadly classified as mild, moderate and severe. Mild to moderate acne is generally treated with topical preparations. Systemic treatment with oral antibacterials is generally used for moderate to severe acne or where topical preparations are not tolerated or are ineffective or where application to the site is difficult Topical preparations for acne 1st Choice Benzoyl Peroxide 2.5% - 10% 2nd Choice Azelaic acid 20% cream (Skinoren ) Further information on managing acne can be found at Dermatology Referral and Management Pathways. Medicines prescribed should be in line with Fife Formulary choices. In mild to moderate acne, comedones and inflamed lesions respond well to benzoyl peroxide. The lower concentrations seem to be as effective as higher concentrations in reducing inflammation. It is usual to start with a lower strength and to increase the concentration of benzoyl peroxide gradually. Adverse effects include local skin irritation, particularly when therapy is initiated, but the scaling and redness often subside with treatment continued at a reduced frequency of application. If the acne does not respond after 2 months then use of a topical antibacterial should be considered. Azelaic acid has antimicrobial and anticomedonal properties. It can be used as an alternative to benzoyl peroxide for treating mild to moderate comedonal acne, particularly of the face. Some patients prefer azelaic acid because it is less likely to cause local irritation than benzoyl peroxide. Topical antibacterials for acne Clindamycin 1% (gel, lotion or solution) Duac (clindamycin 1% + benzoyl peroxide 5%) Zineryt (erythromycin 40mg + zinc acetate 12mg/ml) Topical antibacterials are effective in inflammatory acne and are probably best reserved for patients who wish to avoid oral antibacterials or who cannot tolerate them. Topical antibacterials are as effective as oral antibiotics but encourage resistance and are more expensive. Clindamycin solution (alcohol base) should be replaced with clindamycin lotion (aqueous base) or

14 14 clindamycin gel if skin irritation or drying out develops with the solution. Erythromycin topical solution on its own is not recommended due to antibiotic resistance. Duac Gel may be considered if benzoyl peroxide on its own is ineffective. Treclin may be considered in patients where monotherapy with clindamycin or tretinoin has been ineffective. Alcohol based antibacterials can produce mild irritation of the skin. Topical retinoids and related preparations for acne Combination Products Useful for treating comedones and inflammatory lesions in mild to moderate acne. Patients should be warned that some redness and skin peeling may occur initially but settles with time. Exposure to sunlight of areas treated with retinoids should be avoided or minimised. Topical retinoids are best applied at night. Several months of treatment may be needed to achieve an optimal response and the treatment should be continued until no new lesions develop. Adapalene is less irritant than other topical retinoids. Topical retinoids should be avoided in severe acne involving large areas. Topical retinoids are contra-indicated in pregnancy; women of child bearing age must use effective contraception (oral progestogen-only contraceptives are not considered effective in this scenario). Combination products are approved for use in patients with mild to moderate facial acne when monotherapy has been ineffective Oral preparations for acne 1st Choice Lymecycline 2nd Choice Doxycycline Erythromycin Oxytetracycline Systemic antibacterial treatment is useful for inflammatory acne if topical treatment is not adequately effective or if it is inappropriate. Anticomedonal treatment (e.g. with topical benzoyl Adapalene (Differin ) Isotretinoin gel Aknemycin Plus (tretinoin 0.025% + erythromycin 4%) Epiduo (adapalene 0.1% +benzoyl peroxide 2.5%) Treclin (tretinoin 0.025% + clindamycin 1%)

15 15 peroxide) may also be required. Oxytetracycline is usually given at a dose of 500 mg twice daily. Maximum improvement usually occurs after 4 to 6 months but in more severe cases treatment may need to be continued for 2 years or longer. Erythromycin at a dose of 500 mg twice daily is suitable for those under 12 or in pregnant women. Oral antibiotics may require up to 6 months of compliant use to achieve maximum benefit. Switch to an alternative antibiotic if no response after 6 months. Hormone Treatment for Acne Co-cyprindiol 2000/35 Co-cyprindiol (cyproterone acetate with ethinylestradiol) is no more effective than an oral broadspectrum antibacterial but is useful in women who also wish to also receive oral contraception. Co-cyprindiol should be stopped 3-4 months after the acne has completely resolved. Courses may be repeated if there is a recurrence of the acne. Co-cyprindiol is licensed for women with severe acne which has not responded to oral antibacterials and should not be used solely for contraception due to a higher risk of venous thromboembolism than low-dose combined oral contraceptives. The risk of VTE is rare but this remains an important side effect. Healthcare professionals should be vigilant for signs of DVT or PE in patients prescribed co-cyprindiol. Oral Retinoid for Acne Also see British Association of Dermatology Advice on the safe introduction and continued use of isotretinoin in acne in the U.K Isotretinoin is used in severe acne, acne unresponsive to prolonged courses of oral antibacterials, scarring, or acne associated with psychological problems. Isotretinoin is a toxic drug that should be prescribed only by, or under the supervision of, a consultant dermatologist. It is given for at least 16 weeks; repeat courses are not normally required. The drug is teratogenic and must not be given to women of child-bearing age unless they practice effective contraception. Women must also be registered with a pregnancy prevention programme Warts and calluses H Isotretinoin Occlusal (salicylic acid 26%) Salactol (salicylic acid 16.7% +lactic acid 16.7%) Verrugon (salicylic acid 50%)

16 16 Further information on the management of warts can be found at Dermatology Referral and Management Pathways. Medicines prescribed should be in line with Fife Formulary choices. Warts may regress on their own and treatment is required only if the warts are painful, unsightly, persistent, or cause distress. Wart removing preparations are keratolytic. They can cause irritation and application to normal or broken skin should be avoided. Surrounding skin to the wart can be protected by applying soft paraffin. Anogenital warts Podophyllotoxin 0.15% cream (Warticon ) 1st Choice or 0.5% solution Cryotherapy 2nd Choice S - Imiquimod 5% cream (Aldara ) Podophyllotoxin and cryotherapy are appropriate first line therapies in most instances. Patients with a limited number of external warts or keratinised lesions may be better treated with cryotherapy rather than using podophyllotoxin. Podophyllotoxin cream is recommended for use by women and the solution for use by men. Surrounding skin should be protected when treating anogenital warts. Treatment of warts should also be accompanied by screening for other sexually transmitted infections and counselling on various sexual health issues. Consider referral to GU Medicine when there are extensive warts, perianal warts, keratinised warts, recalcitrant warts and if warts are in immunocompromised/hiv patients, in men who have sex with men or pregnant patients. Imiquimod is relatively expensive and should be used only when other treatments have failed. Podophyllotoxin and imiquimod should not be used during pregnancy. Imiquimod is the only drug licensed for perianal warts. Imiquimod 3.75% cream (Zyclara ) is not approved for use by the SMC due to a nonsubmission. Requires submission and approval of an Individual Patient Treatment Request (IPTR) before prescribing Sunscreens and Camouflagers Sunscreen Preparations (ACBS) Sunsense Ultra lotion (UVB-SPF50+) Uvistat cream (UVB-SPF50) Sunscreen preparations may rarely cause allergic reactions.

17 17 For optimum photoprotection, sunscreen preparations should be applied thickly. Preparations with SPF less than 30 should not normally be prescribed. Sunscreen preparations should only be prescribed in line with ACBS recommendations. See BNF. Photodamage Lesional Small Field Large Field Actikerall (Fluorouracil 0.5%, salicylic acid 10% solution) Cryotherapy 1 st Choice Solaraze (Diclofenac 3% gel) 2 nd Choice Fluorouracil 5% cream (Efudix ) Ingenol mebutate gel (Picato ) 3 rd Choice S - Imiquimod 5% cream ( Aldara ) Solaraze (Diclofenac 3% gel) Fluorouracil 5% cream (Efudix ) Further information on managing actinic keratosis can be found at Dermatology Referral and Management Pathways. Medicines prescribed should be in line with Fife Formulary choices. Actinic keratosis are pre-malignant but transformation to squamous cell carcinoma is rare. Patients must be referred if diagnosis is uncertain or if lesions become thickened or tender. Skin inflammation is common with topical fluorouracil and the concomitant use of a moderate/potent topical corticosteroid can be used. Fluorouracil 0.5% / salicylic acid 10% cutaneous solution (Actikerall ) can be used in immunocompetent patients with slightly palpable and/or moderately thick hyperkeratotic actinic keratosis (grade I/II). For use in patients with <10 isolated lesions of actinic keratoses where cryotherapy is unsuitable. Care should be taken when prescribing diclofenac gel. Only the 3% strength (Solaraze ) is licensed for use in actinic keratosis. Ingenol mebutate may improve adherence as it is only applied for 2-3 days. Local skin reactions peak at day 4 and tend to resolve by day 14. Imiquimod 5% cream (Aldara ) can be used on specialist advice based on the size or number of lesions Camouflagers (ACBS)

18 18 Should only be prescribed in line with ACBS recommendations. See BNF Shampoos and other preparations for scalp and hair conditions Shampoos Benzalkonium chloride 0.5% (Dermax ) Ketoconazole Selenium sulphide (Selsun ) Tar preparations Alphosyl 2 in 1 shampoo (coal tar extract 5%) Capasal (coal tar 1%, coconut oil 1%, salicylic acid 0.5%) T/Gel (coal tar extract 2%) Other Scalp preparations Sebco (Coal tar solution 12 %, salicylic acid 2%, sulphur 4% in a coconut oil base) Ketoconazole shampoo should be considered for persistent or severe dandruff or for seborrhoeic dermatitis of the scalp. Shampoo formulations are preferred for moderate scaly scalp conditions whereas more severe conditions require the use of an ointment. Hirsutism Dermacolor Veil 1st Choice Co-cyprindiol 2000/35 2nd Choice Eflornithine (Vaniqa ) Co-cyprindiol may be effective for moderately severe hirsutism. Treatment is required for 6 12 months before benefit is seen. Co-cyprindiol should be stopped 3-4 months after the hirsutism has completely resolved. Courses may be repeated if there is a recurrence. For further information on the safe prescribing of co-cyprindiol see section Eflornithine is relatively expensive and should only be used when co-cyprindiol can not be used. It should be discontinued if there is no improvement after 4 months of treatment Anti-infective skin preparations Antibacterial preparations Fusidic acid

19 19 Hydrogen peroxide cream (Crystacide ) Metronidazole R- Mupirocin (Bactroban ) Silver sulfadiazine (Flamazine ) Topical antibiotics should only be used for localised skin infections and for a short duration to minimise the risk of bacterial resistance. Hydrogen peroxide cream (Crystacide ) may be used as an alternative agent to topical antibiotics. Hydrogen peroxide cream may also be used in the management of molluscum contagiosom. Further information on managing molluscum contagiosom can be found at Dermatology Referral and Management Pathways. In the community, for acute impetigo systematic review indicates topical and oral treatment produce similar results. As resistance is increasing topical antibiotics should be reserved for very localised lesions. Small areas of the skin may be treated by short-term topical application of fusidic acid three to four times daily for 5 days. Mupirocin should be used only to treat Methicillin-Resistant Staphylococcus Aureus (MRSA). To avoid the development of resistance, topical mupirocin or fusidic acid should not be used for longer than 7 days and local microbiology advice should be sought before using in hospital. If the impetigo is extensive or longstanding, an oral antibacterial such as flucloxacillin (or erythromycin in penicillin-allergy) should be used. Topical antibacterials should be avoided on leg ulcers unless used in short courses for defined infections; treatment of bacterial colonisation is generally inappropriate. Silver sulfadiazine is used in the treatment of infected burns Antifungal Preparations Amorolfine Clotrimazole Miconazole Nystatin Terbinafine Tioconazole 3% Combination products with corticosteroids see section 13.4 Further information on managing fungal nail infections can be found at Dermatology Referral and Management Pathways. Medicines prescribed should be in line with Fife Formulary choices.

20 20 Most localised fungal infections are treated with topical preparations. To prevent relapse, local antifungal treatment should be continued after the disappearance of all signs of infection. See individual products for treatment duration. Topical application of amorolfine or tioconazole may be useful for treating early onychomycosis when involvement is limited to mild distal disease in up to 2 nails, or for superficial white onychomycosis, or where there are contra-indications to systemic therapy. More extensive nail infections require oral treatment (see section 5.2). Skin scrapings should be examined if systemic therapy is being considered or where there is doubt about the diagnosis. Combination of an imidazole antifungal and a mild corticosteroid (see section 13.4) may be of value in the treatment of eczematous intertrigo and, in the first few days only, of a severely inflamed patch of ringworm. Combination of a mild corticosteroid with either an imidazole or nystatin may be of use in the treatment of intertrigo associated with candida (see section 13.4) Antiviral preparations Aciclovir cream can be used for the treatment of initial and recurrent labial herpes simplex infections (cold sores). It is best applied at the earliest possible stage, usually when prodromal changes of sensation are felt in the lip and before vesicles appear Parasiticidal preparations Head lice "Bug busting Kit" Dimeticone 4% lotion (Hedrin ) Malathion 0.5% aqueous liquid (Derbac-M ) Scabies 1st Choice Permethrin 5% cream 2nd Choice Malathion 0.5% aqueous liquid (Derbac-M ) Crab (Pubic) lice Malathion 0.5% aqueous liquid (Derbac-M ) Permethrin 5% cream Dimeticone coats head lice and interferes with water balance in lice by preventing the excretion of water; it is less active against eggs. Head lice can not become resistant to dimeticone due to its mode of action. Aciclovir cream

21 21 Head Lice Scabies Malathion is recommended for scabies, head lice and crab lice. Permethrin is effective for scabies and crab lice but permethrin crème rinse is unsuitable for treatment of head lice. Head lice must be seen before any insecticidal treatments are used. Nits (empty egg shells) do not constitute an infection. Treat only if head lice are found. There is no need to treat members of the family or close contacts that do not have head lice. The policy of rotating insecticides on a Fife-wide basis is now considered outmoded. To overcome the development of resistance, a mosaic strategy is required whereby, if a course of treatment fails to cure, a different insecticide is used for the next course. A Bug Busting Kit can be recommended / prescribed as an alternative to insecticides for the detection and treatment of head lice. Only one kit is required per family and it is reusable. Aqueous formulations (liquids) are preferred. Shampoos or mousses should not be used as they are diluted too much in use and have a limited contact time to be effective. A contact time of 12 hours or overnight treatment is recommended to ensure eggs are killed. In general, a course of treatment for head lice should be 2 applications of product 7 days apart to prevent lice emerging from any eggs that survive the first application. No more than 3 applications of insecticidal preparations per infection are recommended. Applied no more frequently than once per week. Wet combing can be used to mechanically remove head lice by combing wet hair meticulously with a detection comb (probably for at least 30 minutes each time) over the whole scalp at 3- day intervals for a minimum of 3 weeks; hair conditioner can be used to facilitate the process. All members of the affected household and close contacts should be treated simultaneously, even if symptom free. Permethrin 5% dermal cream is the recommended 1 st line treatment of scabies; malathion 0.5% aqueous liquid can be used if permethrin is inappropriate. Treatment should be applied to the whole body including the scalp, neck, face, and ears. Particular attention should be paid to the webs of the fingers and toes and lotion brushed under the ends of nails. Treatment should be left on the skin for 8-12 hours with permethrin and for 24 hours with malathion, before washing off. Malathion and permethrin should be applied on two occasions for treatment at least one week apart. It is important to warn users to reapply treatment to the hands if they are washed. The itch and eczema of scabies can persist for 4-6 weeks after the infestation has been eliminated and treatment for pruritus and eczema may be required. Crotamiton (see section 11.3), a topical corticosteroid (see section 11.4) or a sedating antihistamine (see section 3.4) at

22 22 Crab (Pubic) Lice night may be of benefit. Permethrin and malathion are used to eliminate crab lice. Preparation should be applied, allowed to dry naturally and washed off after 12 hours; a second treatment is needed after 7 days to kill lice emerging from surviving eggs. All surfaces of the body should be treated, including the scalp, neck, and face (paying particular attention to the eyebrows and other facial hair). A different insecticide should be used if a course of treatment fails Preparations for Minor Cuts and Abrasions Magnesium Sulfate Paste Oxidisers and Dyes Crystacide cream is applied 2-3 times daily on the affected skin area. The treatment period should not exceed 3 weeks. Crystacide cream may be used as an alternative agent to topical antibiotics in the treatment of impetigo and molluscum contagiosom Antiperspirants Hydrogen Peroxide cream (Crystacide ) Hydrogen peroxide solution Potassium Permanganate (Permitabs ) Aluminium Chloride Hexahydrate (Anhydrol Forte, Driclor ) H Botulinum toxin type A (Botox ) Botulinum toxin may be used in severe hyperhidrosis of the axillae unresponsive to topical antiperspirants or other treatments.