netFormulary
Data extracted : 24/11/2017
 Formulary Section 13: Skin
 Details...
13.01 Management of skin conditions
For recommended choices of wound care products in UHL see Wound Management Formulary.
Link   Leicestershire Guidance: The use of Kelocote®, Pro-Sil®, Cica-Care®, Advasil Conform®, Mepiform® in the treatment of Hypertrophic Scars
Advasil Conoform® 
For the treatment of hypertrophic scars, in line with guidance
13.02.01 Emollients
  • Emollients should be applied frequently in any dry skin condition. They are particularly useful for dry eczema.  Patients should be encouraged to use them liberally as often as necessary rather than using extra applications of steroid preparations.
  • There are a wide variety of emollients and limited evidence that one is better than another.  There are variations in consistency and patient preference so it is important to find something the patient will use.
  • The formulary choices below are the recommended first line choices, however if none of these suit then alternative products may be used. Please see the prescribing guidelines for further information  Consider cost.
  • If bathing worsens dryness, emulsifying ointment should be used in place of soap; alternatively add 15mL of bath oil to bath water then soak for 10 minutes
  • Preferred Emollients and Soap substitutes include: Epimax cream, ZeroAQS cream, Aquamax cream, Isomol gel, Zerodouble gel, AproDerm cream, Zerobase cream, Oilatum Cream, Emulsifying ointment, WSP 50% / LP 50%, Zeroderm ointment and Hydromol ointment.  See link below for further details. Eczmol may be used for decreasing bacterial load in recurrent atopic eczema in children.
Link   Leicestershire Guidance: Emollients
Link   MHRA Advice: Paraffin-based skin emollients on dressings or clothing: fire risk
Link   NICE CG 57: Atopic eczema in children
First Choice:
Epimax® 
First choice alternative to Aproderm, Aqueous cream, Aquamax, Diprobase cream, E45 cream, Oilatum cream, ZeroAQS and Zerobase
First Choice:
Hydromol Ointment® 
First choice alternative to Zeroderm
First Choice:
Isomol gel® 
First choice alternative to Doublebase gel and Zerodouble gel

Other emollients can be used if directed by dermatology or if first choice options not tolerated. Please see prescribing guidance below
Restricted Drug  Aveeno Cream®  
For use in line with ACBS criteria only. For endogenous and exogenous eczema, xeroderma, ichthyosis and senile pruritus associated with dry skin
Restricted Drug  Dermol® 
For use by dermatologist only
13.02.02 Barrier preparations

  • These preparations protect the skin from repeated exposure to water and other irritants.

  • ’Napkin rash’ is usually irritant dermatitis; frequent napkin changes and thorough cleansing are therefore very important before applying any medication such as metanium ointment. If persistent, consider using hydrocortisone cream 0.5% or 1%.

  • Candidosis requires a topical antifungal agent.
First Choice:
Metanium®Ointment 
Second Choice:
Sudocrem® 
13.03 Topical local anaesthetics and antipruritics

  • A diverse range of conditions may cause itch including skin diseases (e.g. eczema), hypersensitivity reactions, obstructive jaundice, endocrine disorders or malignancy. Where possible investigate and treat underlying cause.

  • Cholestyramine is useful for pruritus in obstructive jaundice. Topical preparations may provide symptomatic relief but are not always effective.

  • Emollients are often helpful, as dry skin tends to exacerbate pruritus, particularly where it is due to eczema. The use of appropriate topical steroids should also be considered.

  • Systemic antihistamines are a useful adjunct in the treatment of itchy dermatoses.
First Choice:
Calamine Lotion 
Topical. Avoid on dry flaky skin.
First Choice:
Cetirizine 
Systemic. Relatively non-sedating, but in some cases of pruritus it may be less effective than a sedative.
First Choice:
Chlorpheniramine 
Systemic. Sedating.
Second Choice:
Crotamiton cream  (Eurax®)
Topical.
Restricted Drug  Calamine aqueous cream  
Prison use only
Restricted Drug  Hydroxyzine 
Sedating. May be used for patients with pruritus if itching at night is troublesome.
13.04 Topical corticosteriods.

  • Topical steroids are the mainstays of treatment for eczematous conditions. A preparation of the weakest potency that is effective should be used for maintenance; the more potent steroids should only be used for short periods for initial control of the disorder. Patients requiring more intensive therapy should be referred to a dermatologist. There is however a danger of under treating the condition when it is severe enough to warrant a short course of a more potent topical steroid. Hydrocortisone 1% can be used for longer periods for active eczema on the body and limbs without a high risk of steroid induced side effects. Once improved switch to an emollient.

  • Only hydrocortisone should normally be used on the face. The potent steroids are best avoided in children unless under specialist advice and supervision. It is suggested that nothing more potent than 1% hydrocortisone should be used on infants unless under specialist care. Steroids should not be used in the presence of infection unless specific anti-infective therapy is also given.

  • Prolonged use of potent steroids, particularly on the face or in skin folds, can lead to local atrophy, striae, purpura, spread and worsening of infection, peri-oral dermatitis and systemic effects including adrenal suppression.

  • Apply sparingly once or twice daily. The applying hand(s) should be washed after use. Generally creams are more cosmetically acceptable but ointments or oily creams are preferable for very dry, fissured lesions or lichenified eczema.

  • As an approximate guide the following usage (adults) should not be exceeded: Mild-moderate potency: 50g per week. Potent: 30g per week. Very potent: 15g per week.
Link   NICE CG 57: Atopic eczema in children
Link   NICE TA 81: Atopic dermatitis (eczema) - topical steroids
First Choice:
Hydrocortisone 1% 
Mild.
First Choice:
Clobetasone Butyrate 0.05%  (Eumovate ®)
Moderately potent.
First Choice:
Betamethasone Esters 0.1%  (Betnovate®)
Potent.
First Choice:
Clobetasol Propionate 0.05%  (Dermovate®)
Very potent.
Second Choice:
Hydrocortisone 0.5%, 2.5% 
Mild potency.
Second Choice:
Betamethasone Esters 0.025%  (Betnovate-RD®)
Moderately potent.
Second Choice:
Fluocinolone Acetonide 0.00625%  (Synalar 1 in 4 Dilution®)
Moderately potent.
Second Choice:
Fluocinonide 0.05%  (Metosyn®)
Potent. Ointment contains lanolin.
Second Choice:
Hydrocortisone Butyrate 0.1%  (Locoid®)
Potent.
Diflucortolone Valerate  (Nerisone®, Nerisone Forte®)
Nerisone cream and oily cream
Nerisone Forte oily cream

At UHL initiation by specialist dermatologists only.
13.05 Preparations for eczema and psoriasis
Systemic drugs affecting the immune response are also used in treatment of severe eczema and psoriasis but are for specialist use in a hospital setting.
13.05.01 Preparations for eczema

  • After eliminating any possible causes of contact dermatitis the mainstay of treatment is a topical steroid. Emollients should also always be used, particularly for dry, scaly eczema as they help to avoid excessive use of steroids. A systemic antipruritic may also be necessary.

  • Chronic eczema which has become lichenified can be treated with an ichthammol preparation if mild, or a tar preparation. Medicated bandages are useful if the limbs are extensively affected. These should not be used if there is active infection. Steroid ointments may also be necessary. Occlusion of an affected area can also break the itch / scratch cycle.

  • Weeping eczema can be treated with dressings soaked in an antiseptic such as potassium permanganate solution, or it can be added to the bath. This should not be used for longer than 48 hours.

  • Seborrhoeic eczema of the scalp can be treated with a tar shampoo if mild or a steroid scalp application.

  • Eczema that becomes secondarily infected should be treated appropriately with antibacterials or antifungals. Bacterial infections, unless superficial, may be more effectively treated with systemic flucloxacillin.
Polytar Emollient ® 
Bath additive containing coal tar.
Use 2-4 capfuls in bath water. Bathe for 20 minutes.
Zinc Paste and Ichthammol Bandage BP 
’Ichthopaste’, ’Ichthaband’ impregnated with paste containing:Ichthammol 2%, Zinc oxide 15%
Potassium permanganate tablets for solution 
Wet dressings or soaks: 1 tablet dissolved in 4 litres water gives a concentration of approx. 1:10,000. Baths: add several tablets to the bath water.
Caution stains skin and clothing.
Restricted Drug  Alitretinoin   (Toctino®)
Specialist dermatologist prescription only. Use supported only in line with NICE TA 177
Pregnancy prevention precautions required
High Cost Therapy excluded to tariff.
13.05.01 Topical preparations for eczema
13.05.01 Oral retinoid for eczema
13.05.02 Preparations for psoriasis

  • Mild or chronic plaque psoriasis can be treated initially with emollients. For more severe cases, salicylic acid, coal tar, calcipotriol or dithranol preparations may be required.

  • Combination therapy tends to be used for scalp psoriasis e.g. a tar shampoo and ointment such as Sebco®(which contains coal tar and salicylic acid) Topical steroids such as ’Betnovate’ scalp application may also help. Very potent steroids are best avoided except on specialist advice as they may cause a relapse or rebound when discontinued. Calcipotriol scalp application is an alternative.

  • A dermatologist should supervise treatment of very active or severe psoriasis and hospitalisation may be necessary. Erythrodermic or pustular psoriasis requires systemic therapy, which should be initiated by a dermatologist. Acitretin (a retinoid) used for this indication is only available from hospital pharmacies.

  • Betamethasone and calcipotriol may be used in combination as an ointment (Dovobet). The recommended treatment period is 4 weeks.  It is less costly to prescribe the ingredients separately reserving the combination product for those with genuine compliance difficulties. When different preparations containing calcipotriol are used together, max total dose in adults is 100g in any one week. Dovobet is available in gel form for use as a scalp application (replacing Xamiol).  This can be used on non scalp areas for mild to moderate psoriasis.
Link   NICE CG 153: Psoriasis
Link   NICE Pathway: Psoriasis
Link   SIGN guidance: Psoriasis and psoriatic arthritis in adults
Calcipotriol 
Vitamin D analogue used in plaque psoriasis affecting up to 40% of skin area. It is more acceptable to patients than dithranol because it is less irritant to ’normal’ skin, is odourless and non-staining.
Dithranol  (Dithrocream®)
Very effective but must be applied carefully, as it is very irritant to unaffected skin. Selection of the most appropriate product depends on the severity and the site of the condition. Patients should be advised that dithranol will stain clothing and hair.
Start with the lowest strength and gradually progress to higher strengths if necessary, over a period of several weeks. Apply sparingly to the lesions only.
Calcipotriol & Betamethasone Cutaneous Foam  (Enstilar®)
To be used in line with the primary care psoriasis pathway
Restricted Drug  Sebco® 
At UHL for initiation by specialist dermatologists only.
Polytar liquid ®(250mL) 
Can be used as a shampoo
Polytar Emollient® (500ml) 
Coal tar and salicylic acid ointment LPS (200g) 
Coal tar & salicylic acid cream LPS (150g) 
Tar cream LPS (150g) 
Restricted Drug  Apremilast 
For use by Specialist Dermatologists only
Supported for use in line with NICE TA 419

Date of entry of decision to formulary: February 2017
13.05.02 Oral retinoids for psoriasis
Restricted Drug  Acitretin 
For use by Specialist Dermatologists only
Pregnancy prevention precautions required
13.05.03 Drugs affecting the immune response
Link   Leicestershire Guidance: Psoriasis Biological Therapy Guidelines
Restricted Drug  Pimecrolimus  (Elidel®)
Tacrolimus and pimecrolimus can be considered as options to treat moderate or severe atopic eczema if other treatments have been tried and in line with NICE recommendations. They are not suitable for treatment of mild atopic eczema. The EMEA has recommended greater caution in the way these medicines are used in order to reduce potential risks of skin cancer and lymphoma as far as possible.
Restricted Drug  Tacrolimus  (Protopic®)
Tacrolimus and pimecrolimus can be considered as options to treat moderate or severe atopic eczema if other treatments have been tried and in line with NICE recommendations. They are not suitable for treatment of mild atopic eczema. The MHRA has issued a reminder of the need for caution in use due to a possible risk of malignancies including lymphomas and skin cancers.
Restricted Drug  Ciclosporin 
Specialist Dermatology initiation only
Restricted Drug  Methotrexate  (Oral)
Specialist Dermatology initiation only
(Amber traffic light for rheumatology - see 10.01.03).
The BNF recommends that only one strength of methotrexate tablet (usually 2.5 mg) is prescribed and dispensed.
Restricted Drug  Azathioprine 
Specialist Dermatology initiation only
Restricted Drug  Etanercept   (Dermatology)
High Cost Drug excluded to tariff
Supported in line with NICE TA 103 only
Specialist Dermatology use only
Restricted Drug  Rituximab 
Specialist Dermatology use only
High Cost Drug excluded to tariff
For use in immunobullous diseases in line with NHSE policy 16035/P only
Restricted Drug  Adalimumab  (Dermatology)
High Cost Drug excluded to tariff
Supported for use in psoriasis in line with NICE TA 146
Also supported for patients with severe hidradentis suppuritiva in line with NICE TA 392 Date of entry of decision to Formulary:September 2016.
(Blueteq required)
Specialist Dermatology use only
Restricted Drug  Infliximab (Inflectra®)  (Dermatology)
High Cost Drug excluded to tariff
Supported for use in line with NICE TA 134 only
Specialist Dermatology use only

Prescribe by brand. Biosimilar inflectra to be used in new patients.
Restricted Drug  Methotrexate   (Subcutaneous)
Specialist Dermatology prescribing
Restricted Drug  Ustekinumab  (Dermatology)
High Cost Drug excluded to tariff
Specialist Dermatology use only
Supported for use in line with NICE guidance as an alternative to other approved biologic agents. Supported for sequential use in patients who have not tolerated approved biologic agents
Restricted Drug  Ixekizumab  
Specialist Dermatology use
High Cost Drug excluded to tariff

For use in line with NICE TA 442 only
Date of entry of decision to formulary: July 2017
Restricted Drug  Secukinumab   (Dermatology)
High Cost Drug excluded to tariff
Supported by TAS in line with NICE TA 350

Date of entry of decision to formulary: October 2015
13.06 Acne and rosacea

  • Mild acne can be treated with topical preparations alone. Benzoyl peroxide is more useful for inflammatory lesions and topical retinoids e.g. tretinoin where comedones predominate. The two can be used in combination if necessary, one at night and one in the morning. Patients should be encouraged to apply the preparations to the whole affected area, not just to individual lesions. They should be warned that irritation is likely at the start of treatment; frequency of application may need to be reduced if excessive irritation occurs. Improvement is unlikely during the first 6-8 weeks of treatment, but should be reviewed after 3 months. Patients should be warned that Benzoyl peroxide preparations may stain clothing and bed linen.

  • Topical antibiotics such as clindamycin or erythromycin also reduce inflammation, but antibiotic resistance is becoming a problem. Combining an antibiotic with benzoyl peroxide (to which resistance does not occur) may help to reduce this, as in the combination product Duac.

  • Epiduo (adapalene in combination with benzoyl peroxide) may be used as an alternative to Duac.  It has the advantage of a once daily application and no issues with antibiotic resistance development. 

  • Patients with moderate-severe acne or those known to scar easily should also receive systemic antibiotics.  Use adequate doses for at least six months; lower doses may be less effective and relapse tends to occur more frequently.

  • Antibiotic resistance is an increasing problem with systemic treatment. It may be minimised by using topical treatments where possible, not continuing treatment longer than necessary, using topical benzoyl peroxide in between antibiotic courses and avoiding oral and topical treatment with different antibiotics at the same time.

  • Patients who do not respond to antibiotics should be referred to a dermatologist for further advice. Severe nodulocystic acne and that resistant to standard treatment may be treated with the retinoid isotretinoin, for which hospital referral is required.

  • Female patients may respond to hormonal contraception, eg Dianette.

  • For Acne use products in line with ’LLR algorithm for Acne treatment’ see link below. At UHL this is restricted to initiation by dermatology specialists.
Link   Leicestershire Guidelines: LLR Algorithm for Acne Treatment
First Choice:
Benzoyl Peroxide 
Topical
First Choice:
Lymecycline 
Systemic antibiotic. Do not use during pregnancy.
Branded products may be lower cost in primary care.
First Choice:
Epiduo gel® 
Topical
Retinoid and benzoyl peroxide
Second Choice:
Clindamycin plus Tretinoin  (Treclin®)
Topical. Contains retinoid and clindamycin
Second line to Epiduo
Second Choice:
Doxycyline 
Alternative systemic choice to lymecycline
Duac gel® 
Topical
Clindamycin and benzoyl peroxide
Adapalene  (Differin®)
Topical
At UHL initiation by specialist dermatologists only.
Azelaic Acid 20% Cream  (Skinoren®)
Topical
At UHL initiation by specialist dermatologists only.
Restricted Drug  Erythromycin 
Systemic choice in pregnancy.
Restricted Drug  Isotretinoin 
Ivermectin Cream  
For rosacea
At UHL for initiation by Dermatologists only
Restricted Drug  Brimonidine Tartrate Gel  
For rosacea
At UHL for initiation by Dermatologists only
13.07 Preparations for warts and calluses

These self limiting conditions should not be referred to secondary care under ’The exceptional treatments policy’.

Salactol® 
For common or planar warts. If there is no response after several months consider cryotherapy.
Podophyllotoxin 0.15% cream  (Warticon®)
For ano-genital warts. Screen for other sexually transmitted disease.
13.08.01 Sunscreen preparations
Restricted Drug  Sunsense® Ultra  
Approved for patients who have a photosensitive disorder with widespread dysplastic lesions and/or a history of skin cancer
At UHL restricted to specialist Dermatology, Oncology or Paediatric prescribing only
13.08.01 Photodamage
Link   Leicestershire Guidelines: Actinic Keratoses (AK) Treatment Pathway
5-Flurouracil cream   (Efudix®)
Actikerall® 
Fluorouracil 0.5%, salicylic acid 10%
Diclofenac sodium   (Solaraze®)
Primary care product
Unlikely to be prescribed at UHL
Imiquimod 5%   (Aldara®)
Actinic keratoses in line with treatment pathway
’Red if used to treat Basal cell carcinoma
Ingenol mebutate  (Picato®)
13.09 Shampoos and other preparations for scalp and hair conditions
Restricted Drug  Ketoconazole shampoo 
Specialist Dermatology and Prison use only.
13.10 Anti-infective skin preparations

  • Topical antiseptics such as povidone-iodine are helpful in preventing perioperative infection. They are also used to treat mild superficial infections where systemic treatment is not necessary. Povidone-iodine has the anti-bacterial properties of iodine but is less irritant and less likely to cause sensitisation. Any underlying condition such as eczema or fungal infection must also be treated.

  • In dermatology at LRI, Unisept (Chlorhexidine 0.05%) is used routinely for skin disinfection prior to dermatological surgery.

  • Stellisept washes are recommended as part of MRSA guidelines.

  • Octenisan antibacterial skin lotion may be used for skin disinfection in young children/neonates
Stellisept 
Restricted Drug  Silver Sulfadiazine  (Flamazine®)
Used to prevent and treat infection in burns. It has good activity against Gram-negative organisms, including Pseudomonas sp. It is not a cost-effective treatment for minor burns where the skin is not broken.
Restricted Drug  Mupirocin Cream  (Bactroban®)
Good activity against Gram-positive organisms including MRSA (methicillin-resistant Staph. aureus). This may occasionally be recommended by microbiologists for the treatment of MRSA infected wounds.
Restricted Drug  Polyfax  
For facial burns for adults and children.
13.10.02 Antifungal preparations

  • Dystrophic nails are common and this doesn’t necessarily indicate fungal infections. They can be caused by other conditions e.g. psoriasis.

  • Infection should be confirmed using microscopy or culture before treatment is initiated.

  • Oral Terbinafine is the treatment of choice for toenail dermatophyte infections as it is more effective than griseofulvin. Topical antifungals such as tioconazole are much less effective than systemic therapy and should only be used for infections confined to the superficial or distal nail.

  • Most dermatophyte skin infections (ringworm) respond to topical clotrimazole but if lesions are extensive systemic therapy may be required. Scalp ringworm should always be treated systemically as topical therapy alone is ineffective. Griseofulvin is the only antifungal licensed for this indication in children, although Terbinafine is often used (unlicensed).

  • Nystatin cream and ointment have now been discontinued
First Choice:
Clotrimazole 
Topical treatment.
Second Choice:
Terbinafine 
Topical treatment - alternative to clotrimazole
Second Choice:
Griseofulvin 
Alternative systemic treatment.
13.10.04 Parasiticidal preparations
13.10.04 Scabies

  • Two courses of treatment are required and must be administered at least one week apart. Itching may persist and the rash may be present for up to 6 weeks after treatment.  This is due to the body’s allergic response to the mite.  The use of calamine lotion, eurax or antihistamines may be helpful in the management of itching.

  • Further courses of treatment may be necessary depending on the extent and severity of the scabies infection.  This must be advised by a dermatologist.

  • All members of the household and close contacts should be treated simultaneously. Permethrin and malathion require only a single application. Benzyl benzoate is no longer recommended as it is irritant and needs multiple applications. Itching may persist for up to 2 weeks despite elimination of scabies. Short-term use of a weak steroid cream (e.g. hydrocortisone 0.5%) may help if the itching is severe.
First Choice:
Permethrin dermal cream 
Treatment of choice in children over 2 months and under 6 months as low toxicity, non-irritant.
Second Choice:
Malathion 
Derbac-M is an alternative for treatment of scabies and is the treatment of choice in pregnancy, during breast feeding and for infants under 2 months.
Treatment of choice for pubic lice.
13.10.04 Head lice

Neuro-toxic insecticide medications are not recommended for the treatment of head lice. Local head lice policies advise use of Dimethicone 4% (Hedrin), two treatments 7 days apart.  Following treatment it is recommended that wet combing should be used weekly as a preventative measure.  If repeated treatment with Hedrin does not clear an infestation alternative methods of treatment will have to be considered. 
Contact the Health Protection Agency for advice prior to recommending an insecticidal treatment. 0116 2631400

First Choice:
Dimeticone 4%  (Hedrin®)
Two treatments 7 days apart.
13.12 Antiperspirants
Restricted Drug  Aluminium chloride  (Driclor®)
At UHL initiation by specialist dermatologists only
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