Local Formulary
BNF Chapter 13 Skin
Subsections are intentionally omitted where there is no formulary drug choice
Staff Group covered by this document
All prescribers working within the Stockport Health Economy
Key Objective of the document
To provide guidance on the most cost effective medications for use in general practice
Verification
This guideline has been reviewed and approved by the following;
NHS Stockport STAMP committee
NHS Stockport Prescribing Advisers
CCG Prescribing Lead
Head of Service Sign Off …………………………………
Date
Signed off by ………………………………………….
Date
(Director)
Version Control
Key
Amber drug (shared care)
These drugs may be prescribed in General Practice provided an Approved Shared
Care Protocol has been Provided and that the GP is happy to accept the clinical
responsibilities and monitoring responsibilities detailed in said protocol.
See SMC website for details of approved Protocols ( add link)
see GMMMG RAG list
Red drug
These drugs should not be prescribed in General Practice, see
GMMMG RAG list
OTC
Over the Counter
These items can be purchased without prescription. Prescribers may suggest
patients buy such medication at their own discretion
Unlicensed - highlighted as follows
Display choices as - Drug name
or OTC or
or
For cost information please go to Drug Tariff or your Clinical System
Version 1.0 - Last updated November 2013
Review date November 2015
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Local Formulary
BNF Chapter 13 Skin
Subsections are intentionally omitted where there is no formulary drug choice
Section 13.2
Emollient and Barrier Preparations
13.2.1
Light Emollients
Emollients
Cetraben® Cream OTC
Diprobase® cream OTC
Preparations containing benzalkonium
chloride (marked with a *) may cause skin
irritation with long term use.
For this and other additives in skin
emollients which may cause irritation click
here
Doublebase® Cream OTC
See also
E45® Cream OTC
Medium Emollient
®
Epaderm Cream OTC
Heavy Emollients-
MHRA Medicines Devices Alert:products
containing chlorhexidine
Emulsifying ointment OTC,
White or Yellow soft Paraffin,
Hydromol Oint OTC
Preparations Containing Urea
Balneum® Cream OTC
Balneum® Plus Cream OTC
All emollients except Doublebase and liquid
paraffin may be used as soap substitutes
by firstly wetting the skin before washing
with the product and rinsing off
Preparations containing
antimicrobials
Dermol® cream* 500g OTC
Dermol 500® lotion* OTC
Eczmol® Cream OTC
Soap substitute
Aqueous cream 500g (not as an
emollient) OTC
Aquamax® Cream OTC
MHRA Alert for Aqueous Cream
Additional notes
Once a suitable emollient has been determined for a patient then prescribe as 500g depending
on the amount of coverage required.
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. For the full NPSA alert please
follow this link: Fire Hazard with Paraffin-based skin products.
This section of the skin chapter offers a first choice and then alternatives that are listed in order
of cost at the time that this chapter was written. Several of these should be tried before
referring to a specialist centre.
Patients who have been discharged from a specialist centre on a particular product should be
maintained on the same product when it is effective.
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BNF Chapter 13 Skin
Subsections are intentionally omitted where there is no formulary drug choice
13.2.1.1
Emollient bath
and shower
preparations
First choice
MHRA Medicines Devices Alert:products
containing chlorhexidine
Hydromol bath and shower®
emollient 500ml OTC
Alternatives
Oilatum emollient® bath additive
500ml OTC
Cetraben® bath additive OTC
E45 emollient® wash cream OTC
Preparations containing benzalkonium
chloride (marked with a *) may cause skin
irritation with long term use.
With antimicrobial
Dermol 500® lotion* OTC
Dermol 600® bath emollient* OTC
13.2.2
First choice
Barrier
Preparations
Zinc and castor oil cream OTC
Apply as a preventative, should normally be
purchased OTC.
Alternatives
Conotrane® cream OTC
Drapolene® cream OTC
13.3
Topical local anaesthetics and antipruritics
First choice
Crotamiton (Eurax®) cream OTC
Alternative
Menthol 1% in aqueous cream OT
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Review date November 2015
Should usually be bought OTC where
possible
Do not prescribe other strengths
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Local Formulary
BNF Chapter 13 Skin
Subsections are intentionally omitted where there is no formulary drug choice
13.4
Topical Corticosteroids
First Choice
MILD
Hydrocortisone 0.5% and 1% cream 30g,
50g
Hydrocortisone 0.5% and 1% ointment
30g, 50g
MILD with antimicrobial
Canesten HC ®cream
Daktacort® cream
Daktacort ®ointment
Timodine® cream
Fucidin H® cream
See also Nice TA-81 Topical
corticosteroids
15g Hydrocortisone cream 1% is
available OTC but cannot be sold
OTC for use on the face
15g Canesten HC® cream available
OTC for athletes foot and fungal
infection of skin folds with associated
inflammation
15g Daktacort HC® cream is available
OTC for athletes foot and candidal
intertrigo
MILD with crotamiton
Eurax-Hydrocortisone ®cream 30g OTC
MODERATELY POTENT
Eumovate® 0.05% cream 30g (small
lesions) OTC
Eumovate ®0.05% ointment 30g (small
lesions)
Betnovate RD® 0.025% cream 100g.
(large lesions)
Betnovate RD ®0.025% ointment 100g
(large lesions)
5g Eumovate® available OTC for short
term treatment of eczema and
dermatitis in adults and children over
12 years.
MODERATELY POTENT with urea
Alphaderm ®cream 100g
Hydromol HC intensive® cream
MODERATELY POTENT with
antimicrobial
Trimovate ®cream 30g
POTENT
Betnovate® 0.1% cream 100g
Betnovate ®0.1% ointment 100g
Betacap ®0.1% scalp application 100ml
POTENT with salicyclic acid
Diprosalic® ointment 100g
Diprosalic ®scalp application 100ml
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BNF Chapter 13 Skin
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POTENT with antimicrobial
Fucibet ®cream 30g
Synalar C® cream 30g
Synalar C ®ointment 30g
Synalar N ®cream 30g
VERY POTENT
Dermovate® 0.05% cream
Dermovate ®0.05% ointment
Dermovate ®0.05% scalp application 100g
Alternatives
MILD
Synalar 1 in 10® 0.001% cream 50g
MODERATELY POTENT
Modrasone® 0.05% cream
Modrasone® 0.05% ointment
Synalar 1 in 4 dilution® 0.00625% cream
50g
Synalar 1 in 4 dilution® 0.00625%
ointment 50g
2
Haelan ®4 microgram/cm tape 7.5cm 2m,
5m
POTENT
Locoid ®0.1% cream 30g, 100g
Locoid ®0.1% ointment 30g, 100g
Synalar ®0.025% cream 30g, 100g
Synalar ®0.025% gel 30g, 60g
Synalar ®0.025% ointment 30g, 100g
Elocon® 0.1% cream 30g, 100g
Elocon® 0.1% ointment 30g, 100g
VERY POTENT
Nerisone Forte® 0.3% oily cream 15g
Nerisone Forte ®0.3% ointment 15g
13.5
Preparations for Eczema and Psoriasis
First choice
13.5.1
Preparations
for eczema
Oral Retinoid
Alitretinoin ®30mg capsules
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Review date November 2015
Alitretinoin should be prescribed
only by or under the supervision of a
consultant dermatologist
NICE TA177 Alitretinoin for severe
chronic hand eczema
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BNF Chapter 13 Skin
Subsections are intentionally omitted where there is no formulary drug choice
Additional notes
See section 13.2.1 emollients and 13.4 topical corticosteroids.
Also see section 13.5.3 Drugs affecting the immune response and NICE TA82 Atopic dermatitis
(eczema)-pimecrolimus and tacrolimus
13.5.2
Preparations
for psoriasis
Also see
section 13.2.1
emollients.
Vitamin D analogues
Calcipotriol 50microgram/g ointment
120g
Calcipotriol 50microgram/ml scalp
solution 120ml
Calcitriol 3microgram/g ointment (Silkis®)
NICE CG153 Psoriasis
Vitamin D with corticosteroid
Betnovate® 0.1% ointment PLUS
Dovonex ®50microgram/g ointment
Dovobet® gel 60g
Tar preparations: Proprietary products
Psoriderm® cream 225ml
Exorex ®5% lotion 100ml, 250ml
Bath preparations
Psoriderm emulsion® 40% bath
additive200ml
Specials are unlicensed, may be
difficult to obtain and patients may find
proprietary preparations more
acceptable.
Cost of non proprietary products
ranges from £150 to £1000 per 500g.
Polytar emollient® 500ml
Scalp Preparations
Sebco® ointment 40g, 100g
Psoriderm® scalp lotion 250ml
Dithranol
Dithrocream® 0.1%, 0.25%, 0.5%, 1% &
2% cream 50g
Micanol ® 3% cream 50g
Alternatives
For initiation by specialist only.
13.5.3 Drugs
affecting the
immune
response
Atopic mild to moderate eczema
Pimecrolimus 1% cream
NOT for first line use unless there is a
specific reason to avoid or reduce the
use of topical corticosteroids.
Atopic mild to moderate eczema
Tacrolimus 0.03% ointment
Tacrolimus 0.1% ointment
NICE TA82 Atopic dermatitis
(eczema)-pimecrolimus and
tacrolimus
Severe refractory eczema
Azathioprine 50mg tablets
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as no Shared Care Protocol
available
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BNF Chapter 13 Skin
Subsections are intentionally omitted where there is no formulary drug choice
Additional notes
Most unlicensed coal tar preparations (specials) will have been advised initially by a specialist
hospital team and will need to be sourced from a specialist supplier.
Cytokine modulators may be used by specialist centers
Adalimumab
as per NICE TA146 Adalimumab for the treatment of adults with psoriasis
Etanercept
Infliximab
as per NICE TA103 Etanercept& efalizumab for the treatment of adults with psoriasis
as per NICE TA134: Psoriasis - infliximab
Ustekinumab
13.6
as per NICE TA 180 Psoriasis - ustekinumab
Acne and rosacea
First choice
13.6.1 Topical
preparations
for rosacea
Rozex® 0.75% cream 30g
(metronidazole)
Prescribe by brand due to strength and
cost variations
Rozex® 0.75% gel 30g
(metronidazole)
Finacea® 15% gel (azelaic acid)
First choice
13.6.1 Topical
preparations
for acne
Topical antibacterials
Clindamycin 1% topical solution
30ml 50ml
Erythromycin 2% topical solution
50ml
Topical retinoids
Treatment for mild acne is considered
cosmetic treatment and is not funded by
NHS Stockport CCG
To avoid development of cross-resistance
to erythromycin and clindamycin use nonantibacterials such as benzoyl peroxide
which should be purchased OTC
Avoid in pregnancy.
Isotretinoin 0.05% gel 30g
Adapalene 0.1% cream 45g
Adapalene 0.1%, benzoyl peroxide
2.5% gel 45g (Epiduo®)
First choice
13.6.2 Oral
preparations
for rosacea
Oxytetracycline 250mg tablets
See BNF for guidance on course lengths
and refer to local antibacterial guidelines
Erythromycin 250mg tablets
Antibiotic Guidelines
See Chapter 5 appendix
Alternatives
Doxycycline 100mg capsules
13.6.2 Oral
preparations
for acne
First choice
Oral antibiotics for acne
Oxytetracycline 250mg tablets
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BNF Chapter 13 Skin
Subsections are intentionally omitted where there is no formulary drug choice
Alternatives
Lymecycline 408mg capsules
Doxycycline 100mg capsules
Erythromycin 250mg tablets
Hormone treatment for acne
Co-cyprindiol tablets 2mg/35
microgram (Dianette®)
13.7
Preparations for warts and calluses
First choice
Salicylic acid 16.7% lactic acid
16.7% paint 10ml (Salactol) ® 15ml
OTC (Duofilm® 15ml) OTC
Treatment with occlusion by duct tape
should be tried first, If this is unsuccessful
a prescribed therapy can be considered but
see additional notes
Alternatives
Salicylic acid 11%, lactic acid 4%
gel 5g (in collodion base: Cuplex®)
OTC
Salicylic acid 26% solution 10ml
(Occlusal®) OTC
Anogenital warts
Imiquimod 5% cream 250mg sachet
(Aldara®) cream
Podophyllotoxin
0.5%
(Warticon®, Condyline®)
solution
Additional notes
Warts normally resolve spontaneously though this may take up to 2 years. Treatment for warts should
only be considered if warts are symptomatic i.e. very painful or itchy, interfere with functioning, have
been present >2years or are extensive. Cryotherapy should only be considered if the above
treatments fail. Referral to dermatology should only be considered where there is doubt about the
diagnosis, the wart is recalcitrant or rapidly growing or if malignancy is suspected (malignancy is rare
but should be excluded in older people or people with immunosuppression or subungual warts.
13.8
Sunscreens and Camouflagers
First choice
13.8.1
Sunscreen
Preparations
Only for use in ACBS conditions-see below
®
Sunsense Ultra lotion SPF 50+
50ml,125ml, 500ml OTC
Preparations with an SPF less than 30
should not normally be prescribed.
Uvistat® cream UVB-SPF 50 125ml
OTC
Photodamage
Diclofenac sodium 3% gel
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(Solaraze®)
Fluorouracil 5% cream (Efudix®)
Fluorouracil 0.5% cream
(Actikerall®)
Additional notes
Sunscreens are only prescribable for ACBS approved conditions i.e. for skin 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.
13.8.2
Camouflagers
Do not prescribe
13.9
Shampoos and other preparations for scalp and hair conditions
Cosmetic treatment with these agents
is not funded by NHS Stockport other
than by approved individual funding.
First choice
Coal tar shampoos
Alphosyl 2 in 1® shampoo 125ml, 250ml
OTC
T/Gel Therapeutic® shampoo 125ml,
250ml OTC
Polytar® liquid 250ml, 350ml OTC
Polytar Plus ®liquid 500ml OTC
C
Coal tar and salicylic acid shampoo
Capasal® shampoo 250ml OTC
Other shampoos
Ketoconazole 2% shampoo 120ml OTC
Selsun® shampoo 125ml, 250ml OTC
13.10
Anti-infective skin preparations
First choice
13.10.1
Antibacterial
preparations
Mupirocin 2% cream (Bactroban®) 15g
Mupirocin 2% ointment 15g
Mupirocin - limit to use for MRSA
Silver sulfadiazine 1% cream
(Flamazine®) 50g
Silver sulfadiazine - for infected burns
Polymyxin B 10,000units/g bacitracin
500units/g ointment (Polyfax®) 20g
Fusidic acid 2% cream 15g, 30g
Sodium fusidate 2% ointment 15g, 30g
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Review date November 2015
Fusidic acid/Sodium fusidate for
impetigo – for use on small skin
areas, max 10 days use
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Metronidazole 0.75% cream 30g
Rozex cream (Rosacea)
Metronidazole 0.75% gel 15g, 30g, 40g
Anabact/Metrogel (Malodorous
fungating tumours and malodorous
gravitational and decubitus ulcers.)
First choice
20g Clotrimazole 1% cream available
to buy OTC
Clotrimazole 1% cream 50g
13.10.2
Antifungal
preparations
Alternatives
Miconazole 2% cream 45g
Ketoconazole 2% cream 30g
Terbinafine 1% cream 30g
Additional notes
For oral antifungal options such as terbinafine see chapter 5
13.10.3
Antiviral
preparations
First choice
Aciclovir 5% cream
First choice
13.10.4
Parasiticidal
preparations
Malathion 0.5% aqueous liquid (Derbac
M®) OTC
Also see oral antiviral options in
chapter 5
2g tube and pump pack are available
OTC for cold sores.
For Head lice and scabies
Currently Unavailable (December
2013, no date from manufacturer, use
alternatives)
Alternatives
Dimeticone 4% lotion (Hedrin®) OTC
For head lice
Permethrin 5% cream (Lyclear® Dermal For scabies
Cream) OTC
Additional notes
Wet combing methods: Head lice can be mechanically removed by combing wet hair
meticulously with a plastic detection comb (probably for at least 30 minutes each time) over the
whole scalp at 4-day intervals for a minimum of 2 weeks, and continued until no lice are found
on 3 consecutive sessions.
Many Pharmacies provide a Minor Ailment Service for Head Lice
13.10.5
Preparations
for minor cuts
and abrasions
First choice
Cetrimide® 0.5% cream 15g, 30g, 50g
OTC
Cetrimide ®1% cream 15g,60g OTC
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BNF Chapter 13 Skin
Subsections are intentionally omitted where there is no formulary drug choice
13.11
Skin cleansers, antiseptics, and desloughing agents
13.11.2
Chlorhexidine
First choice
Chlorhexidine gluconate 4% solution
(Hibiscrub®) OTC
MHRA Medicines Devices
Alert:products containing chlorhexidine
First choice
13.11.4 Iodine
Povidone-iodine 2.5% dry powder spray
(Betadine®) 100ml OTC
Alternatives
Povidine-iodine 1.14% dry powder spray
(Savlon®) 50ml OTC
13.11.6
Oxidisers and
dyes
First choice
13.12
Antiperspirants
Potassium permanganate 400mg tablets
for cutaneous solution (Permitabs®) OTC
First choice
Aluminium chloride 20% solution
(Anhydrol forte® / Driclor®) 20ml, 60ml,
75ml OTC
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Review date November 2015
Treatment for cosmetic purposes is
not funded by NHS Stockport CCG.
Treatment should only funded where
there is a risk of repeated fungal
infections
Chapter 13 – page 11 of 11