Tablets, f/c, pilocarpine hydrochloride 5 mg. Net price 84-tab pack = £41.14. Label: 21, 27, counselling, driving
13 Skin
This chapter also includes advice on the drug management of the following:
For information on wound management products and elasticated garments, see Appendix 5.
The British Association of Dermatologists list of preferred unlicensed dermatological preparations (specials) is available at www.bad.org.uk/specials.
13.1 Management of skin conditions
13.1.1 Vehicles
Both vehicle and active ingredients are important in the treatment of skin conditions; the vehicle alone may have more than a mere placebo effect. The vehicle affects the degree of hydration of the skin, has a mild anti-inflammatory effect, and aids the penetration of active drug.
Applications are usually viscous solutions, emulsions, or suspensions for application to the skin (including the scalp) or nails.
Collodions are painted on the skin and allowed to dry to leave a flexible film over the site of application.
Creams are emulsions of oil and water and are generally well absorbed into the skin. They may contain an antimicrobial preservative unless the active ingredient or basis is intrinsically bactericidal and fungicidal. Generally, creams are cosmetically more acceptable than ointments because they are less greasy and easier to apply.
Gels consist of active ingredients in suitable hydrophilic or hydrophobic bases; they generally have a high water content. Gels are particularly suitable for application to the face and scalp.
Lotions have a cooling effect and may be preferred to ointments or creams for application over a hairy area. Lotions in alcoholic basis can sting if used on broken skin. Shake lotions (such as calamine lotion) contain insoluble powders which leave a deposit on the skin surface.
Ointments are greasy preparations which are normally anhydrous and insoluble in water, and are more occlusive than creams. They are particularly suitable for chronic, dry lesions. The most commonly used ointment bases consist of soft paraffin or a combination of soft, liquid, and hard paraffin. Some ointment bases have both hydrophilic and lipophilic properties; they may have occlusive properties on the skin surface, encourage hydration, and also be miscible with water; they often have a mild anti-inflammatory effect. Water-soluble ointments contain macrogols which are freely soluble in water and are therefore readily washed off; they have a limited but useful role where ready removal is desirable.
Pastes are stiff preparations containing a high proportion of finely powdered solids such as zinc oxide and starch suspended in an ointment. They are used for circumscribed lesions such as those which occur in lichen simplex, chronic eczema, or psoriasis. They are less occlusive than ointments and can be used to protect inflamed, lichenified, or excoriated skin.
Dusting powders are used only rarely. They reduce friction between opposing skin surfaces. Dusting powders should not be applied to moist areas because they can cake and abrade the skin. Talc is a lubricant but it does not absorb moisture; it can cause respiratory irritation. Starch is less lubricant but absorbs water.
Dilution The BP directs that creams and ointments should not normally be diluted but that should dilution be necessary care should be taken, in particular, to prevent microbial contamination. The appropriate diluent should be used and heating should be avoided during mixing; excessive dilution may affect the stability of some creams. Diluted creams should normally be used within 2 weeks of preparation.
13.1.2 Suitable quantities for prescribing
| Suitable quantities of dermatological preparations to be prescribed for specific areas of the body | ||
|---|---|---|
| Area of body | Creams and Ointments | Lotions |
| Face | 15–30 g | 100 mL |
| Both hands | 25–50 g | 200 mL |
| Scalp | 50–100 g | 200 mL |
| Both arms or both legs | 100–200 g | 200 mL |
| Trunk | 400 g | 500 mL |
| Groins and genitalia | 15–25 g | 100 mL |
These amounts are usually suitable for an adult for twice daily application for 1 week. The recommendations do not apply to corticosteroid preparations — for suitable quantities of corticosteroid preparations, see section 13.4.
13.1.3 Excipients and sensitisation
Excipients in topical products rarely cause problems. If a patch test indicates allergy to an excipient, products containing the substance should be avoided (see also Anaphylaxis). The following excipients in topical preparations are associated, rarely, with sensitisation; the presence of these excipients is indicated in the entries for topical products. See also Excipients, under General Guidance.
| Beeswax Benzyl alcohol Butylated hydroxyanisole Butylated hydroxytoluene Cetostearyl alcohol (including cetyl and stearyl alcohol) Chlorocresol Edetic acid (EDTA) Ethylenediamine Fragrances Hydroxybenzoates (parabens) | Imidurea Isopropyl palmitate N-(3-Chloroallyl)hexaminium chloride (quaternium 15) Polysorbates Propylene glycol Sodium metabisulfite Sorbic acid Wool fat and related substances including lanolin301 |
13.2 Emollient and barrier preparations
Borderline substances The preparations marked ‘ACBS’ are regarded as drugs when prescribed in accordance with the advice of the Advisory Committee on Borderline Substances for the clinical conditions listed. Prescriptions issued in accordance with this advice and endorsed ‘ACBS’ will normally not be investigated. See Appendix 2 for listing by clinical condition.
13.2.1 Emollients
Emollients soothe, smooth and hydrate the skin and are indicated for all dry or scaling disorders. Their effects are short-lived and they should be applied frequently even after improvement occurs. They are useful in dry and eczematous disorders, and to a lesser extent in psoriasis (section 13.5.2). The choice of an appropriate emollient will depend on the severity of the condition, patient preference, and the site of application. Emollient preparations contained in tubs should be removed with a clean spoon or spatula to reduce bacterial contamination of the emollient. Emollients should be applied in the direction of hair growth to reduce the risk of folliculitis. Ointments may exacerbate acne and folliculitis. Some ingredients rarely cause sensitisation (section 13.1.3) and this should be suspected if an eczematous reaction occurs. The use of aqueous cream as a leave-on emollient may increase the risk of skin reactions, particularly in eczema.
Fire hazard with paraffin-based emollients
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. The risk is greater when these preparations are applied to large areas of the body, and clothing or dressings become soaked with the ointment. Patients should be told to keep away from fire or flames, and not to smoke when using these preparations. The risk of fire should be considered when using large quantities of any paraffin-based emollient.
Preparations such as aqueous cream (section 13.2.1.1) and emulsifying ointment can be used as soap substitutes for hand washing and in the bath; the preparation is rubbed on the skin before rinsing off completely. The addition of a bath oil (section 13.2.1.1) may also be helpful.
Preparations containing an antibacterial (section 13.10) should be avoided unless infection is present or is a frequent complication.
Urea is a keratin softener and hydrating agent used in the treatment of dry, scaling conditions (including ichthyosis) and may be useful in elderly patients. It is occasionally used with other topical agents such as corticosteroids to enhance penetration of the skin.
Non-proprietary emollient preparations
Emulsifying Ointment, BP
Ointment, emulsifying wax 30%, white soft paraffin 50%, liquid paraffin 20%, net price 500 g = £2.34
Excipients include cetostearyl alcohol
Hydrous Ointment, BP
Ointment, (oily cream), dried magnesium sulfate 0.5%, phenoxyethanol 1%, wool alcohols ointment 50%, in freshly boiled and cooled purified water, net price 500 g = £4.89
Liquid and White Soft Paraffin Ointment, NPF
Ointment, liquid paraffin 50%, white soft paraffin 50%, net price 500 g = £4.57
Proprietary emollient preparations
Aquamax® (Dermato Logical)
Cream, light liquid paraffin 8%, white soft paraffin 20%, phenoxyethanol 1%, net price 100 g = £1.89, 500 g = £3.99
Excipients include cetostearyl alcohol, polysorbate 60
For dry skin conditions
Aquamol® (Thornton & Ross)
Cream, containing liquid paraffin, white soft paraffin, net price 50 g = £1.22, 500-g pump pack = £6.40
Excipients include cetostearyl alcohol, chlorocresol
For dry skin conditions
Aveeno® (J&J)
Cream, colloidal oatmeal in emollient basis, net price 100 mL = £3.97, 300-mL pump pack = £6.80
Excipients include benzyl alcohol, cetyl alcohol, isopropyl palmitate
ACBS: For endogenous and exogenous eczema, xeroderma, ichthyosis, and senile pruritus (pruritus of the elderly) associated with dry skin
Lotion, colloidal oatmeal in emollient basis, net price 500 mL = £6.66
Excipients include benzyl alcohol, cetyl alcohol, isopropyl palmitate, stearyl alcohol
ACBS: as for Aveeno® Cream
Cetraben® (Genus)
Emollient cream, white soft paraffin 13.2%, light liquid paraffin 10.5%, net price 50-g pump pack = £1.40, 150-g pump pack = £3.98, 500-g pump pack = £5.99, 1.05-kg pump pack = £11.62
Excipients include cetostearyl alcohol, hydroxybenzoates (parabens)
For inflamed, damaged, dry or chapped skin including eczema
Dermamist® (Alliance)
Spray application, white soft paraffin 10% in a basis containing liquid paraffin, fractionated coconut oil, net price 250-mL pressurised aerosol unit = £5.97
Excipients none as listed in section 13.1.3.
For dry skin conditions including eczema, ichthyosis, pruritus of the elderly
Note Flammable
Diprobase® (MSD)
Cream, cetomacrogol 2.25%, cetostearyl alcohol 7.2%, liquid paraffin 6%, white soft paraffin 15%, water-miscible basis used for Diprosone® cream, net price 50 g = £1.28; 500-g pump pack = £6.32
Excipients include cetostearyl alcohol, chlorocresol
For dry skin conditions
Ointment, liquid paraffin 5%, white soft paraffin 95%, basis used for Diprosone® ointment, net price 50 g = £1.28, 500 g = £5.99
Excipients none as listed in section 13.1.3.
For dry skin conditions
Doublebase® (Dermal)
Gel, isopropyl myristate 15%, liquid paraffin 15%, net price 100 g = £2.65, 500 g = £5.83
Excipients none as listed in section 13.1.3.
For dry, chapped, or itchy skin conditions
Dayleve Gel, isopropyl myristate 15%, liquid paraffin 15%, net price 100 g = £2.65, 500-g pump pack = £6.29
Excipients none as listed in section 13.1.3.
For dry, chapped, or itchy skin conditions
E45® (Reckitt Benckiser)
Cream, light liquid paraffin 12.6%, white soft paraffin 14.5%, hypoallergenic anhydrous wool fat (hypoallergenic lanolin) 1% in self-emulsifying monostearin, net price 50 g = £1.61, 125 g = £2.90, 350 g = £5.17, 500-g pump pack = £5.62
Excipients include cetyl alcohol, hydroxybenzoates (parabens)
For dry skin conditions
Lotion, light liquid paraffin 4%, cetomacrogol, white soft paraffin 10%, hypoallergenic anhydrous wool fat (hypoallergenic lanolin) 1% in glyceryl monostearate, net price 200 mL = £2.40, 500-mL pump pack = £4.50
Excipients include isopropyl palmitate, hydroxybenzoates (parabens), benzyl alcohol
ACBS: for symptomatic relief of dry skin conditions, such as those associated with atopic eczema and contact dermatitis
Emollin® (C D Medical)
Spray, liquid paraffin 50%, white soft paraffin 50% in aerosol basis, net price 150 mL = £3.97, 240 mL = £6.35
Excipients none as listed in section 13.1.3.
For dry skin conditions
Epaderm® (Mölnlycke)
Cream, yellow soft paraffin 15%, liquid paraffin 10%, emulsifying wax 5%, net price 50-g pump pack = £1.70, 500-g pump pack = £6.95
Excipients include cetostearyl alcohol, chlorocresol
For use as an emollient or soap substitute
Ointment, emulsifying wax 30%, yellow soft paraffin 30%, liquid paraffin 40%, net price 125 g = £3.85, 500 g = £6.53, 1 kg = £12.02
Excipients include cetostearyl alcohol
For use as an emollient or soap substitute
Hydromol® (Alliance)
Cream, sodium pidolate 2.5%, liquid paraffin 13.8%, net price 50 g = £2.19, 100 g = £4.09, 500 g = £11.92
Excipients include cetostearyl alcohol, hydroxybenzoates (parabens)
For dry skin conditions
Ointment, yellow soft paraffin 30%, emulsifying wax 30%, liquid paraffin 40%, net price 125 g = £2.88, 500 g = £4.89, 1 kg = £9.09
Excipients include cetostearyl alcohol
For use as an emollient, bath additive, or soap substitute
Lipobase® (Astellas)
Cream, fatty cream basis used for Locoid Lipocream®, net price 50 g = £1.46
Excipients include cetostearyl alcohol, hydroxybenzoates (parabens)
For dry skin conditions, also for use during treatment with topical corticosteroid and as diluent for Locoid Lipocream®
Oilatum® (Stiefel)
Cream, light liquid paraffin 6%, white soft paraffin 15%, net price 50 g = £1.63, 150 g = £2.46, 500-mL pump pack = £4.99, 1.05-litre pump pack = £9.98
Excipients include benzyl alcohol, cetostearyl alcohol
For dry skin conditions
Oilatum® Junior Cream, light liquid paraffin 6%, white soft paraffin 15%, net price 150 g = £3.38, 350 mL = £4.65, 500 mL = £4.99, 1.05-litre pump pack = £9.98
Excipients include benzyl alcohol, cetostearyl alcohol
For dry skin conditions
QV® (Crawford)
Cream, glycerol 10%, light liquid paraffin 10%, white soft paraffin 5%, net price 100 g = £2.04, 500 g = £5.86, 1.05-kg pump pack = £11.94
Excipients include cetostearyl alcohol, hydroxybenzoates (parabens)
For dry skin conditions including eczema, psoriasis, ichthyosis, pruritus
Intensive ointment, light liquid paraffin 50.5%, white soft paraffin 20%, net price 450 g = £5.65
Excipients include cetostearyl alcohol
For dry skin conditions including eczema, psoriasis, ichthyosis, pruritus
Lotion, white soft paraffin 5%, net price 250 mL = £3.14, 500-mL pump pack = £5.24
Excipients include cetostearyl alcohol, hydroxybenzoates (parabens)
For dry skin conditions including eczema, psoriasis, ichthyosis, pruritus
Ultrabase® (Derma UK)
Cream, water-miscible, containing liquid paraffin and white soft paraffin, net price 50 g = £1.40, 500-g pump pack = £4.80
Excipients include fragrance, hydroxybenzoates (parabens), disodium edetate, stearyl alcohol
For dry skin conditions
Unguentum M® (Almirall)
Cream, containing saturated neutral oil, liquid paraffin, white soft paraffin, net price 50 g = £1.41, 100 g = £2.78, 200-mL pump pack = £5.50, 500 g = £8.48
Excipients include cetostearyl alcohol, polysorbate 40, propylene glycol, sorbic acid
For dry skin conditions and nappy rash
ZeroAQS® (Thornton & Ross)
Cream, macrogol cetostearyl ether 1.8%, liquid paraffin 6%, white soft paraffin 15%, net price 100 g = £1.65, 500 g = £3.29
Excipients include cetostearyl alcohol, chlorocresol
For use as an emollient or soap substitute
Zerobase® (Thornton & Ross)
Cream, liquid paraffin 11%, net price 50 g = £1.04, 500-g pump pack = £5.26
Excipients include cetostearyl alcohol, chlorocresol
For dry skin conditions
Zerocream® (Thornton & Ross)
Cream, liquid paraffin 12.6%, white soft paraffin 14.5%, net price 50 g = £1.17, 500-g pump pack = £4.08
Excipients include cetyl alcohol, hydroxybenzoates (parabens), lanolin anhydrous
For dry skin conditions
Zeroderm® (Thornton & Ross)
Ointment, liquid paraffin 40%, white soft paraffin 30%, net price 125 g = £2.41, 500 g = £4.10
Excipients include cetostearyl alcohol, polysorbate 60
For dry skin conditions
Zeroguent® (Thornton & Ross)
Cream, light liquid paraffin 8%, white soft paraffin 4%, refined soya bean oil 5%, net price 100 g = £2.33, 500 g = £6.99
Excipients include cetostearyl alcohol, polysorbate 40, propylene glycol, sorbic acid
For dry skin conditions
Preparations containing urea
Aquadrate® (Alliance)
Cream, urea 10%, net price 100 g = £4.37
Excipients none as listed in section 13.1.3.
Dose for dry, scaling and itching skin, apply thinly twice daily
Balneum® (Almirall)
Cream, urea 5%, ceramide 0.1%, net price 50-g pump pack = £2.85, 500-g pump pack = £9.97
Excipients include cetostearyl alcohol, polysorbates, propylene glycol
Dose for dry skin conditions, apply twice daily
Balneum® Plus Cream, urea 5%, lauromacrogols 3%, net price 100 g = £3.29, 500-g pump pack = £14.99
Excipients include benzyl alcohol, polysorbates
Dose for dry, scaling and itching skin, apply twice daily
Calmurid® (Galderma)
Cream, urea 10%, lactic acid 5%, net price 100 g = £9.27, 500-g pump pack = £35.70
Excipients none as listed in section 13.1.3.
Dose for dry, scaling and itching skin, apply a thick layer for 3–5 minutes, massage into area, and remove excess, usually twice daily. Use half-strength cream for 1 week if stinging occurs
Note Can be diluted with aqueous cream (life of diluted cream 14 days)
Dermatonics Once Heel Balm® (Dermatonics)
Cream, urea 25%, net price 75 mL = £3.60, 200 mL = £8.50
Excipients include beeswax, lanolin
Dose for dry skin on soles of feet, ADULT and CHILD over 12 years, apply once daily
E45® Itch Relief Cream (Reckitt Benckiser)
Cream, urea 5%, macrogol lauryl ether 3%, net price 50 g = £2.81, 100 g = £3.74, 500-g pump pack = £14.99
Excipients include benzyl alcohol, polysorbates
Dose for dry, scaling, and itching skin, apply twice daily
Eucerin® Intensive (Beiersdorf)
Cream, urea 10%, net price 100 mL = £7.59
Excipients include benzyl alcohol, isopropyl palmitate, wool fat
Dose for dry skin conditions including eczema, ichthyosis, xeroderma, hyperkeratosis, apply thinly and rub into area twice daily
Lotion, urea 10%, net price 250 mL = £7.93
Excipients include benzyl alcohol, isopropyl palmitate
Dose for dry skin conditions including eczema, ichthyosis, xeroderma, hyperkeratosis, apply sparingly and rub into area twice daily
Flexitol® (LaCorium)
Heel balm, urea 25%, net price 40 g = £2.75, 75 g = £3.80, 200 g = £9.40, 500 g = £14.75
Excipients include benzyl alcohol, cetostearyl alcohol, fragrance, lanolin
Dose for dry skin on soles of feet and heels, ADULT and CHILD over 12 years, apply 1–2 times daily
Hydromol® Intensive (Alliance)
Cream, urea 10%, net price 30 g = £1.64, 100 g = £4.37
Excipients none as listed in section 13.1.3.
Dose for dry, scaling and itching skin, apply thinly twice daily
With antimicrobials
Dermol® (Dermal)
Cream, benzalkonium chloride 0.1%, chlorhexidine hydrochloride 0.1%, isopropyl myristate 10%, liquid paraffin 10%, net price 100-g tube = £2.86, 500-g pump pack = £6.63
Excipients include cetostearyl alcohol
Dose for dry and pruritic skin conditions including eczema and dermatitis, apply to skin or use as soap substitute
Dermol® 500 Lotion, benzalkonium chloride 0.1%, chlorhexidine hydrochloride 0.1%, liquid paraffin 2.5%, isopropyl myristate 2.5%, net price 500-mL pump pack = £6.04
Excipients include cetostearyl alcohol
Dose for dry and pruritic skin conditions including eczema and dermatitis, apply to skin or use as soap substitute
13.2.1.1 Emollient bath and shower preparations
Emollient bath additives should be added to bath water; hydration can be improved by soaking in the bath for 10–20 minutes. Some bath emollients can be applied to wet skin undiluted and rinsed off. In dry skin conditions soap should be avoided (see section 13.2.1 for soap substitutes). The quantities of bath additives recommended for adults are suitable for an adult-size bath. Proportionately less should be used for a child-size bath or a washbasin; recommended bath additive quantities for children reflect this.
These preparations make skin and surfaces slippery — particular care is needed when bathing
Aqueous Cream, BP
Aquamax® (Dermato Logical)
Cream wash, light liquid paraffin 8%, white soft paraffin 20%, phenoxyethanol 1%, net price 250 g = £2.99
Excipients include cetostearyl alcohol, polysorbate 60
Dose for dry skin conditions, apply to wet or dry skin and rinse
Aveeno® (J&J)
Aveeno® Bath oil, colloidal oatmeal, white oat fraction in emollient basis, net price 250 mL = £4.49
Excipients include beeswax, fragrance
Dose ACBS: for endogenous and exogenous eczema, xeroderma, ichthyosis, and senile pruritus (pruritus of the elderly) associated with dry skin, add 20–30 mL/bath or apply to wet skin and rinse
Balneum® (Almirall)
Balneum® bath oil, soya oil 84.75%, net price 200 mL = £2.48, 500 mL = £5.38, 1 litre = £10.39
Excipients include butylated hydroxytoluene, propylene glycol, fragrance
Dose for dry skin conditions including those associated with dermatitis and eczema; add 20–60 mL/bath (INFANT 5–15 mL); do not use undiluted
Balneum Plus® bath oil, soya oil 82.95%, mixed lauromacrogols 15%, net price 500 mL = £6.66
Excipients include butylated hydroxytoluene, propylene glycol, fragrance
Dose for dry skin conditions including those associated with dermatitis and eczema where pruritus also experienced; add 20 mL/bath (INFANT 5 mL) or apply to wet skin and rinse
Cetraben® (Genus)
Emollient bath additive, light liquid paraffin 82.8%, net price 500 mL = £5.75
Excipients none as listed in section 13.1.3.
Dose for dry skin conditions, including eczema, add 1–2 capfuls/bath (CHILD ½–1 capful) or apply to wet skin and rinse
Dermalo® (Dermal)
Bath emollient, acetylated wool alcohols 5%, liquid paraffin 65%, net price 500 mL = £3.44
Excipients none as listed in section 13.1.3.
Dose for dermatitis, dry skin conditions including ichthyosis and pruritus of the elderly; add 15–20 mL/bath (INFANT and CHILD 5–10 mL) or apply to wet skin and rinse
Doublebase® (Dermal)
Emollient bath additive, liquid paraffin 65%, net price 500 mL = £5.45
Excipients include cetostearyl alcohol
Dose for dry skin conditions including dermatitis, ichthyosis, and pruritus of the elderly; add 15–20 mL/bath, (INFANT and CHILD 5–10 mL)
Emollient shower gel, isopropyl myristate 15%, liquid paraffin 15%, net price 200 g = £5.21
Excipients none as listed in section 13.1.3.
Dose for dry, chapped, or itchy skin conditions, apply to wet or dry skin and rinse, or apply to dry skin after showering
Note Also available as Doublebase® Emollient Wash Gel
E45® (Reckitt Benckiser)
Emollient bath oil, cetyl dimeticone 5%, liquid paraffin 91%, net price 250 mL = £3.19, 500 mL = £5.11
Excipients none as listed in section 13.1.3.
Dose ACBS: for endogenous and exogenous eczema, xeroderma, ichthyosis, and senile pruritus (pruritus of the elderly) associated with dry skin; add 15 mL/bath (CHILD 5–10 mL) or apply to wet skin and rinse
Emollient wash cream, soap substitute, zinc oxide 5% in an emollient basis, net price 250-mL pump pack = £3.19
Excipients none as listed in section 13.1.3.
Dose ACBS: for endogenous and exogenous eczema, xeroderma, ichthyosis and senile pruritus (pruritus of the elderly) associated with dry skin, use as soap substitute
Hydromol® (Alliance)
Bath and shower emollient, isopropyl myristate 13%, light liquid paraffin 37.8%, net price 350 mL = £3.88, 500 mL = £4.42, 1 litre = £8.80
Excipients none as listed in section 13.1.3.
Dose for dry skin conditions including eczema, ichthyosis and pruritus of the elderly, add 1–3 capfuls/bath (INFANT ½–2 capfuls) or apply to wet skin and rinse
LPL 63.4® (Huxley)
Emollient bath additive, light liquid paraffin 63.4%, net price 500 mL = £3.10
Excipients include acetylated wool alcohols, isopropyl palmitate
Dose for dry skin conditions, add 1–3 capfuls/bath (CHILD 1 month–12 years, ½–2 capfuls) or apply to wet skin and rinse
Oilatum® (Stiefel)
Emollient bath additive (emulsion), light liquid paraffin 63.4%, net price 250 mL = £2.75, 500 mL = £4.57
Excipients include acetylated lanolin alcohols, isopropyl palmitate, fragrance
Dose for dry skin conditions including dermatitis, pruritus of the elderly, and ichthyosis, add 1–3 capfuls/bath (INFANT 0.5–2 capfuls) or apply to wet skin and rinse
Junior bath additive, light liquid paraffin 63.4%, net price 150 mL = £2.82, 250 mL = £3.25, 300 mL = £5.10, 600 mL = £5.89
Excipients include acetylated lanolin alcohols, isopropyl palmitate
Dose for dry skin conditions including dermatitis, pruritus of the elderly, and ichthyosis, add 1–3 capfuls/bath (INFANT 0.5–2 capfuls) or apply to wet skin and rinse
Shower emollient (gel), light liquid paraffin 70%, net price (with fragrance or fragrance-free) 150 g = £5.15
Excipients none as listed in section 13.1.3.
Dose for dry skin conditions including dermatitis, pruritus of the elderly, and ichthyosis, apply to wet skin and rinse
QV® (Crawford)
Bath oil, light liquid paraffin 85.13%, net price 200 mL = £2.20, 500 mL = £4.66
Excipients none as listed in section 13.1.3.
Dose for dry skin conditions including eczema, psoriasis, ichthyosis, and pruritus, add 10 mL/bath (INFANT 5 mL) or apply to wet skin and rinse
Gentle wash, glycerol 15%, net price 250 mL = £3.14, 500-mL pump pack = £5.24
Excipients include hydroxybenzoates (parabens)
Dose for dry skin conditions including eczema, psoriasis, ichthyosis, and pruritus, use as soap substitute
Zerolatum® (Thornton & Ross)
Emollient medicinal bath oil, liquid paraffin 65%, acetylated wool alcohols 5%, net price 500 mL = £4.79
Excipients none as listed in section 13.1.3.
Dose for dry skin conditions including dermatitis, pruritus of the elderly, and ichthyosis, add 15–20 mL/bath (CHILD 5–10 mL)
Zeroneum® (Thornton & Ross)
Bath oil, refined soya bean oil 83.35%, net price 500 mL = £4.48
Excipients include butylated hydroxytoluene, fragrance, propylene glycol
Dose for dry skin conditions including eczema, add 20 mL/bath (CHILD 5 mL)
With antimicrobials
Dermol® (Dermal)
Dermol 600® Bath Emollient, benzalkonium chloride 0.5%, liquid paraffin 25%, isopropyl myristate 25%, net price 600 mL = £7.55
Excipients include polysorbate 60
Dose for dry and pruritic skin conditions including eczema and dermatitis, add up to 30 mL/bath (INFANT up to 15 mL); do not use undiluted
Dermol® 200 Shower Emollient, benzalkonium chloride 0.1%, chlorhexidine hydrochloride 0.1%, liquid paraffin 2.5%, isopropyl myristate 2.5%, net price 200 mL = £3.55
Excipients include cetostearyl alcohol
Dose for dry and pruritic skin conditions including eczema and dermatitis, apply to skin or use as soap substitute
Dermol® Wash Emulsion, benzalkonium chloride 0.1%, chlorhexidine hydrochloride 0.1%, liquid paraffin 2.5%, isopropyl myristate 2.5%, net price 200-mL = £3.55
Excipients include cetostearyl alcohol
Dose for dry and pruritic skin conditions including eczema and dermatitis, apply to skin or use as soap substitute
Emulsiderm® (Dermal)
Liquid emulsion, benzalkonium chloride 0.5%, liquid paraffin 25%, isopropyl myristate 25%, net price 300 mL (with 15-mL measure) = £3.85, 1 litre (with 30-mL measure) = £12.00
Excipients include polysorbate 60
Dose for dry skin conditions including eczema and ichthyosis, add 7–30 mL/bath or rub into dry skin until absorbed
Oilatum® Plus (Stiefel)
Bath additive, benzalkonium chloride 6%, triclosan 2%, light liquid paraffin 52.5%, net price 500 mL = £6.98
Excipients include acetylated lanolin alcohols, isopropyl palmitate
Dose for topical treatment of eczema including eczema at risk from infection, add 1–2 capfuls/bath (INFANT over 6 months 1 mL); do not use undiluted
13.2.2 Barrier preparations
Barrier preparations often contain water-repellent substances such as dimeticone or other silicones. They are used on the skin around stomas, bedsores, and pressure areas in the elderly where the skin is intact. Where the skin has broken down, barrier preparations have a limited role in protecting adjacent skin. Barrier preparations are not a substitute for adequate nursing care.
Nappy rash The first line of treatment is to ensure that nappies are changed frequently and that tightly fitting water-proof pants are avoided. The rash may clear when left exposed to the air and a barrier preparation, applied with each nappy change, can be helpful. A mild corticosteroid such as hydrocortisone 0.5% or 1% (section 13.4) can be used if inflammation is causing discomfort, but it should be avoided in neonates. The barrier preparation should be applied after the corticosteroid preparation to prevent further skin damage. Preparations containing hydrocortisone should be applied for no more than a week; the hydrocortisone should be discontinued as soon as the inflammation subsides. The occlusive effect of nappies and water-proof pants may increase absorption of corticosteroids (for cautions, see section 13.4). If the rash is associated with candidal infection, a topical antifungal such as clotrimazole cream (section 13.10.2) can be used. Topical antibacterial preparations (section 13.10.1) can be used if bacterial infection is present; treatment with an oral antibacterial may occasionally be required in severe or recurrent infection. Hydrocortisone may be used in combination with antimicrobial preparations if there is considerable inflammation, erosion, and infection.
Non-proprietary barrier preparations
Zinc and Castor Oil Ointment, BP
Ointment, zinc oxide 7.5%, castor oil 50%, arachis (peanut) oil 30.5%, white beeswax 10%, cetostearyl alcohol 2%, net price 500 g = £5.68
For nappy and urinary rash
Proprietary barrier preparations
Conotrane® (Astellas)
Cream, benzalkonium chloride 0.1%, dimeticone ‘350’ 22%, net price 100 g = 88p, 500 g = £3.51
Excipients include cetostearyl alcohol, fragrance
For nappy and urinary rash and pressure sores
Drapolene® (Omega Pharma)
Cream, benzalkonium chloride 0.01%, cetrimide 0.2% in a basis containing white soft paraffin, cetyl alcohol and wool fat, net price 100 g = £1.76, 200 g = £2.86, 350 g = £4.28
Excipients include cetyl alcohol, chlorocresol, wool fat
For nappy and urinary rash; minor wounds
Medicaid® (LPC)
Cream, cetrimide 0.5% in a basis containing light liquid paraffin, white soft paraffin, cetostearyl alcohol, glyceryl monostearate, net price 50 g = £1.69
Excipients include cetostearyl alcohol, fragrance, hydroxybenzoates (parabens), wool fat
For nappy rash, minor burns, and abrasions
Metanium® (Thornton & Ross)
Ointment, titanium dioxide 20%, titanium peroxide 5%, titanium salicylate 3% in a basis containing dimeticone, light liquid paraffin, white soft paraffin, and benzoin tincture, net price 30 g = £2.24
Excipients none as listed in section 13.1.3.
For nappy rash
Morhulin® (Actavis)
Ointment, cod-liver oil 11.4%, zinc oxide 38%, in a basis containing liquid paraffin and yellow soft paraffin, net price 50 g = £1.91
Excipients include wool fat derivative
For minor wounds, varicose ulcers, pressure sores, eczema, and nappy rash
Siopel® (Derma UK)
Barrier cream, dimeticone ‘1000’ 10%, cetrimide 0.3%, arachis (peanut) oil, net price 50 g = £2.15
Excipients include butylated hydroxytoluene, cetostearyl alcohol, hydroxybenzoates (parabens)
For protection against water-soluble irritants
Sprilon® (Ayrton Saunders)
Spray application, dimeticone 1.04%, zinc oxide 12.5%, in a basis containing wool alcohols, cetostearyl alcohol, dextran, white soft paraffin, liquid paraffin, propellants, net price 115-g pressurised aerosol unit = £8.90
Excipients include cetostearyl alcohol, hydroxybenzoates (parabens), wool fat
For urinary rash, pressure sores, leg ulcers, moist eczema, fissures, fistulae and ileostomy care
Note Flammable
Sudocrem® (Forest)
Cream, benzyl alcohol 0.39%, benzyl benzoate 1.01%, benzyl cinnamate 0.15%, hydrous wool fat (hypoallergenic lanolin) 4%, zinc oxide 15.25%, net price 60 g = £1.45, 125 g = £2.15, 250 g = £3.67, 400 g = £5.25
Excipients include beeswax (synthetic), propylene glycol, butylated hydroxyanisole, fragrance
For nappy rash and pressure sores
13.3 Topical local anaesthetics and antipruritics
Pruritus may be caused by systemic disease (such as obstructive jaundice, endocrine disease, chronic renal disease, iron deficiency, and certain malignant diseases), skin disease (e.g. psoriasis, eczema, urticaria, and scabies), drug hypersensitivity, or as a side-effect of opioid analgesics. Where possible, the underlying causes should be treated. An emollient (section 13.2.1) may be of value where the pruritus is associated with dry skin. Pruritus that occurs in otherwise healthy elderly people can also be treated with an emollient. Levomenthol cream can be used to relieve pruritus; it exerts a cooling effect on the skin. For advice on the treatment of pruritus in palliative care, see Prescribing in Palliative Care, Miscellaneous Conditions.
Preparations containing crotamiton are sometimes used but are of uncertain value. Preparations containing calamine are often ineffective.
A topical preparation containing doxepin 5% is licensed for the relief of pruritus in eczema; it can cause drowsiness and there may be a risk of sensitisation.
Pruritus is common in biliary obstruction, especially in primary biliary cirrhosis and drug-induced cholestasis. Oral administration of colestyramine is the treatment of choice (section 1.9.2).
Topical antihistamines and local anaesthetics are only marginally effective and occasionally cause sensitisation. For insect stings and insect bites, a short course of a topical corticosteroid is appropriate. Short-term treatment with a sedating antihistamine (section 3.4.1) may help in insect stings and in intractable pruritus where sedation is desirable. Calamine preparations are of little value for the treatment of insect stings or bites.
For preparations used in pruritus ani, see section 1.7.1.
CALAMINE 
Indications pruritus
Contra-indications avoid application prior to x-ray (zinc oxide may affect outcome of x-ray)
Calamine (Non-proprietary) 
Aqueous cream, calamine 4%, zinc oxide 3%, liquid paraffin 20%, self-emulsifying glyceryl monostearate 5%, cetomacrogol emulsifying wax 5%, phenoxyethanol 0.5%, freshly boiled and cooled purified water 62.5%, net price 100 mL = £1.23
Lotion (= cutaneous suspension), calamine 15%, zinc oxide 5%, glycerol 5%, bentonite 3%, sodium citrate 0.5%, liquefied phenol 0.5%, in freshly boiled and cooled purified water, net price 200 mL = 88p
Oily lotion (BP 1980), calamine 5%, arachis (peanut) oil 50%, oleic acid 0.5%, wool fat 1%, in calcium hydroxide solution, net price 200 mL = £1.57
CROTAMITON
Indications pruritus (including pruritus after scabies — section 13.10.4); see notes above
Cautions avoid use near eyes, in buccal mucosa, or on broken or very inflamed skin; use on doctor’s advice for children under 3 years
Contra-indications acute exudative dermatoses
Pregnancy manufacturer advises avoid, especially during the first trimester — no information available
Breast-feeding no information available; avoid application to nipple area
Dose
Pruritus, apply 2–3 times daily; CHILD under 3 years, apply once daily
Eurax® (Novartis Consumer Health)
Cream, crotamiton 10%, net price 30 g = £2.38, 100 g = £4.15
Excipients include beeswax, fragrance, hydroxybenzoates (parabens), stearyl alcohol
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