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On this page you will find information, links and resources relating to prescribing for skin conditions.

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The NHS Health and Care Video Library has some useful videos for patients to support them with various skin conditions

Acne

See [NG198] Acne vulgaris: management*New* June 2021

Formulary Chapter 13.6.1- Acne and Rosacea

Oral isotretinoin is a RED drug. See Traffic Light System, MHRA Drug Safety Update and Safety Advice. If the person has the potential to become pregnant then they will need to follow the MHRA Pregnancy Prevention Programme.

British Association of Dermatologists – Patient Information Leaflets.ACNE

See our formulary page on contraceptives with acne.

A combined oral contraceptive may be chosen for people with PCOS and acne if first line treatment options are not effective alone for their acne. See FSRH CEU Statement: Strengthening of Warnings about use of Dianette and other brands of co-cyprindiol (June 2013) – Faculty of Sexual and Reproductive Healthcare

Co-cyprindiol remains second line where an alternative combined oral contraceptive has not been effective, patients should be aware of the increased risk of thrombosis when using co-cyprindiol. FSRH Clinical Guideline: Combined Hormonal Contraception (January 2019, Amended November 2020) – Faculty of Sexual and Reproductive Healthcare found few differences between the combined oral contraceptives studied in terms of their effectiveness in treating acne.

Emollients – Information and Quick Reference Guide

  • Emollients should only be prescribed for the management of diagnosed dermatological conditions such as eczema or psoriasis. Minor conditions are suitable for self-care.
  • Patients who do not have a diagnosed dermatological condition or risk to skin integrity (maintenance) should no longer receive NHS prescriptions and are advised to purchase emollients over the counter. Refer for self-care.
  • See emollient quick reference guide below for cost effective emollients.
  • If the most cost effective choice emollients are not satisfactory for a patient, after a trial, then all other emollients remain on formulary as patient choice is an important factor in the management of eczema and other skin conditions.
  • Bath oils/ shower products should not be prescribed. See BATHE study.
  • Aqueous cream is non-formulary: may cause skin irritation, particularly in children with eczema, possibly due to sodium lauryl sulfate content.

View BNF prescribing quantity guidance

Emollients are flammable

Dressings and clothing that have contact with emollients are easily ignited by a naked flame. Advise patients to keep them away from fire or flames and not smoke when using them. Patients should be counselled to wash bedding/clothing regularly at 60 degrees celcius, to minimise the build-up of impregnated emollient.

Patients on medical oxygen who require an emollient should not use any paraffin based products.

The risk of fire should be considered when using any emollient as there is a risk with all emollients, including paraffin-free emollients.

For more information please refer to MHRA drug safety update.

Further guidance for patients and useful resources can be found on the MHRA website. A useful presentation pack from the MHRA and National Fire Chiefs Council (NFCC) can be found under further advice and resources.

Hidradenitis Suppurativa

Hidradenitis suppurativa is a long term, recurrent, and painful disease in which there is inflammation (redness, tenderness and swelling) in areas of skin containing apocrine sweat glands. These glands are found mainly in the armpits, breasts, groin, abdomen folds and buttocks. Within HS there is a blockage of the hair follicles. This causes a mixture of boil-like lumps, areas leaking pus, and scarring. Hidradenitis suppurativa tends to begin around puberty. It is more common in women and in people with Dark or Black skin. It is estimated to affect about 1% of the population.

British Association of Dermatologists-HIDRADENITIS SUPPURATIVA  Patient information leaflet.

new research shared by NIHR describes how people with HS missed out on life events. The condition could limit their social and professional opportunities so severely that it could change the course of their lives. People described pain as relentless, extreme, and sometimes unbearable. The discharge from boils could have a bad smell. The condition led people to avoid situations, which had an impact on career choices and relationships. The stigma of their condition was highlighted, as well as the delay in diagnosis having an impact on quality of life and access to care.

More information can be found on the Hidradenitis suppurativa – NHS website.

See the infection management formulary for infected boils and carbuncles Infection Management – Somerset CCG

Management of HS is covered by British Association of Dermatologists-HIDRADENITIS SUPPURATIVA  Patient information leaflet.

Hidradenitis Suppurativa Trust | Pain UK

NICE TA392- Adalimumab for treating moderate to severe hidradenitis suppurativa

Topical Corticosteroids

Topical corticosteroids are effective and have few adverse effects if they are used appropriately.

Use the NICE CKS topical corticosteroids guidance for initiation, choice and management of topical steroid treatment.

The dose should not exceed that specified in the SPC which is typically once or twice daily dosing

Potent topical steroids are normally licensed for max 4 weeks use – DO NOT place on repeat.

We would recommend that new patients requiring topical steroids are prescribed on acute prescription only, so requests for repeat supplies are closely monitored and repeats are not automatically generated.

For patients who have been on long term repeat treatment we would recommend that a safety review is prioritised, and consideration given to the 2 MHRA alerts Topical corticosteroids and NPSA Emergency Steroid Card.

Long term use will have skin consequences and potential hypothalamic pituitary-adrenal (HPA) axis suppression (likelihood increased if also prescribed steroid inhaler/nose drops etc). Abrupt withdrawal therefore has clinical risks so must be carefully managed with a step-down approach to less potent steroid and consideration of rebound skin reaction and HTA axis Issues. Adrenal insufficiency and adrenal crisis-who is at risk and how should they be managed safely is discussed in the factsheet about exogenous steroids treatment in adults endorsed by the Society for Endocrinology and the British Association of Dermatologists.

Steroid potency and formulary position

NICE CKS: What potency of topical corticosteroids should I prescribe?

Steroid potencySteroid and strengthFormulationFormulary position
Mild
Do not exceed once or twice daily application – see SPC
Hydrocortisone 0.1%, 0.5%, 1.0%, 2.5%Cream and ointmentFirst line 1% cream or ointment.
Hydrocortisone oily cream 1% prescribe as Mildison® Lipocream.
Medium
Do not exceed once or twice daily application – see SPC
Betamethasone valerate 0.025%Cream and ointmentFirst line medium potency steroid. Prescribe as:
Audavate RD® or Betnovate RD®
Clobetasone butyrate 0.05% Cream and ointment Second line medium potency steroid. Prescribe as:
Clobavate® or Eumovate®
Potent
Not suitable for repeat prescribing
Do not exceed once or twice daily application – see SPC
Beclometasone dipropionate 0.025%Cream and ointment
Betamethasone dipropionate 0.05% Cream, ointment, and lotion Second line potent steroid prescribe as Diprosone®
Betamethasone valerate 0.1% Cream, ointment, lotion, scalp application, and foam First line Potent steroid. Prescribe as Audavate®, Betnovate® or Betacap®
Betamethasone valerate 0.1% Cream, ointment, and scalp application Second line potent steroid. Prescribe as Locoid®
Very potent
Not suitable for repeat prescribing
See SPC for dosing instructions
Clobetasol propionate 0.0525%Cream, ointment, scalp application and foamPrescribe as Clobaderm® or Etrivex® shampoo.

What formulation of topical corticosteroid should I prescribe?

NICE CKS: What formulation of topical corticosteroids should I prescribe?

Use water miscible cream or gel products on the nipple if lactating, avoiding ointments which may expose the infant to high levels of mineral paraffins via direct licking. Our formulary page Breastfeeding and medicines has more information on dry skin and eczema while breastfeeding. Use the least potent preparations for the shortest duration where possible.  Hydrocortisone (mild potency) and clobetasone (moderate potency) are preferred for application to the nipple and areola area – avoid application of high potency steroids to these areas.

Quantity to prescribe

NICE CKS: How much topical corticosteroid should I prescribe?

Area of the bodyQuantity to prescribe
Face and neck15g to 30g
Both hands15g to 30g
Scalp15g to 30g
Both arms30g to 60g
Both legs100g
Trunk100g
Groin and genitalia15g to 30g

Guys and St Thomas have a useful patient information leaflet for use of topical steroids including how much to apply.