Dermatology

See [NG198] Acne vulgaris: management

Formulary Chapter 13.6.1- Acne and Rosacea and Somerset Infection Management Guidance

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.

See also MHRA Drug Safety Update – Isotretinoin (Roaccutane▼): new safety measures to be introduced in the coming months, including additional oversight on initiation of treatment for patients under 18 years.

Trifarotene (Aklief) has been added to the formulary (Traffic Light Status: Green) - The MHRA advises females of childbearing potential should use effective contraception.

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.

Emollient 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 above for cost effective emollients.

• The Best Emollients for Eczema (BEE) study found there is no clinically important difference between lotions, creams, gels, or ointments. Start with a cost-effective choice, if ineffective or not tolerated by the patient, trial other cost-effective choices in a step-wise approach other moving through the formulary.

• 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.

Formulary chapter 13.1

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 Celsius, 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.

MHRA and NFCC emollients A4 information sheet for healthcare professionals

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 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 Foundation

NICE TA392 – Adalimumab for treating moderate to severe hidradenitis suppurativa

Lichen Sclerosus Patient information leaflet from the British Association of Dermatologists.

Persistent or fluctuating vaginal itch is not normal and is a common symptom of lichen sclerosus, which is generally under-recognised. 

Signs may be subtle initially, possibly just a slight whitening of skin in figure-of-8 pattern around perineum and peri-anal areas, so if nothing is observed visually initially, consider re-examination if symptoms persist. 

Lichen sclerosus is a chronic inflammatory skin condition which can affect any part of the skin, but it most often affects the genital skin (vulva) and the skin around the anus. It can start in childhood or adulthood, most commonly after menopause.

Care of Vulval Skin from the British Association of Dermatologists patient information leaflet.

Research has shown that online support improved eczema symptoms in children and young people. EczemaCareOnline provides an online toolkit with various useful resources to help manage eczema and is free to use without registration. One version of the website is aimed at parents and carers of children with eczema; another for young people starting to self-manage their eczema.

NICE [CG153] Psoriasis: assessment and management

Formulary chapter 13.3

Consider the possibility of Diabetes in people who have Acanthosis Nigricans

For antimicrobial guidance see the Infection Management page

Formulary chapter 13.2

See our Specials page to access the current specials guidance

Specials Recommended by the British Association of Dermatologists for Skin Disease

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 two 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.

NPSA: Steroid Emergency Card to support early recognition and treatment of adrenal crisis in adults

Topical corticosteroids: information on the risk of topical steroid withdrawal reactions

Topical corticosteroids and withdrawal reactions – Patient Safety Leaflet

NICE CKS: How long can I prescribe topical corticosteroids for?

MHRA Alert: Topical corticosteroids: information on the risk of topical steroid withdrawal reactions

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.

NICE CKS: How much topical corticosteroid should I prescribe?

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

See Wound Care page

See our Medication Safety page