NHS Kernow emollient prescribing guideline September 2021 

NHS Kernow moisture associated skin damage pathway September 2021

Emollient Pathway 2022 

Fire risk with paraffin-containing products

Greasy preparations (ointments) are often preferable to creams in most circumstances because:

However, patient preference or activity may necessitate a combination of ointments and creams, for example, patients may prefer to apply creams during the day and use ointments at night, or different preparations on different parts of the body.

Application technique: It is important to educate patients with the correct application technique. Ointments and creams should be applied down the direction of hair growth. They should also be smeared on and not rubbed in.

Pot Hygiene: When supplying patients with pots of emollient, it is important to educate them about the hygiene required. Patients should be advised to decant from the pot onto plate/bowl etc. using a spoon or a spatula. Hands should not be put into the pot as this will lead to the introduction of foreign particles.

In many cases generic prescribing will be difficult because products contain a combination of active ingredients. In this chapter brand names are used for products which should not be prescribed generically.

Extemporaneous preparations: A product should only be extemporaneously prepared when there is no product with a marketing authorisation available. Depending on the formulation this may be done in a pharmacy, or by a specials manufacturer, usually depending on the formulation. Where a specials manufacturer prepares the product, additional charges will be incurred. The cost can, and usually does, exceed £100 for a cream. The cost is usually the same whether 500 g or 50 g of a product is ordered. Specials all have a very short shelf life with an expiry date of a maximum of 28 days from manufacture.

A range (but not all) of specials preferred by the British Association of Dermatologists has been approved for use within Cornwall mainly for prescribing by secondary care.

Topical corticosteroids and antimicrobial combinations

The advantages of including other substances (such as antibacterials or antifungals) with corticosteroids in topical preparations are debatable. They may have a place where there is associated bacterial or fungal infection.

Topical corticosteroids are classified according to their potency:- mild, moderately potent, potent and very potent. Preparations in the mild and moderately potent groups are rarely associated with side-effects. This is not the case with potent and very potent preparations. Prescribers should aim to use the lowest possible strength of the least potent drug for the shortest possible time. For patients requiring maintenance therapy of steroids, it is important to review prescribing at least every 3 months. For patients using steroids short term, the need for repeat prescriptions should be reviewed every four weeks. The long-term use of potent and very potent steroids should only be recommended by a dermatologist / GPwSI / nurse specialist. With very rare exceptions potent and very potent preparations should not be used on the face. In this formulary we recommend:

Mild - hydrocortisone 0.5%, 1%, 2.5%

Moderately potent - clobetasone butyrate 0.05%, betamethasone valerate 0.025%

Potent - betamethasone valerate 0.1% or mometasone furoate 0.1% or fluocinolone acetonide 0.025% (for use on scalp and other hairy areas)

Very potent - clobetasol propionate 0.05%

Very potent topical steroids should not be used unless a firm diagnosis has been established.

Where a steroid is deemed appropriate for use on a child's face avoid the more potent steroids and ensure that any steroid used is applied sparingly.

How much to prescribe and use?

The length of a corticosteroid ointment or cream expelled from a tube may be used to specify the quantity to be applied to a given area of skin. This length may be measured in terms of a fingertip unit (the distance from the tip of the adult index finger to the first crease). One fingertip unit (approximately 500 mg) is sufficient to cover an area that is twice that of the flat adult hand.

Diluting a proprietary topical steroid preparation will alter the shelf life of the finished product and may reduce the effectiveness of any preservative.

The table below shows suitable quantities of dermatological preparations to be prescribed for specific areas of an average adult body based on a single daily application for 2 weeks.

NICE Guidance on the Frequency of application of topical corticosteroids for atopic eczema (issued August 2004) recommends that corticosteroids should not be applied to the affected skin of people with atopic eczema more than twice a day.