Formulary 1: Topical Treatments

Formulary 1 Topical Treatments Our selection has been determined by personal preferences and we accept that we have left out many effective remedies. However, the preparations listed here are those that we use most often. As a result some appear only in the UK column but not in the USA one, and vice versa. To conform with current prescribing recommendations whenever possible we have listed these products under their active ingredients, with their proprietary names in brackets. Up-to-date information can be found at www.bnf.org.uk or www.fda.gov. There is a limited range of licensed topical products for the treatment of common skin conditions such as eczema and psoriasis. As a result dermatologists may prescribe unlicensed alternatives or ‘specials’. These Type of preparation and general comments Emollients These are used to make dry scaly skin smoother. Most are best applied after a shower or bath. The opposite of dry is wet, not greasy. While greasy formulations make the skin look moister, those containing humectants such as glycerin, urea or lactic acid generally moisturize better. On the face, use moisturizers designed for the face to minimize acne cosmetica should only be used when a licensed alternative is unavailable. Many of these specials have a proven track record over many years; however, the evidence for their usage is largely empirical. Nonetheless, they have become a trusted and essential part of the dermatological armamentarium. Due to a small potential market and short shelf life they are often considered non-viable for commercial production, which is reflected in their disproportionately high price. In an attempt to rationalize the array of specials, the British Association of Dermatologists has produced an excellent booklet on the most commonly used preparations, their indications and treatment regimes (http://www.bad.org.uk/healthcareprofessionals/clinical-standards/specials). UK preparations USA preparations Soft white paraffin BP Emulsifying ointment BP Liquid and White Soft Paraffin Ointment, NPF (liquid paraffin 50%, white soft paraffin 50%) Aqueous cream BP – can be used as a soap substitute Aveeno range Doublebase range Hydromol cream and ointment Epaderm cream and ointment Diprobase cream and ointment E45 range Oilatum range Unguentum M – a useful diluent: contains propylene glycol and sorbic acid, which may sensitize Neutrogena dermatological cream Aquadrate, Balneum, Eucerin Intensive, Hydromol Intensive and Calmurid creams contains urea Dermol range – contains antimicrobials Petrolatum alba USP Vanicream – devoid of fragrances and many sensitizers Aquaphor – a hydrophilic petrolatum Aveeno cream (Eczema Therapy) Plastibase – a hydrophilic polyglycol Eucerin – hydrophilic petrolatum containing water Curel Moisturel Lubriderm Hydrolatum – petrolatum, methylparaben Carmol range – contains urea humectant Complex 15 facial – phospholipids Lacticare lotion – contains alphahydroxy acid Clinical Dermatology, Fifth Edition. Richard B. Weller, Hamish J.A. Hunter and Margaret W. Mann. © 2015 John Wiley & Sons, Ltd. Published 2015 by John Wiley & Sons, Ltd. 397 398 Formulary 1 Type of preparation and general comments Bath additives/shower gels These are a useful way of ensuring application to the whole skin. Most contain emollients which help with dry itchy skin. Others contain tar (see section on psoriasis) or antibacterials. Caution: makes bathtubs slippery Shampoos All contain detergents which help to remove debris and scales; some have added ingredients to combat psoriasis, seborrhoeic eczema and bacterial infections. Most work best if their lather is left on the scalp for 5 minutes before being rinsed off Cleansing agents These are used to remove debris and to combat infection. Some are astringents which precipitate protein and in doing so help to seal the moist surface of a weeping eczema or a stasis ulcer UK preparations USA preparations Balneum range Emulsiderm – contains benzalkonium chloride Oilatum range Aveeno range Doublebase range Hydromol bath emollient Dermol and Oilatum Plus ranges contain antimicrobials Mineral oil bath emulsion (Keri Moisture Rich Shower and Bath Oil, Eucerin Bath Therapy) Colloidal oatmeal (Aveeno Eczema Therapy Bath Treatment) Balneum Hydromol Emollient Containing tar Alphosyl 2 in 1 Polytar range T-Gel Capasal – also contains salicylic acid Containing tar DHS Tar Gel Denorex shampoo – tingles on scalp Neutrogena T-Gel Tarsum Shampoo Polytar range Others Betadine – contains antibacterial povidone iodine Ceanel concentrate – contains cetrimide, undecenoic acid Selsun – contains selenium sulfide and can be used to treat pityriasis versicolor (p. 245) Nizoral – contains ketoconazole and is useful for seborrhoeic dermatitis and pityriasis versicolor Meted – contains salicylic acid and sulfur Dermax – contains benzalkonium chloride Solution of sodium chloride 0.9% (Normasol) – used to clean wounds and ulcers Potassium permanganate (Permitabs – one tablet in 4 L water makes a 0.01% solution) – will stain clothing and skin Aluminium acetate lotion – use at 0.65% in water – is mildly astringent and used as wet dressing Silver nitrate – use at 0.5% in water – is astringent, stains skin brown Chlorhexidine acetate 0.05% Chlorhexidine gluconate 4% (Hibiscrub) Others Selsun contains selenium sulfide and can be used to treat pityriasis versicolor (p. 245) Nizoral – contains ketoconazole and is useful for seborrhoeic dermatitis and pityriasis versicolor Head and Shoulders, Zincon – contains zinc pyrethione Sebulex, Scalpicin, T-sal – contain salicylic and sulfur Caprex – contains fluocinonide Syndets – neutral cleansers generally milder than soap (Dove) Chlorhexidine 4% (Hibiclens) concentrate – use diluted to 1 in 100 (a 0.04% solution of chlorhexidine in water for skin disinfection) Cetaphil gentle skin cleanser (lipid-free) Benzalkonium chloride (Ionax line) Triclosan (Dial, Lever 2000) – deodorant, antibacterial Sulfacetamide/Sulfur (Plexon) – cleanser for rosacea Ethyl alcohol gel (non-irritating disinfectant for hand washing) Topical Treatments Type of preparation and general comments Barrier preparations These are used to protect the skin from irritants and are of value in the napkin (diaper) area and around stomas. Many contain the silicone, dimethicone. The choice of barrier creams for use at work depends upon individual circumstances: recommendations are not given here Depigmenting agents Most contain hydroquinone. The use of agents containing monobenzone causes permanent complete depigmentation Camouflaging preparations Blemishes that cannot be removed can often be made less obvious by covering. Expert cosmetic advice may be needed to obtain the best colour match 399 UK preparations USA preparations Petrolatum Zinc and castor oil ointment BP Dimethicone and benzalkonium chloride (Conotrane) Dimethicone and cetrimide (Siopel) Petrolatum Zinc oxide ointment Kerodex 51 (water-miscible) Kerodex 71 cream (water-repellent) Bentoquatum (Ivy Block Lotion) protective against toxicodendron (poison ivy allergy) Dermaguard spray Flexible collodion (film) Zinc oxide, lanolin, talc and vitamins A and D (Desitin ointment) Dimethicone (Diaper Guard Ointment) Anusol (zinc oxide plus pramoxine) Bag Balm (contains 8-hydroxyquinoline sulfate) None in BNF but some preparations available without prescription from chemists/cosmetic counters Azelaic acid (Finacea gel 15%, Skinoren cream 20%) Hydroquinone 2–4% (Ambi Fade Cream (2% HQ), EpiQuin Micro (4% HQ), Glyquin XM (4% HQ, oxybenzone, avobenzone and glycolic acid) Lustra (4% HQ), Lustra-AF (4% HQ, sunscreen) Hydroquinone (4%), tretinoin (0.05%) and fluocinolone acetonide (0.1%) (Tri-Luma) Monobenzene/monobenzyl ether of hydroquinone (Benaquin) (Caution: permanent depigmentation) Azelaic acid (Finacea gel 15%, Azelex cream 20%) Covermark range Dermablend range Keromask range Covermark range of products Dermablend Powder Palette (Physician’s Formula – Pierre Fabre) in green for correcting red blush of rosacea 400 Formulary 1 Type of preparation and general comments Sunscreens and sunblocks These help the light-sensitive but are not a substitute for sun avoidance and sensible protective clothing. The sun protection factor (SPF) is a measure of their effectiveness against UVB more than UVA, but those recommended here block UVA also Allergic contact dermatitis from the sunscreen ingredients may be missed and the rash put down to a deterioration of the original photosensitivity Antipruritics Remember that these are of limited value. Try to make a firm diagnosis that will lead to an effective line of treatment Antiperspirants Most antiperspirants are deodorants too, but many deodorants (e.g. triclosan) are not antiperspirants UK preparations USA preparations Titanium dioxide (E45 Sun range) Cinnamate, oxybenzone and titanium dioxide (Sunsense Ultra, Roc Sante Soleil, Uvistat range) Avobenzone, homosalate, oxybenzone (Neutrogena range, Aveeno range, Solbar range) Titanium dioxide, zinc oxide (Blue Lizard, Aveeno Natural Protection, CoTZ, MelaShade, Neutrogena Pure & Free, TiZO3, Vanicream) Helioplex – stabilizes avobenzone and oxybenzone, prolonging duration of protection (Neutrogena Ultra Sheer Dry Touch, Neutrogena Age Shield) Mexoryl SX – contains a photostable UVA-absorbing chemical ecamsule (Anthelios) Calamine lotion BP Oily Calamine lotion BP – contains arachis oil Menthol (0.5–2%) or phenol (1.0%) in aqueous cream Crotamiton cream and lotion (Eurax) – also used to treat scabies Doxepin (Xepin cream) Calamine lotion Crotamiton (Eurax cream and lotion) also used to treat scabies Menthol and camphor (Sarna lotion) contains menthol and camphor Doxepin (Zonalon cream) Pramoxine (Prax, Pramegel, Itch-X) Pramoxine and hydrocortisone (Pramosone, Aveeno Anti-itch cream, Epifoam) Benzocaine (Boil ease ointment, solarcaine) – caution: may sensitize Aluminium chloride hexahydrate 20% (Anhydrol Forte solution or Driclor solution). Botulinum toxin (Botox) injections – for local temporary anhidrosis of axillae or palms Glycopyrronium bromide 0.05% solution by iontophoresis (Robinul) to palmar or plantar skin Aluminum zirconium tetrachlorhydroxy gly (many drugstore products, e.g. Gillette and Speed stick lines) Aluminum chlorate 20% (Drysol) 12.5% (CertainDri Roll-On), 6.25% (Xerac-AC) Formaldehyde 10% solution (Lazerformaldehyde) – caution: may sensitize Botulinum toxin (Botox) injections – for local temporary anhidrosis of axillae or palms Glycopyrronium bromide 0.05% solution by iontophoresis (Robinul) to palmar or plantar skin Topical Treatments 401 Type of preparation and general comments UK preparations USA preparations Keratolytics These are used to counter an excessive production of keratin. Salicylic acid preparations should be used for limited areas only and not above 6%, as absorption and toxicity may follow their prolonged and extensive application, especially in infants Salicylic acid, 2–4% in emulsifying ointment or soft white paraffin Zinc and salicylic acid (2%) paste (Lassar’s paste). Useful for hyperkeratotic, fissured skin disorders Urea preparations (see Emollients) Propylene glycol, 20% in aqueous cream Salicylic acid (6% Keralyt gel, Salex, Salkera) Salicylic acid, 2–4% in emulsifying ointment or soft white paraffin Urea preparations at high concentrations (Carmol 20%, 40%) Propylene glycol (Epilyt) Eflornithine 11.5% (Vaniqa) retards hair regrowth Sulfides (Magic Shaving Powder) Thioglycollates (Nair line, Neet line) Zip wax, Nair microwave wax – mechanical hair removal Eflornithine hydrochloride cream 13.9% (Vaniqa) retards hair regrowth Mildly potent Hydrocortisone 0.5, 1.0, 2.5% preparations Fluocinolone acetonide (Synalar cream 1 in 10) Mildly potent Hydrocortisone 0.5, 1.0, 2.5% (numerous manufacturers) Desonide (Desowen, Tridesilon, Desonate) Alclometasone (Aclovate) Fluocinolone acetonide 0.01% (Synalar, Dermasmoothe) Moderately potent Alclometasone dipropionate (Modrasone cream and ointment) Betamethasone valerate (Betnovate RD cream and ointment) Clobetasone butyrate cream and ointment (Eumovate) Moderately potent Betamethasone valerate (Valisone, Luxiq Foam) Hydrocortisone valerate (Westcort) Triamcinolone 0.025%, 0.1% (Kenalog, Aristocort, various manufacturers) Potent Betamethasone valerate (Betnovate range including scalp application, Betacap scalp application, Bettamousse scalp application) Fluticasone propionate (Cutivate cream and ointment) Mometasone furoate (Elocon range) Hydrocortisone butyrate (Locoid range) Fluocinolone acetonide (Synalar range) Potent Betamethasone dipropionate (Diprosone) Mometason Furoate (Elocon) Fluticasone propionate (Cutivate) Fluocinonide (Lidex) Desoximetasone (Topicort range) Hydrocotisone butyrate (Locoid range) Very potent Clobetasol propionate (Dermovate range, Clarelux foam scalp treatment and Etrivex shampoo) Diflucortolone valerate (Nerisone Forte range) Very potent Clobetasol propionate (Temovate, Olux Foam, Clobex) Halobetasol propionate(Ultravate) Betamethasone dipropionate in enhanced vehicle (Diprolene) Diflorasone diacetate (Psorcon) Depilatories Over-the-counter depilatories are used to remove unwanted facial hairs and are all irritating. Eflornithine inhibits ornithine decarboxylase in hair follicles Steroids Our selection here has had to be ruthless as so many brands and mixtures are now on the market Conventionally, they are classified according to their potency. Your aim should be to use the least potent preparation that will cope with the skin disorder being treated. Side effects and dangers are listed in Table 26.2, p. 361. Nothing stronger than 1% hydrocortisone should be used on the face (except in special circumstances, e.g. discoid lupus erythematosus) or in infancy. Be reluctant to prescribe more than 200 g of a mildly potent, 50 g of a moderately potent or 30 g of a potent preparation per week for any adult for more than 1 month Most of the preparations listed are available as lotions, creams, oily creams and ointments; your choice of vehicle will depend upon the condition under treatment (p. 363). Use twice daily except for Cutivate and Elocon, which are just as effective if used once a day 402 Formulary 1 Type of preparation and general comments Steroid combinations With antiseptics With antibiotics UK preparations USA preparations Potent Betamethasone valerate and clioquinol cream and ointment Fluocinolone acetonide with clioquinol (Synalar-C cream and ointment) Mildly potent Clioquinol and hydrocortisone (1%) Iodoquinol 1% and hydrocortisone 1% (Vytone cream) Iodoquinol 1% and hydrocortisone 2% (Alcortin cream) Iodoquinol 1.25% and aloe (Aloquin gel) Mildly potent Hydrocortisone and fusidic acid (Fucidin H cream) Hydrocortisone and oxytetracycline (Terra-Cortril ointment) Mildly potent Neomycin, bacitracin, hydrocortisone 1% (Corticosporin) Moderately potent and potent Betamethasone valerate and neomycin (Betnovate-N cream and ointment) Fluocinolone acetonide and neomycin (Synalar-N cream and ointment) With antifungals Mildly potent Hydrocortisone and clotrimazole (Canesten HC cream) Hydrocortisone and miconazole (Daktacort cream and ointment) Very potent Clotrimazole and betamethasone dipropionate (Lotrisone) Potent Betamethasone dipropionate and clotrimazole (Lotriderm cream) With antibacterials and antifungals Mildly potent Hydrocortisone, chlorhexidine and nystatin (Nystaform HC cream and ointment) Hydrocortisone, benzalkonium, nystatin and dimeticone (a silicone) (Timodine cream) Moderately potent Nystatin and triamcinolone (Mycolog II) Moderately potent Clobetasone butyrate, oxytetracycline and nystatin (Trimovate cream) Very potent Clobetasol propionate with neomycin and nystatin cream and ointment With calcipotriol (For psoriasis) Potent Betamethasone dipropionate (Dovobet ointment and gel) With salicylic acid Potent Betamethasone dipropionate and salicylic acid (Diprosalic ointment – and scalp application) Potent Betamethasone dipropionate (Taclonex ointment) Topical Treatments Type of preparation and general comments 403 UK preparations USA preparations Benzydamine hydrochloride solution (Difflam oral rinse) – an analgesic for painful inflammation in the mouth Chlorhexidine gluconate 1% (Corsodyl mouth wash) Hexetidine solution (Oraldene) an antiseptic gargle Cetylpyridinium (Cepacol antiseptic mouthwash) Listerine antiseptic mouth rinse (contains thymol, eucalyptol, methylsalicylate, menthol) ‘All-purpose mouthwash’ – different formulations – e.g. compounded as nystatin suspension 100 000 U/mL, 120 mL; diphenhydramine elixir 12.5 mg/5 mL, 480 mL; hydrocortisone powder 240 mg; sodium carboxymethylcellulose 2%, 720 mL ‘Magic mouthwash’ – different formulations – e.g. compounded as equal parts Maalox (Magnesia and alumina oral suspension) and diphenhydramine elixir 12.5 mg/5 mL) – some also add dexamethasone Mucotrol – slow dissolving wafer, diphenhydramine elixir 12.5 mg/5 mL) Topical steroids Betamethasone soluble tablets Hydrocortisone mucoadhesive buccal tablets to be dissolved slowly in mouth near the lesion – usually an aphthous ulcer Triamcinolone acetonide (Kenalog in orabase) – a paste that adheres to mucous membranes Fluocinonide gel (Lidex gel) Clobetasol gel (Temovate gel) For yeast infections Miconazole (Daktarin oral gel) Nystatin (Nystan oral suspension) Clotrimazole (Mycelex troches) Nystatin oral suspension or pastilles (Nilstat, Mycostatin) Pimecrolimus (Elidel cream 1%). For mild to moderate eczema Tacrolimus (Protopic ointment 0.03%, 0.1%). For moderate to severe eczema Pimecrolimus (Elidel cream 1%). For mild to moderate eczema Tacrolimus (Protopic ointment 0.03%, 0.1%). For moderate to severe eczema Aluminium acetate ear drops 8% – an effective astringent for the weeping phase; best applied on ribbon gauze Hydrocortisone with neomycin and polymyxin (Otosporin drops) Cotrimazole (Canesten solution) Aluminium acetate ear drops 8% – an effective astringent for the weeping phase; best applied on ribbon gauze Hydrocortisone, neomycin and polymyxin (Corticosporin drops) Ciprofloxacin 0.2% and hydrocortisone 1% (Cipro HC Otic) Acetic acid 2% with or without hydrocortisone (VoSol/VoSol-HC) Tridesilon otic solution Preparations for use in the mouth Useful mouth washes Topical analgesics Topical immunomodulators Long-term safety data not yet available, so should not generally be used as first-line agents Preparations for otitis externa Otitis externa, essentially an eczema, is often complicated by bacterial or yeast overgrowth – hence the combinations listed here 404 Formulary 1 Type of preparation and general comments UK preparations USA preparations Antibacterial preparations The ideal preparation should have high antibacterial activity, low allergenicity and the drug should not be available for systemic use; this combination is hard to find. Some compromises are given here Mupirocin (Bactroban cream and ointment) Fusidic acid (Fucidin ointment and cream) Polymyxin and Bacitracin (Polyfax ointment) Mupirocin (Bactroban 2% ointment, 2% cream) Nitrofurazone (Furacin ointment, cream or solution) Bacitracin Gentamicin (Garamycin ointment) Bacitracin and polymyxin (Polysporin ointment) Silver sulfadiazine 1% cream – various manufacturers Benzoyl peroxide 5–10% (antiseptic) To eliminate nasal carriage of staphylococci Mupirocin (Bactroban Nasal ointment) Chlorhexidine and neomycin (Naseptin cream) To eliminate nasal carriage of staphylococci Mupirocin (Bactroban nasal ointment) Antifungal preparations In our view, imidazole, terbinafine, butenafine and amorolfine creams have now supplanted their messier, more irritant and less effective rivals (e.g. Whitfield’s ointment). They are fungicidal and the fungistatic azoles such as ketoconazole and clotrimazole have the added advantage of combating yeasts as well as dermatophytes Systemic therapy will be needed for tinea of the scalp, of the nails and of widespread or chronic skin infections that prove resistant to topical treatment Antiviral preparations Topical products have little part to play in the management of herpes zoster. However, if used early and frequently, they may help with recurrent herpes simplex infections Wart treatments Palmoplantar warts Clotrimazole (Canesten cream) Miconazole (Daktarin cream) Ketoconazole (Nizoral cream) Terbinafine (Lamisil cream) Amorolfine (Loceryl nail lacquer) Tioconazole (Trosyl cutaneous solution) – applied locally it may increase the success rate of griseofulvin. Used by itself it may also cure or improve some nails Clotrimazole (Lotrimin cream, solution and powder, Mycelex) Miconazole (Micatin cream) Econazole (Spectazole cream, Zeasorb-AF Powder) Terbinafine (Lamisil cream) Butenafine (Mentax cream) Ciclopirox (Loprox cream and lotion, Penlac nail lacquer, Ciclodan Kit) Naftifine (Naftin cream) Oxiconazole (Oxistat) Sertaconazole (Ertaczo) Aciclovir (Zovirax cream) Penciclovir (Vectavir cream) Penciclovir (Denavir cream) Aciclovir (Zovirax cream) Docosanol (Abreva cream) Salicylic acid and lactic acid (Salactol paint or Salatac and Cuplex gel) Salicylic acid (at 26%, Occlusal solution: at 50%, Verrugon ointment) Glutaraldehyde (Glutarol solution) Formaldehyde (Veracur gel) Salicylic acid (Duofilm, Occlusal-HP) Salicylic acid plasters 40% (Compound W) Topical Treatments Type of preparation and general comments Anogenital warts Podophyllum should only be used for non-keratinized warts 405 UK preparations USA preparations Imiquimod (Aldara cream) – an immunomodulator (p. 230) Podophyllotoxin (Condyline solution, Warticon cream and solution) Podophyllin resin, 15% (Podophyllin paint compound – use with care (p. 230) Podophyllin/benzoin (Podocon-25 powder) Podofilox (Condylox gel) Imiquimod (Aldara cream) (p. 230) Preparations for treatment of scabies (p. 253) Permethrin (Lyclear Dermal Cream) Poor results follow inefficient usage rather than ineffective preparations. Malathion (Derbac-M liquid) Benzyl benzoate application (BP). We prefer permethrin or sulfur in Irritant and less effective than young children, and pregnant and malathion or permethrin. lactating women. Written Crotamiton (Eurax cream) for use if instructions are helpful (p. 256) itching persists after treatment with more effective scabicides Permethrin (Elimite cream) Lindane (Kwell lotion) Crotamiton (Eurax cream) for use if itching persists after treatment with more effective scabicides Precipitated sulfur 6% in soft white paraffin Preparations for treatment of pediculosis (p. 249) Malathion (Derbac-M liquid) Resistance is a growing problem. Permethrin (Lyclear Creme Rinse) Lotions left on for a minimum of 12 hours are more effective, although less convenient than shampoos Malathione (Ovide) Permethrin (Nix) Permethrin/piperonyl butoxide (Rid) Benzyl benzoate solution 20–25% Precipitated sulfur 6% in Nivea Oil Preparations for acne Active ingredient Benzoyl peroxide (an antibacterial agent) induces dryness during the first few weeks; this usually settles, even with continued use Benzoyl peroxide (Panoxyl ranges) Potassium hydroxyquinoline with benzoyl peroxide (Quinoderm range) Benzoyl peroxide (Panoxyl, Benzac, Desquam-X Oxy, Clearasil range 2.5, 5 and 10%) With sulfur (Sulphoxyl) Isotretinoin (Isotrex gel) Isotretinoin and erythromycin (Isotrexin gel) Tretinoin (Retin-A preparations) Adapalene (Differin gel and cream) Adapalene and benzoyl peroxide (Epiduo gel) Tretinoin (Retin-A preparations) Tretinoin and clindamycin (Ziana, Veltin) Tazarotene (Tazarac gel 0.05 and 0.1%) Adapalene (Differin gel, lotion and cream) Adapalene and benzoyl peroxide (Epiduo gel) Clindamycin (Dalacin-T solution or roll-on) Erythromycin (Stiemycin solution) Erythromycin and zinc acetate (Zineryt) Clindamycin and benzoyl peroxide (Duac Once daily gel) Clindamycin (Cleocin-T solution and gel, Evoclin Foam) Erythromycin 2% solution – various manufacturers Sulfacetamide (Klaron lotion) Clindamycin and benzoyl peroxide (Duac, Benzaclin, Acanya) Erythromycin and benzoyl peroxide (Benzamycin) Sulfur and sulfacetamide (Sulfacet-R, Sumadan) Retinoids Potent comedolytic agents, also used to reverse photoageing. May irritate. Must be avoided during pregnancy/lactation Antibiotics Bacterial resistance is increasing, but can be reduced by concomitant administration of benzoyl peroxide 406 Formulary 1 Type of preparation and general comments UK preparations USA preparations Azelaic acid (Skinoren cream, Finacea gel) Azelaic acid (Azalex cream, Finacea gel) Salicylic acid (Neutrogena clear pore gel, Clearasil stick, Stridex gel) Metronidazole (Metrogel, Rozex cream, Rosiced cream) Azelaic acid (Finacea gel) Metronidazole gel, lotion, cream (Metrogel, Metrocream, Metrolotion, Noritate) Sulfur and Sulfacetamide (Sulfacet-R) Sulfacetamide (Klaron) Calcipotriol ointment and scalp solution (Dovonex ointment). Maximum weekly doses: 6–12 years, 50 g; over 12–16 years, 75 g; adults, 100 g. Can be irritant. Avoid on face Calcitriol (Silkis ointment). Maximum daily dose for adults, 30 g. Less irritant than calcipotriol. Can be used on face/flexures. Tacalcitol (Curatoderm ointment and lotion). Maximum daily dose for adults, 10 g. Not recommended for children Calcipotriene (Dovonex cream, lotion and ointment) Calcitriol (Vectical) Maximum doses same as UK Calcipotriol with betamethasone diproprionate (Dovobet ointment and gel) Calcipotriene with betamethasone diproprionate (Taclonex) Betamethasone (Betnovate scalp application, Diprosalic scalp lotion – also contains salicylic acid) Fluocinolone (Synalar gel) Dovobet gel Clobetasol propionate (Etrivex shampoo) Clobetasol (Temovate scalp application, Olux foam) Fluocinonide (Lidex solution) Fluocinonide in peanut oil (Dermasmoothe FS) Betamethasone valerate (Valisone lotion), Luxiq foam) Micanol range 1% Dithrocream range 0.1, 0.25, 0.5, 1, 2% Micanol 1% Dithrocreme 0.1, 0.25, 0.5, 1% Dritho-Scalp Tazarotene (Zorac gel) Tazarotene (Tazorac gel) Azelaic acid and salicylic acid Preparations for rosacea Preparations for psoriasis Vitamin D derivatives Calcipotriol (calcipotriene, USA) and tacalcitol. Avoid using in patients with disorders of calcium metabolism Steroids Routine long-term treatment with potent or very potent steroids is not recommended. For indications (p. 60) Scalp applications Dithranol/anthralin Stains normal skin and clothing. May be irritant, therefore start with low concentration (for 30-minute regimen see p. 61) Retinoid Contraindicated in pregnancy and during lactation Topical Treatments Type of preparation and general comments 407 UK preparations USA preparations Bath additives Polytar emollient bath additive Psoriderm bath emulsion Balnetar liquid Applications Exorex lotion Carbo-Dome cream Psoriderm cream Denorex Psoriasis overnight treatment MG-217 2% ointment Scalp applications Polytar liquid Exorex lotion Psoriderm scalp lotion T-Gel shampoo 10% Liquor carbonis detergens in Nivea oil DHS Tar Gel Denorex shampoo Neutrogena T-Gel Tarsum Shampoo Polytar range Tar – salicylic acid combinations Sebco scalp ointment Cocois ointment Capasal shampoo Sebulex, Scalpicin, T-sal For cleansing Saline, potassium permanganate (see Cleansing agents) Hydrogen peroxide solution (3%) Saline, potassium permanganate (see Cleansing agents) Hydrogen peroxide solution (3%) Bleach (sodium hypochlorite) 1/4 cup to bathtub of water, or 1 tablespoon per quart for soaking) – may bleach fabrics Low adherent dressings Tulle dressings (e.g. Bactigras, contains chlorhexidine; Jelonet, paraffin gauze) Textiles (e.g. Mepitel) Telfa Vaseline gauze (contains petrolatum) Tar These clean refined tar preparations are suitable for home use. Messier, although more effective, formulations exist but are best used in treatment centres Preparations for venous ulcers Regardless of topical applications, venous ulcers will heal only if local oedema is eliminated. Remember that the surrounding skin is easily sensitized. To choose treatment for an individual ulcer see p. 150 Enzymes Antiseptics Enzymes (Elase Ointment – contains fibrinolysin and deoxyribonuclease; Collagenase Santyl ointment – contains collagenase) Silver sulfadiazine – active against Pseudomonas (Flamazine cream) Cadexomer iodine (Iodosorb powder) Silver sulfadiazine (Silvadene cream) Nitrofurazone (Nitrofurazone solution) Mupirocin (Bactroban Ointment) 408 Formulary 1 Type of preparation and general comments Other applications Medicated bandages Beware of allergic contact reactions to parabens preservatives which are in most bandages UK preparations USA preparations Zinc paste and ichthammol (Ichthopaste) Zinc oxide (Viscopaste PB7, steripaste) Zinc oxide Dextranomer (Debrisan) – for absorbing exudates Becaplermin (Regranex) – growth factor Hydrocolloid (Granuflex, DuoDERM Extra Thin) Calcium alginate (Kaltostat) Hydrogels (Intrasite, Aquaform) Polyurethane foam (Tielle) Vapour-permeable film dressing (Opsite) Activated charcoal with silver (Actisorb silver 200) Hydrocolloid (Duoderm) Vapour-permeable film dressing (Opsite, Tegaderm) Hydrogel (Vigilon) Calcium alginate Biafin – recruits macrophages Efudix cream fluorouracil 5% cream containing 5-fluorouracil is useful. It should be applied twice daily for 2–3 weeks. For such cases patients should be warned about the inevitable inflammation and soreness which appears after a few days Actikerall fluorouracil 0.5%, salicylic acid 10%, apply once daily for up to 12 weeks Efudex cream 2% or 5%) Fluroplex 1% cream Carac 0.5% solution – drug incorporated into microsphere Imiquimod 5% (Aldara) Applied 5 days per week for 6 weeks. The response is related to the degree of inflammation. When used to treat actinic keratoses, apply three times per week for 4 weeks Imiquimod 5% (Aldara) Applied 5 days per week for 6 weeks for treatment of superficial basal cell carcinomas. The response is related to the degree of inflammation. When used to treat actinic keratoses, apply two times per week for 16 weeks and wash off after 8 hours 3% Diclofenac sodium in sodium hyaluronate base (Solaraze gel). Applied twice daily for 60–90 days 3% Diclofenac sodium in sodium hyaluronate base (Solaraze). Applied twice daily for 60–90 days Picato. For treatment of face and scalp, use 0.015% gel daily for 3 days. For treatment of trunk and extremities, use 0.05% gel daily for 2 days Picato 0.015% or 0.05%. For treatment of face and scalp, use 0.015% gel daily for 3 days. For treatment of trunk and extremities, use 0.05% gel daily for 2 days Other dressings For photodamage 5-Fluorouracil The treatment of individual lesions in patients with multiple actinic keratoses is tedious or impossible. Lesions on the scalp and face do better than those on the arms and hands Imiquimod Enhances the immune response to superficial basal cell carcinomas and actinic keratoses Miscellaneous For actinic keratoses Diclofenac Ingenol mubutate Topical Treatments Type of preparation and general comments Minoxidil May be used as a possible treatment for early male-pattern alopecia. The response is slow, and only a small minority of patients will obtain a dense regrowth even after 12 months. Hair regained will fall out when treatment stops – warn patients about this Capsaicin A topical pepper that depletes substance P. Useful for the treatment of post-herpetic neuralgia. May itself sting. Apply up to 3–4 times daily after lesions have healed. May take 2–4 weeks to relieve pain Lidocaine/prilocaine A local anaesthetic for topical use. Applied on skin as a thick layer of cream under an occlusive dressing or on adult genital mucosa with no occlusive dressing. Read manufacturer’s instructions for times of application 409 UK preparations USA preparations Regaine liquid 2 or 5% – only on private prescription Rogaine 2% solution Rogaine 5% solution for men Axsain cream (0.075%), Zacin cream (0.075%) Zostrix cream (0.025%) Capzasin HP cream (0.075%) Axsain cream (0.075%) Lidocaine and prilocaine (EMLA cream) Lidocaine 4% (LMX 4) Lidocaine 5% (LMX 5) Lindocaine 2.5%/prilocaine 2.5% (EMLA cream)