Emollient Prescribing Guidelines & Formulary - Hampshire ...
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Emollient Prescribing Guidelines
&
Formulary
Version 2/092019 Review date: July 2021
1|Page
Contents:
Section Page Number
Introduction 3
Self-Care 3
Prescribing Guidance 3
General Advice 3
Product advice 4
Types of emollients 6
Suitable Quantities 7
Primary Secondary Care Interface 7
Prescribing guidance for under 12’s 7
Unlicensed prescribing 7
Formulary 8
Sensitizer list for formulary products 12
Patient information leaflet. 13
The following document has been produced to support clinicians in primary care in the prescribing of
emollients.
It is not intended to override clinical judgement
2|PageIntroduction
There is no evidence from controlled trials to support the use of one emollient over another. Therefore
selections should be based on the type and severity of symptoms, area of skin involved and most importantly
patient acceptability.
Individuals have different expectations and requirements from their treatment. This includes and is affected
by elements like lifestyle, skin age and skin type. These expectations should be address alongside health
education to ensure they have a clear understanding about their condition.
People can be sensitive or even allergic to various irritants which can cause skin problems. There are known
ingredients in available emollients and other topical dermatological treatments that can exacerbate these
sensitivities. These include excipients such as sodium lauryl sulphate, wool fat, lanolin and perfumes. When
trying a new emollient consider previous treatments, the reactions and success experienced and if a reaction
occurred, what sensitizers were present in the previous emollient(s).
Self-Care
Individuals with dry skin not related to dermatological condition should be encouraged to buy an
emollient of their choice from retail outlets.
The IOW minor ailment scheme and pharmacy first can support patients for occasional use where
needed. Long term self-care is encouraged for persistent issues.
Self-care messages should be promoted with the following messages:
o Increase emollient use when there is an exacerbation of the condition
o Adequate hydration is important for skin health
o Triggers should be identified and exposure minimised
o Application of an emollient should not be followed by immediate topical steroid use – allow
about 30 mins.
o Apply correctly, liberally and frequently even after improvement
Prescribing Guide
General Advice
Choice of emollient should be a cost effective joint decision by between the prescriber and the
patient. Prescribing should fit the individual and their lifestyle. It should also take into consideration
the severity and affected skin, correct hydration potency and skin type.
Initiation of any emollient should be considered as a trial. A number of products may need to be tried
by some patients before the ideal product is found.
COMPLIANCE is the most important factor when prescribing emollients.
Any initiation product should be given in the smallest appropriate pack
size to allow the product to be trialled.
This is to reduce waste should the chosen product not be suitable.
If a trialled product is suitable and the patient is happy using it then the pack size can be increased for
regular use, where appropriate.
3|Page This should be reviewed regularly (at least once a year) to check progression of condition, continuing
suitability, usage and sensitivities. If emollient is being applied by a carer they should be included in
the review where suitable.
Emollients should not be prescribed for non-clinical, cosmetic purposes at NHS expense. Emollients for
these purposes can be readily purchased from retail outlets.
Care homes must discard all creams and ointments in pots 3 months after opening. Pumps and tubes
can be kept up to 6 months after opening.
Pump dispensers are designed to minimise the risk of bacterial contamination. These products should
be considered for patients with broken skin, skin prone to infection, patients in care homes and
patients who are having the emollient applied by a carer or relative. Where the most suitable
emollient is not available in pump dispenser format, extracting the required amount using a clean
spoon or spatula instead of fingers and the lid kept securely on when not in use are ways to minimize
contamination.
Do: Apply emollients regularly as possible. Carry some with you when you are out and
about. Keep fingernails short and smooth
Do NOT: Rub into the skin. Put fingers in a tub product. Smoke or be near flames or fire
when using paraffin-based emollients.
Product advice
Emollient is defined as a substance that is designed to occlude the skin surface and to encourage
build-up of water within the stratum corneum
Generally the greasier the emollient the more effective it is.
All emollients should be applied frequently – at least twice a day. Advise the patient that liberal
application is important and the frequency can be a minimum 2-4 times a day, with very dry skin this
can need applications of every 2-3 hours. Quantities should reflect the frequency of application
Soap substitutes:
Can be prescribed for individuals whose condition is worsened by traditional soap products.
Soap, liquid cleansers and perfumed products can be very drying.
Any cream emollient can be used as a soap substitute. They will not foam but are as effective as
cleaning with soap
They can be applied before bathing/ showering or washing, or while in the water( 1)
As with other emollients these should be trialled in small quantities until a suitable product is
established.
Antimicrobials:
Routinely using products containing antimicrobials should be avoided, as should using them long
term. This is to reduce resistance. NICE recommends the option of topical antiseptics to decrease
bacterial load in children who have recurrent infected atopic eczema. When indicated – use one
formulation at a time.
4|Page There is limited evidence to support routine use. In selected cases recurrent infection is a
contributory factor to relapse. In these cases antimicrobial emollients can play a role in stabilizing
the patient’s condition
Do not prescribe Dermol 200 shower gel and 600 bath additive
Urea based products:
Urea is a keratin softener and a hydrating agent. It is helpful in the treatment of dry and scaling
conditions included icthyosis. Urea can be irritant and can cause stinging, also these products tend
to be more costly. It is reasonable to reserve these products for specific target groups rather than
using routinely or first line. The type of patients would include those with scaling skin or those who
have tried multiple other emollients without success. As with other trials the smallest pack size
should be selected initially.
Urea based emollients should be an ‘add on’ to a patient’s regular emollient regimen due to
potential for stinging.
Not all patients will tolerate these products. They should not replace established emollients and be
avoided in minor dry skin.
Paraffin based products – WARNING –
Dressings and clothing that have contact with paraffin based emollients are known to easily ignite
near a naked flame. Patients should be advised of this and that they should keep away from fire or
flames and not smoke when using them. The risk tends to be associated with the use of large
quantities of these products. It is important to consider someone’s profession when selecting these
items.
Aqueous Cream:
This carries a higher risk of skin irritation, possibly due to the sodium lauryl sulphate (SLS) content.
This is particularly prevalent in children with eczema and older people. Its use is no longer
recommended as a leave on emollient or soap substitute. There are more cost effective and less
irritant leave-on emollients and soap substitutes available.
Bath additives:
There is little evidence to support efficacy of bath additives. Some emollients can be used as soap
substitutes and ointments (except 50:50) can be dissolved in some hot water and added to the
bath water.
Topical Steroids:
Intensive use of emollients can reduce the need for topical steroids. Emollients should be applied in
greater quantities and frequency than any steroid. If a topical steroid is indicated emollients should
be applied at least 30 minutes before or after the steroid.
Storage:
Care homes are asked to discard all creams and ointments in pots 3 months after opening.
Pumps and tubes can be kept and used for 6 months after opening.
5|PageTypes of emollients:
Need reapplying frequently on very dry skin
Good for very mild dry skin and also for the face
Lotions More water so spreads easily, but makes them less effective emollients
Emulsion of oil and water
Less greasy than ointments, but more effective than lotions as an emollient.
Creams/ gels More cosmetically acceptable than ointments.
Most Creams can be used as soap substitutes.
The greasiest preparation so very occlusive and traps the most moisture
Made from oil and/or fats
Can be less accepted/tolerated due to their greasiness
Ointments Tend to be low in preservatives so less likely to irritate the skin than creams
and lotions
Useful for very dry and thickened skin, ideal under wet wraps
Aerosols: sprays These tend to generally be more costly but may have a limited role where
and mousses application without touching the skin is justified
Urea based emollients should be an add on to a patient’s regular emollient
regimen due to potential for stinging.
Urea containing Not all patients will tolerate these products. They should not replace
established emollients and be avoided in minor dry skin.
Bath oils are not recommended. Most Ointments except 50:50 can be
dissolved in some hot water and added to the bath water
Avoid bubble baths as they can be irritant
Bath and Shower Emollients can be used as soap substitutes. These are indications on the
formulary by the bar of soap symbol .
Leave on emollients should be used as traditional soaps strip skin of natural
oils and promote skin shedding
Encourage regular bathing. A daily bath removes dirt and skin debris which
could cause infection.
Patients should use a non-slip bath mat.
Bath emollients are restricted to use in children only. Sufficient time (10-
20mins) MUST be spent in the bath to allow the emollient to be absorbed.
Use in adults is not recommended unless there are exceptional clinical cases
indicating use
6|PageSuitable quantities to prescribe:
Quantities can vary greatly. For an emollient this can run to 250-600g per week depending on the severity of
dryness, the product and area of application.
The following table gives a rough guide to quantity based on an adult applying for a minimum of twice a day.
(For children this is approximately half the below quantities.) During a flare up patients should aim for two
hourly application where possible.
Body site Creams and Ointments Corticosteroid Cream / ointment
One week supply One month supply One week supply
Face 15-30g 60-120g 15-30g (neck)
Both hands 25-50g 100-200g 15-30g
Scalp 50-100g 200-400g 15-30g
Both arms OR legs 100-200g 400-800g 30-60g (arms); 100g (legs)
Trunk 400g 1600g 100g
Groin or gentialia 15-25g 60-100g 15-30g
Primary/ Secondary Care interface:
The hospital dermatologist will not routinely supply emollients in the outpatient setting and therefore this
will fall on the GP to prescribe.
Where a non-formulary product has been recommended by a hospital dermatologist, GP’s can switch to a
formulary product in the same category unless there is clear clinical reasons not to, which have been stated
by the dermatologist.
Following a stay in hospital, any changes to emollients must be clearly indicated on the discharge
summary or the patient will revert back to those they were using on admission.
Prescribing in Children under 12
Based on clinical experience dermatologists prefer greasy based emollients on children.
This should be considered when engaging with the parent or the carer of the child.
Emollients should be provided in a format that they are easily available at home, at nursery or at school. A
greasy emollient may be suitable at home with a lighter one elsewhere to improve compliance. Where
possible it may be easier to supply multiple smaller pack sizes so one can be kept at home and one can go
with the child.
A child with severe eczema can use up to 1000g of emollient per month.
Olive oil and other natural oils are not recommended for use on neonates and babies for dry skin and
infant massage. There is no evidence to support their use. Olive oil has the potential to promote the
development of or exacerbate existing atopic dermatitis as it can significantly damage the skin barrier.
Unlicensed Prescribing
Most prescribing aims for the use of licensed products. This is to ensure safety and efficacy.
For many conditions the range of products is limited, this can lead to the use of ‘specials’ by dermatology
clinics.
This is an area of concern for primary care as the prices of these products vary greatly and so do the varying
of standards.
To address these concerns the British Association of Dermatologists has a list of preferred specials. BAD
guidance on this can be found at the following web page:
http://www.bad.org.uk/healthcare-professionals/clinical-standards/specials
7|PageEMOLLIENT
FORMULARY
To be used in line with the full emollient prescribing guidelines
Colour ranking not to be confused with net.Formulary RAG ratings. The positions in this
document are only an indication of order/ choice preference
8|PageProduct Product Ingredients Rank Pack Cost (£) Comments
category & size DT Mar Pack
Dryness 20
Emulsifying WSP 50% EW
500g 4.15 POT No sensitisers
Ointment 30% LP 20%
125g 1.92 POT Equivalent to Hydromol®
ointment.
Epimax® WSP 30% LP Paraffin Free option
Ointment 40% EW 30% 500g 2.99 POT available
Greasy/ Heavy Cost effective alternative
Leave on to Epaderm® ointment
Emollient 250g 1.83 POT No sensitisers
Fifty:50 WSP 50% LP NOT to be used as soap or
Ointment 50% bath additive substitute
500g 3.66 POT
Severe and very
dry skin 125g 2.41 POT Similar to Hydromol®
Zeroderm®
Low risk of WSP 30% LP ointment.
Ointment
sensitivities low 40% EW 30% 500g 4.10 POT Cost effective alternative
excipients to Epaderm® ointment
125g 2.92 POT Equivalent to Zeroderm®
Hydromol® YSP 30% LP 40% ointment.
Ointment EW 30% 500g 4.96 POT Cost effective alternative
to Epaderm® ointment
ExCetra® 100g 1.75 TUBE Different componenets
Epimax WSP 13.2% LLP
to Epimax. Richer cream
Rich Cream 10.5% 500g 2.95 BOTTLE
Cream
Leave on
emollient WSP 10% LP 50g 1.04 TUBE
Zerobase®
Moderately dry 11% 500g 5.26 PUMP
Cream
Skin
50g 1.40 PUMP
Less greasy than Good variety of pack sizes
Cetraben® WSP 13.2% LLP 150g 3.98 PUMP
ointments Alternative to regular use
Cream 10.5% 500g 5.99 PUMP
of Dermol®
1050g 11.62 PUMP
Good for
everyday use WSP 15% LP 6% 50g 1.28 TUBE
Diprobase®
CM 2.25% CSA
Cream 500g 6.32 PUMP
7.2%
WSP = white YSP = Yellow EW = Emulsifying BAC = IM = Isopropyl LP/LLP – Liquid
soft paraffin soft paraffin wax Benzylalkonium Myristate paraffin/ light liquid
FIRST SECOND THIRD
Chloride paraffin
Choice Choice Choice
= Paraffin LM = Lauromacrogols CO = Colloidal Oat CSA = Cetosteraryl CH = Chlorhexidine
containing alcohol
9|PageProduct Product Ingredients Rank Pack Cost (£) Pack Comments
category size DT Aug format
& Dryness 19
Isomol® IM 15% LP 15% 100g 1.99 TUBE Equivalent to
Opaque Gel
Epimax Gel 500g 2.92 PUMP Doublebase® Gel
Leave on
Emollient Aproderm® 100g 1.99 TUBE
IM 15% LP 15% Equivalent to
Moderately dry Gel
500g 3.99 PUMP Doublebase® Gel
Skin
Less greasy than Zerodouble® IM 15% LP 15% 100g 2.25 TUBE Equivalent to
ointments Gel 500g 4.90 PUMP Doublebase® Gel
Good for
100g 2.65 TUBE Not as cost effective as
everyday use Doublebase® IM 15% LP 15%
Aproderm® Gel and
Gel 500g 5.83 PUMP
Zerodouble® Gel
Light and Epimax® 100g 0.75 TUBE
Original WSP 15% LP 6% Cost effective alternative
creamy leave 500g 2.49 PUMP to Diprobase®
Cream
on emollients
Mild to moderate Aquamax® WSP 20% LP 8% 100g 1.89 TUBE
Thicker than Epimax®
dryness Cream 500g 3.99 POT
Zerocream® WSP 14.5% LP 50g 1.04 TUBE Cost effective alternative
Good for
12.6% 500g 5.26 PUMP to E45®
everyday use
ZeroAQS® WSP 15% LP 6% Alternative to Aqueous
500g 3.29 POT
(no SLS)
Colloidal Oat Most cost effective oat
Epimax® 100g 1.99 TUBE
Based based emollient.
Oatmeal CO 1%
Mild to moderate Cost effective alternative
Cream 500g 2.99 BOTTLE
to Aveeno®
dryness Good for
100ml 2.74 TUBE Cost effective alternative
everyday use Aproderm®
CO 1% to Aveeno®
Use after trying Oat 500ml 5.80 PUMP Paraffin free
rich cream for
100g 2.74 TUBE Cost effective alternative
maintenance Zeroveen® CO 1%
500g 5.89 PUMP to Aveeno®
Lotions
Mild dryness. Mostly cosmetic therefore OTC options available and self-care should be encouraged. Should not be used as
a barrier emollient.
WSP = YSP = Yellow EW = Emulsifying BAC = Benzylalkonium IM = LP/LLP – Liquid
white soft soft paraffin wax Chloride Isopropyl paraffin/ light liquid
FIRST SECOND THIRD
paraffin Myristate paraffin
Choice Choice Choice
= Paraffin LM = CO = Colloidal CSA = Cetosteraryl CH = CM = cetamacrogol
containing Lauromacrogols Oat alcohol Chlorhexidine
10 | P a g eProduct category Product Ingredients Rank Pack Cost (£) Pack Comments
& Dryness size DT Mar format
20
Can cause stinging and
50g 2.85 PUMP
irritation
Balnuem ® 500g 9.97 PUMP
Urea 5% 5% urea first line.
Cream (5%)
Small pack size should be
500g 14.99 PUMP
trialled first
Hydromol® 30g 1.67 TUBE Hydromol® good choice for
Urea containing intensive Urea 10% small areas due to small
cream 100g 4.45 TUBE pack size
Keratin softener Flexitol® 10% 150g 5.00 TUBE
for dry scaling Urea 10%
cream 500g 11.77 PUMP 10% urea creams are second
conditions line when 5% not provided
Eucerin®
10% Urea 10% 250ml 7.93 BOTTLE complete benefit.
intensive.
Balneum® Plus Cream – can be continued for existing patients.
Calmurid 500g = very expensive by comparison (£33.40) – Consider switching to more cost effective
option if Urea based product indicated.
Recommended alternative to long term Dermol use.
Anti- Glycerol, 100g 2.69 TUBE Reduces use of
Carbomer, IM, antimicrobial elements
inflammatory Adex® Gel
LP and and provides anti-
500g 5.99 PUMP
Gel nicotinamide inflammatory component
For use in confirmed recurrent infections only. Avoid Routine Use
LP 10% IM 10% 100g 2.86 TUBE
Dermol®
Antimicrobial BAC 0.1% CH SHORT TERM USE ONLY
Cream 500g 6.63 PUMP
containing 0.1% Small tube used for trial
Short term use LP 2.5% IM 2.5% before prescribing larger
Dermol® 500
infected skin BAC 0.1% CH 500ml 6.04 PUMP pack
lotion
0.1%
Potential sensitizer Formulary products (A-Z)
Fragrance Flexitol 10%
Ceto/ Ceto Stearyl/ Aproderm oat Cetraben Cream Epimax Cream, Oat & ointment Hydromol Zerocream
Stearyl Alcohol Aquamax Dermol Flexitol 10% ZeroAQS Zeroderm
Balneum Diprobase Cream Excetra Cream Zerobase Zeroveen
Propylene glycol Balneum Cream
Triethanolamine Doublebase Isomol gel Zerodouble
Lanolin/ derivatives Eucerin Intensive Flexitol 10% Zerocream
Benzalkonium Dermol
Chloride
Benzyl Alcohol Epimax Oat Eucerin Intensive Flexitol 10% Zeroveen
Phenoxyethanol Adex Gel Cetraben cream Doublebase ExCetra Cream Zerocream
Aproderm Gel Dermol Epimax cream & oat Flexitol 10% Zerodouble
Aquamax cream
Sorbic acid/ Sorbates Balneum Cream Adex Gel
Disodium edetate Aproderm oat
Chlorhexidine Dermol
Chlorocresol Diprobase cream ZeroAQS Zerobase
Isopropyl palmitate Epimax oat Eucerin intensive cream Zeroveen
Isopropyl myristate Zerodouble
Myristyl alcohol Zeroveen
11 | P a g eInformation about your emollient
.
What are emollients?
Emollients are substances that replace the natural oils that help keep water in our skin to prevent it becoming dry, cracked,
rough, scaly and itchy.
Why use emollients?
Applying emollients to your skin regularly is worthwhile as it can prevent eczema and other dry skin conditions from
becoming worse.
Using emollients may reduce or remove the need for other treatments that may cause side effects, e.g. steroid creams.
Which emollient should I use?
There is a wide range of emollients available and they all work to keep water in the skin. Emollients can be creams and
ointments.
You may need to try more than one emollient before you find the one that suits you best.
If you only have mild skin dryness and flare-ups do not happen often, then a lotion or cream may be best.
If you have moderate-to-severe dryness then a thicker cream or an ointment is ideal.
For areas of weeping eczema a cream or lotion is usually best as ointments will tend to be very messy.
12 | P a g eAre there any possible side-effects from emollients?
Prescription emollients tend to be non-perfumed. However, some creams contain preservatives, fragrances and other
additives.
Some people become sensitised (allergic) to an ingredient. This can make the skin inflammation worse rather than better.
If you suspect that you are sensitive to an emollient then see your doctor or pharmacist for advice and try an alternative.
If you find an emollient is making your skin sore and/or very itchy, you may be allergic to one of the ingredients and you
should discuss this with your doctor, pharmacist or nurse. If you are having ultraviolet light treatment or radiotherapy, ask
for specific guidance on emollient use as instructions may differ slightly.
Note: Ointments tend to cause fewer problems with skin sensitivity as, unlike creams, ointments usually do not contain
preservatives.
Warning: Paraffin-based emollients are flammable. Keep them away from lights and flames. Dressings and clothing
that have contact with paraffin-based products are easily ignited by a naked flame.
Paraffin-based emollients are flammable so take care near any open flames or potential causes of ignition, such as
cigarettes. Ointments and creams used in the bath and shower can make the surface slippery so take extra care.
How to apply emollients
Wash hands and apply the emollient thinly (just so the skin glistens), gently and quickly in smooth downward strokes in the
direction of hair growth.
Apply as often as needed to keep the skin supple and moist, usually at least 3 - 4 times a day but some people may need to
increase this to up to every hour if the skin is very dry.
As a rule, ointments need to be applied less often than creams or lotions for the same effect.
Apply emollients after washing to trap moisture in the skin.
Avoid massaging creams or ointments in or applying too thickly as this can block hair follicles, trap heat and cause itching.
Emollients can be applied before or after any other treatments e.g. steroid creams but it is important to leave at least 30
minutes before applying the next treatment.
Don’t stop using your emollient if your skin looks better as skin can flare up again quickly
13 | P a g eHow much leave-on emollient should I apply?
The quantity of leave-on emollient required will vary depending on the size of the person, the severity of the skin condition,
and whether the emollient is also being used as a soap substitute.
As a general guide, if you needed to treat the whole body, the recommended quantities used are 600 g per week for an
adult and 250-500g per week for a child.
Lifestyle
Light emollient during day and greasy one at night.
Greasier the emollient, more effective at retaining hydration.
You may wish to use different types of emollients at different times of the day, on different areas of the body or when
severity of your condition varies. For example, use a cream in the morning if dressing to go to work or school and an
ointment in the evening when wearing pyjamas. Most emollients (except white soft paraffin alone) can be used as a soap
substitute as well
Bathing and washing
Avoid bubble baths and soaps as they can be irritating and dry the skin.
Bathe regularly in tepid (luke warm) water only. Regular bathing cleans and helps prevent infection by removing scales,
crusts, dried blood and dirt.
Use an emollient as a soap substitute (most emollients can be used in this way). Apply the emollient prior to washing and
directly afterwards onto damp skin. Alternatively you could use a bath or shower emollient designed specifically for washing
with, then apply your usual leave-on emollient afterwards. Some doctors prefer to recommend the first option as they think
this method is better at moisturising the skin.
When drying, do not rub with a towel but pat the skin dry to avoid damage to the skin.
Take care when entering the bath/shower after applying emollients as they make surfaces slippery.
14 | P a g eUsing emollients and topical steroids together
Topical steroids are very different to emollients, and should be used and applied in a different way.
When using the two treatments, apply the emollient first.
Wait 20- 30 minutes after applying an emollient before applying a topical corticosteroid. That is, the emollient should be
allowed to absorb before a topical steroid is applied (the skin should be moist or slightly tacky, but not slippery, when
applying the steroid). Topical steroids should be applied sparingly, as a thin layer.
Washing up clothes for children
It is advisable to put the washing machine on 60 degrees. This ensures pipes are kept free of grease as well as clothes
thoroughly washed to prevent any local irritation
Adapted from NHS Rotherham CCG Emollient Prescribing Guidelines October 2012, and based on information from www.patient.co.uk and the National Eczema
Society www.eczema.org
15 | P a g eYou can also read
