Eczema

Prescribing Notes:

• There is a risk of severe and fatal burns with all paraffin based emollients regardless of the paraffin concentration. Data suggest there is also a risk for paraffin-free emollients. Patients who use these products should not smoke or go near naked flames. Emollients can transfer from the skin onto clothing, bedding, dressings, and other fabric. Once there, they can dry onto the fabric and build up over time. In the presence of a naked flame, fabric with emollient dried on is easily ignited. Although emollients are not flammable in themselves or when on the skin, when dried on to fabric they act as an accelerant, increasing the speed of ignition and intensity of the fire.
• Patient clothing and bedding should be changed regularly - preferably daily. Washing clothing or bedding at a high temperature may reduce the emollient build up but not totally remove it.
• Resources are available for health and social care professionals to support the safe use of emollients see MHRA guidance.
• A similar risk may apply for other products which are applied to the skin over large body areas, or in large volumes for repeated use for more than a few days.
• Content is available on the Dermatology pages of the Right Decision Service to provide an accessible resource for primary care practitioners to support the diagnosis and management of patients presenting with common skin conditions.
• The vehicle used in topical preparations influences skin hydration, has a mild anti-inflammatory effect and facilitates penetration of the active component.
• Creams are more cosmetically acceptable than ointments because they are less greasy and easier to apply. Gels may be used on the face and scalp while lotions have a cooling effect and are used for moist conditions and hairy areas. Lotions in alcoholic basis can sting if used on broken skin. Ointments are greasy preparations and are much less likely to sensitise and are suitable for chronic dry lesions. Creams and lotions are absorbed into the skin more quickly than ointments or gels.
• Pastes can be used to protect inflamed, lichenified, or excoriated skin.
• Possible contact sensitivity to preservatives or antiseptics is the reason for the range of topical agents.
• Rarely, severe adverse effects can occur on stopping treatment with topical corticosteroids, often after long-term continuous or inappropriate use of moderate to high potency products. To reduce the risks of these events, prescribe the topical corticosteroid of lowest potency needed and ensure patients know how to use it safely and effectively. See MHRA warning - Topical corticosteroids: information on the risk of topical steroid withdrawal reactions.
• Exacerbation of eczema may represent secondary bacterial or viral infection (eczema herpeticum). Appropriate swabs should be taken, and appropriate anti-infective therapy prescribed.

Unlicensed / Special Manufacture Preparations

• The British Association of Dermatologists (BAD) list of preferred unlicensed dermatological preparations (‘Specials’) is available at the BAD website.
• Use a licensed product wherever available. Consider cost versus benefit of a licensed preparation versus an unlicensed preparation (often in excess of £100). If an unlicensed topical preparation is required, consider only those listed on the BAD list.
• If prescribing specials, prescribe appropriate quantities, as expiry dates are likely to be short for these unlicensed specials products. Do not put the special onto a repeat prescription and ensure that the condition is reviewed regularly.
• If a ‘Specials’ product is required Dermatologists in the East Region have agreed to use only BAD approved ‘Specials’ whenever possible.

Quantities are based on single daily application for 2 weeks in adults:

Quantities are based on twice daily application for 1 week in adults:

Prescribing Notes:

• The choice of emollient should be based on the severity of the condition, patient preference, site of application and preparation cost.
• See general prescribing notes pathway above for information on fire risk with all paraffin based and paraffin free emollients.
• Emollients soothe, smooth and hydrate the skin and are indicated for all dry scaling disorders.
• Emollients should be applied regularly (up to 3-4 times per day) to maintain improvement; and are particularly effective applied after a shower or bath.
• Emollients should be applied in the direction of hair growth.
• Most emollients (apart from white soft paraffin 50%/liquid paraffin 50%) may be used as soap substitutes (hand washing and in bath/shower) by firstly wetting the skin, washing with the cream or ointment, then rinsing off. Alternatively, emollients can be put on the skin before bathing or showering and then washed off to reduce stinging from broken areas.
• If emollients are being applied to the whole body twice daily, children may need 250g per week and adults 500g per week.
• It is more cost-effective to prescribe emollients in large pack sizes and products that come in pump dispensers may be more suitable for long term use in order to reduce the risk of microbial contamination.
• Preparations containing antimicrobials or antiseptics should only be used when treating patients with infected eczema or when antisepsis is required.

Prescribing Notes:

• The choice of emollient should be based on the severity of the condition, patient preference, site of application and preparation cost.
• See general prescribing notes pathway above for information on fire risk with all paraffin based and paraffin free emollients.
• Emollients soothe, smooth and hydrate the skin and are indicated for all dry scaling disorders.
• Emollients should be applied regularly (up to 3-4 times per day) to maintain improvement; and are particularly effective applied after a shower or bath.
• Emollients should be applied in the direction of hair growth.
• Most emollients (apart from white soft paraffin 50%/liquid paraffin 50%) may be used as soap substitutes (hand washing and in bath/shower) by firstly wetting the skin, washing with the cream or ointment, then rinsing off. Alternatively, emollients can be put on the skin before bathing or showering and then washed off to reduce stinging from broken areas.
• If emollients are being applied to the whole body twice daily, children may need 250g per week and adults 500g per week.
• It is more cost-effective to prescribe emollients in large pack sizes and products that come in pump dispensers may be more suitable for long term use in order to reduce the risk of microbial contamination.
• Preparations containing antimicrobials or antiseptics should only be used when treating patients with infected eczema or when antisepsis is required.

Prescribing Notes:

• The choice of emollient should be based on the severity of the condition, patient preference, site of application and preparation cost.
• See general prescribing notes pathway above for information on fire risk with all paraffin based and paraffin free emollients.
• Emollients soothe, smooth and hydrate the skin and are indicated for all dry scaling disorders.
• Emollients should be applied regularly to maintain improvement; and are particularly effective applied after a shower or bath.
• Emollients should be applied in the direction of hair growth.

Prescribing Notes:

• Preparations containing urea are suitable for the treatment of very dry or hyperkeratotic, scaling skin conditions. Balneum plus is suitable for general skin care. Flexitol 10% Urea cream is suitable for general skin care and for the skin on the hands and feet. Dermatonics Once Heel Balm is suitable for use on the soles of the feet.

Prescribing Notes:

• Most emollients (apart from white soft paraffin 50%/liquid paraffin 50%) may be used as soap substitutes (hand washing and in bath/shower) by firstly wetting the skin, washing with the cream or ointment, then rinsing off. Alternatively, emollients can be put on the skin before bathing or showering and then washed off to reduce stinging from broken areas.
• Addition of emollient bath products can make baths slippy.
• A convenient way to apply emulsifying ointment and Hydromol ointment is as “soap balls”, which are made by putting a scoop of the ointment into tubinette or stockinette.
• The presence of antiseptics (e.g. benzalkonium chloride) in emollients can rarely cause allergic reactions or irritation - this should be considered if skin becomes irritated, and an alternative product prescribed.
• Dermol 500 lotion contains an antiseptic, so may be suitable for patients who specifically require an antiseptic soap substitute e.g. infected eczema.

Prescribing Notes:

• Topical corticosteroids should be tailed off and withdrawn as the condition settles (ideally over 1-3 weeks) but may need to be used intermittently in chronic eczema.
• Often local specialists recommend once daily application of a topical corticosteroid and if no benefit after review at 7-10 days, will consider a higher potency topical corticosteroid rather than increasing the frequency of application.
• To minimise the risk of side-effects, reduce the frequency of application as the condition settles or step-down potency. The risk of systemic side-effects increases with prolonged use particularly on thin skin surfaces, use in flexures, or use of more potent corticosteroids. Occlusion increases efficacy and side-effects. Only mild corticosteroids should generally be used on the face.
• There is no benefit in changing to a higher percentage strength of topical hydrocortisone. Instead, patients should be moved up the steroid potency ladder i.e. to a moderately potent steroid.
• The potency of the steroid should be stepped up or stepped down depending on the severity of symptoms.
• Water-miscible corticosteroid creams are suitable for moist areas e.g. axillae or groin or for weeping lesions.
• Ointments are generally chosen for dry, lichenified or scaly lesions or where a more occlusive effect is required.
• Mixing topical preparations (e.g. steroid, emollient) on the skin should be avoided where possible; apply emollient and corticosteroid at different times of the day.
• Topical corticosteroids are not recommended in urticaria, rosacea, acne or when a primary infective disease is suspected.
• Topical corticosteroids should not be used on infected skin unless the infection is being treated
• Topical corticosteroids should not routinely be added to repeat dispensing systems. For intermittent use in chronic eczema it may be appropriate to include topical steroids on repeat prescription provided there are clear instructions on intermittent use and regular review of therapy.
• Gloves should be worn during, or hands washed after, application of large quantities of steroid preparations.
• For the use of topical corticosteroids for lichen sclerosus, see the Obstetrics, gynaecology, and urinary-tract disorders chapter of the formulary.
• Loss of effect with time (tachyphylaxis) can occur with prolonged use of topical corticosteroids. Intermittent use is preferred to continuous use.

Prescribing Notes:

• Topical corticosteroids should be tailed off and withdrawn as the condition settles (ideally over 1-3 weeks) but may need to be used intermittently in chronic eczema.
• Often local specialists recommend once daily application of a topical corticosteroid and if no benefit after review at 7-10 days, will consider a higher potency topical corticosteroid rather than increasing the frequency of application.
• To minimise the risk of side-effects, reduce the frequency of application as the condition settles or step-down potency. The risk of systemic side-effects increases with prolonged use particularly on thin skin surfaces, use in flexures, or use of more potent corticosteroids. Occlusion increases efficacy and side-effects. Only mild corticosteroids should generally be used on the face.
• The potency of the steroid should be stepped up or stepped down depending on the severity of symptoms.
• Water-miscible corticosteroid creams are suitable for moist areas e.g. axillae or groin or for weeping lesions.
• Ointments are generally chosen for dry, lichenified or scaly lesions or where a more occlusive effect is required.
• Mixing topical preparations (e.g. steroid, emollient) on the skin should be avoided where possible; apply emollient and corticosteroid at different times of the day.
• Topical corticosteroids are not recommended in urticaria, rosacea, acne or when a primary infective disease is suspected.
• Topical corticosteroids should not be used on infected skin unless the infection is being treated
• Topical corticosteroids should not routinely be added to repeat dispensing systems. For intermittent use in chronic eczema it may be appropriate to include topical steroids on repeat prescription provided there are clear instructions on intermittent use and regular review of therapy.
• Gloves should be worn during, or hands washed after, application of large quantities of steroid preparations.
• For the use of topical corticosteroids for lichen sclerosus, see the Obstetrics, gynaecology, and urinary-tract disorders chapter of the formulary.
• Fludroxycortide tape can be used for localised areas that also require occlusion. It is applied for 12 hours each day. Please note this is a moderately potent steroid.
• Loss of effect with time (tachyphylaxis) can occur with prolonged use of topical corticosteroids. Intermittent use is preferred to continuous use.

Prescribing Notes:

• Topical corticosteroids should be tailed off and withdrawn as the condition settles (ideally over 1-3 weeks) but may need to be used intermittently in chronic eczema.
• Topical steroids should be applied once daily initially, if no benefit after 7-10 days, change to twice daily for a further 7-10 days.
• To minimise the risk of side-effects, reduce the frequency of application as the condition settles or step-down potency. The risk of systemic side-effects increases with prolonged use particularly on thin skin surfaces, use in flexures, or use of more potent corticosteroids. Occlusion increases efficacy and side-effects. Only mild corticosteroids should generally be used on the face.
• The potency of the steroid should be stepped up or stepped down depending on the severity of symptoms.
• Potent corticosteroids should generally be avoided on the face and skin flexures
• In general, the most potent topical corticosteroids should be reserved for recalcitrant dermatoses such as chronic discoid lupus erythematosus, lichen simplex chronicus, hypertrophic lichen planus, and palmoplantar pustulosis.
• Water-miscible corticosteroid creams are suitable for moist areas e.g. axillae or groin or for weeping lesions.
• Ointments are generally chosen for dry, lichenified or scaly lesions or where a more occlusive effect is required.
• Mixing topical preparations (e.g. steroid, emollient) on the skin should be avoided where possible; apply emollient and corticosteroid at different times of the day.
• Topical corticosteroids are not recommended in urticaria, rosacea, acne or when a primary infective disease is suspected.
• Topical corticosteroids should not be used on infected skin unless the infection is being treated
• Gloves should be worn during, or hands washed after, application of large quantities of steroid preparations.
• Palms of the hands and soles of the feet may require potent or very potent steroids.
• For the use of topical corticosteroids for lichen sclerosus, see the Obstetrics, gynaecology, and urinary-tract disorders chapter of the formulary.
• Loss of effect with time (tachyphylaxis) can occur with prolonged use of topical corticosteroids. Intermittent use is preferred to continuous use.

Prescribing Notes:

• Topical corticosteroids should be tailed off and withdrawn as the condition settles (ideally over 1-3 weeks) but may need to be used intermittently in chronic eczema.
• Topical steroids should be applied once daily initially, if no benefit after 7-10 days, change to twice daily for a further 7-10 days.
• To minimise the risk of side-effects, reduce the frequency of application as the condition settles or step-down potency. The risk of systemic side-effects increases with prolonged use particularly on thin skin surfaces, use in flexures, or use of more potent corticosteroids. Occlusion increases efficacy and side-effects. Only mild corticosteroids should generally be used on the face.
• The potency of the steroid should be stepped up or stepped down depending on the severity of symptoms.
• Potent corticosteroids should generally be avoided on the face and skin flexures
• In general, the most potent topical corticosteroids should be reserved for recalcitrant dermatoses such as chronic discoid lupus erythematosus, lichen simplex chronicus, hypertrophic lichen planus, and palmoplantar pustulosis.
• Water-miscible corticosteroid creams are suitable for moist areas e.g. axillae or groin or for weeping lesions.
• Ointments are generally chosen for dry, lichenified or scaly lesions or where a more occlusive effect is required.
• Mixing topical preparations (e.g. steroid, emollient) on the skin should be avoided where possible; apply emollient and corticosteroid at different times of the day.
• Topical corticosteroids are not recommended in urticaria, rosacea, acne or when a primary infective disease is suspected.
• Topical corticosteroids should not be used on infected skin unless the infection is being treated
• Gloves should be worn during, or hands washed after, application of large quantities of steroid preparations.
• Palms of the hands and soles of the feet may require potent or very potent steroids.
• For the use of topical corticosteroids for lichen sclerosus, see the Obstetrics, gynaecology, and urinary-tract disorders chapter of the formulary.
• Loss of effect with time (tachyphylaxis) can occur with prolonged use of topical corticosteroids. Intermittent use is preferred to continuous use.
• Patients prescribed very potent topical corticosteroids should be reviewed regularly (at least monthly) and the preparation should not be prescribed on repeat prescription except on specialist advice.

Prescribing Notes:

• Do not routinely offer either topical or oral antibiotic if not systemically unwell. Take skin swabs if there are clinical signs of infection. If an oral antibiotic is appropriate for empirical treatment see recommendations for cellulitis.
• Increasing concerns about the development of resistance have led to topical antibiotic therapy being discouraged.
• For more information see NICE NG190 ‘Secondary bacterial infection of eczema and other common skin conditions: antimicrobial prescribing’.
• Guidance on the treatment of skin infections including impetigo can be found in the Infections chapter of the formulary.

Prescribing Notes:

• Antibacterials and antifungals with corticosteroids may have a role if there is associated infection. Long term use of products containing antibacterials and antifungals increases the likelihood of resistance and sensitisation. Normally products should be used on a regular basis but for a short period only, usually 7 days.
• For more information see NICE NG190 secondary bacterial infection of eczema and other common skin conditions: antimicrobial prescribing.
• Topical corticosteroids should be tailed off and withdrawn as the condition settles (ideally over 1-3 weeks). Where it is desirable to alter steroid frequency when treating an infection prescribe a separate topical antimicrobial to be applied regularly for a short duration to avoid the development of resistance.
• Occlusion increases efficacy and side-effects. Only mild corticosteroids should generally be used on the face.
• The potency of the steroid should be stepped up or stepped down depending on the severity of symptoms.
• Potent corticosteroids should generally be avoided on the face and skin flexures
• In general, the most potent topical corticosteroids should be reserved for recalcitrant dermatoses such as chronic discoid lupus erythematosus, lichen simplex chronicus, hypertrophic lichen planus, and palmoplantar pustulosis.
• Water-miscible corticosteroid creams are suitable for moist areas e.g. axillae or groin or for weeping lesions.
• Ointments are generally chosen for dry, lichenified or scaly lesions or where a more occlusive effect is required.
• Mixing topical preparations (e.g. steroid, emollient) on the skin should be avoided where possible; apply emollient and corticosteroid at different times of the day.
• Topical corticosteroids are not recommended in urticaria, rosacea, acne or when a primary infective disease is suspected.
• Topical corticosteroids should not be used on infected skin unless the infection is being treated
• Topical corticosteroids with antimicrobials should not be put on repeat dispensing systems.
• Gloves should be worn during, or hands washed after, application of large quantities of steroid preparations.
• Palms of the hands and soles of the feet may require potent or very potent steroids.
• For the use of topical corticosteroids for lichen sclerosus, see the Obstetrics, gynaecology, and urinary-tract disorders chapter of the formulary.
• Loss of effect with time (tachyphylaxis) can occur with prolonged use of topical corticosteroids. Intermittent use is preferred to continuous use.
• Combination antifungal/ mild potency steroid can be used for seborrhoeic dermatitis affecting the face.

Prescribing Notes:

• For more information see NICE NG190 secondary bacterial infection of eczema and other common skin conditions: antimicrobial prescribing.
• Potassium permanganate soaks are not suitable for dry skin conditions and may leave a brown stain on skin, nails and the bath or vessel holding the solution.
• The British Association of Dermatologists (BAD) have developed guidance on safe use of potassium permanganate soaks and an information leaflet for patients which can be found here British Association of Dermatologists (bad.org.uk).

Prescribing Notes:

• Ichthammol has anti-inflammatory properties and can be a useful addition to emollients and corticosteroid therapy.
• When ichthammol preparations are introduced as an add-on therapy there is increased absorption of topical corticosteroids, therefore the potency of concurrent steroid therapy may require reduction.
• 1% ichthammol in YSP is an option for easier application and wash off.
• ichthammol 1%/zinc oxide 15% in Yellow Soft Paraffin and ichthammol 1% in Yellow Soft Paraffin unlicensed specials are available from NHS Scotland specials service (formerly Tayside pharmaceuticals).
• See the Wound section of the formulary for information on ichthopaste bandages for chronic lichenified skin conditions such as chronic eczema.

Prescribing Notes:

• For the purposes of this guidance, atopic eczema that has not been controlled by topical corticosteroids refers to disease that has not shown a satisfactory clinical response to adequate use of the maximum strength and potency that is appropriate for the patient's age and the area being treated.
• Tacrolimus 0.03% ointment is recommended, within its licensed indications, as an option for the second-line treatment of moderate to severe atopic eczema in adults and children aged 2 years and older that has not been controlled by topical corticosteroids where there is a serious risk of important adverse effects from further topical corticosteroid use, particularly irreversible skin atrophy.
• Tacrolimus 0.1% ointment is recommended, within its licensed indications, as an option for the second-line treatment of moderate to severe atopic eczema in adults and adolescents aged 16 years and older that has not been controlled by topical corticosteroids where there is a serious risk of important adverse effects from further topical corticosteroid use, particularly irreversible skin atrophy. Review need of preventative therapy after 1 year.
• Tacrolimus 0.1% ointment can also be used for the prevention of flares in patients aged 16 years and over with moderate to severe atopic eczema in accordance with the licensed indications.
• Pimecrolimus 1% cream is recommended, within its licensed indications, as an option for the second-line treatment of moderate atopic eczema on the face and neck in children aged 2 to 16 years that has not been controlled by topical corticosteroids where there is a serious risk of important adverse effects from further topical corticosteroid use, particularly irreversible skin atrophy.
• Tacrolimus and pimecrolimus can be initiated by a physician (including GPs) with a special interest and experience in dermatology, where eczema is uncomplicated and topical corticosteroid usage has not given sustained benefit or is considered likely to cause adverse effects. GPs are advised to seek advice from the dermatology department where support is required to initiate treatment and to support discussion with the patient on the risks and benefits of available alternative treatment options.

Prescribing Notes:

General notes

• Systemic treatments for moderate to severe eczema or atopic dermatitis are initiated by specialists and include methotrexate, ciclosporin, alitretinoin or azathioprine. Alternative treatment includes systemic corticosteroids or biologic therapy. Biologic therapy should be offered in line with SMC advice, see the pathway for biologic treatment of moderate to severe atopic dermatitis for more details.
• For treatments continuing in primary care responsibility for monitoring to be agreed, refer to individual board shared care policies for more information.

Methotrexate

• Methotrexate can be prescribed, after specialist initiation, for severe atopic eczema unresponsive to conventional therapy.
• To avoid prescribing, dispensing and administration errors only the 2.5mg strength of methotrexate should be prescribed and dispensed. The patient should be advised on the dose and frequency for taking methotrexate. New measures have been implemented to prompt healthcare professionals to record the day of the week for intake and to remind patients of the dosing schedule and the risks of overdose due to continued reports of inadvertent overdose. For further advice see MHRA Drug Safety Update September 2020.
• The patient should be advised to report immediately any signs of methotrexate toxicity.
• Regular monitoring of full blood count, renal function and liver function should be undertaken in line with local protocols.

Ciclosporin

• Ciclosporin can be prescribed, after specialist inititiation for atopic dermatitis where conventional therapy is ineffective or inappropriate. Preparations should be prescribed by brand name only due to differences in bio-availability.
• The formulary choice for ciclosporin is Capimune (10mg capsules and liquid formulation must be prescribed as Neoral).
• Patients on ciclosporin should be regularly monitored for adverse effects including hypertension and renal impairment.

Azathioprine

• Azathioprine (off-label) can be prescribed, after specialist initiation, for severe refractory eczema or as a steroid sparing agent in severe autoimmune bullous dermatoses. It is contraindicated if there is absent or very low thiopurine methyltransferase (TPMT) activity.

Alitretinoin

• Alitretinoin is accepted for use in adults with severe hand eczema unresponsive to treatment with potent topical corticosteroids. It should be prescribed only by, or under the supervision of, a consultant dermatologist and be dispensed by a hospital-based pharmacy. Prescribers include medical and non-medical prescribers with competence to prescribe retinoids for severe hand eczema unresponsive to treatment with potent topical corticosteroids. It is teratogenic and females of childbearing age must practice effective contraception and engage with a pregnancy prevention programme. Refer to MHRA/CHM advice: Oral retinoid medicines: revised and simplified pregnancy prevention educational materials for healthcare professionals and women (June 2019).

Mycophenolate mofetil

• Mycophenolate mofetil (off-label) can be prescribed, after specialist initiation, for patients with moderate to severe eczema where other preferred treatment options are contraindicated or subtherapeutic. 

Prescribing Notes:

• Dupilumab is available for the treatment of moderate-to-severe atopic dermatitis for patients aged 6 years and over who are candidates for systemic therapy. Use is restricted to patients who have had an inadequate response to existing systemic immunosuppressants such as ciclosporin, or in whom such treatment is considered unsuitable.
• Upadicitinib is available for the treatment of moderate to severe atopic dermatitis in adults and adolescents 12 years and older who are candidates for systemic therapy. Use is restricted to patients who have had an inadequate response to at least one conventional systemic immunosuppressant such as ciclosporin, or in whom such treatment is considered unsuitable.
• Tralokinumab is available for treatment of moderate-to-severe atopic dermatitis in adult patients who are candidates for systemic therapy. Use is restricted to patients who have had an inadequate response to an existing systemic immunosuppressant such as ciclosporin, or in whom such treatment is considered unsuitable.
• Abrocitinib is available for the treatment of moderate-to-severe atopic dermatitis in adults and adolescents 12 years and older who are candidates for systemic therapy. Use is restricted to patients who have not responded to, or have lost response to, at least one systemic immunosuppressant therapy, or in whom these are contraindicated or not tolerated.
• Baricitinib is available for the treatment of moderate to severe atopic dermatitis in adult patients who are candidates for systemic therapy and who have failed at least one current systemic immunosuppressant due to intolerance, contraindication or inadequate disease control.

Prescribing Notes:

• There is a risk of severe and fatal burns with all paraffin-based emollients regardless of the paraffin concentration. Data suggest there is also a risk for paraffin-free emollients. Patients who use these products should not smoke or go near naked flames. Emollients can transfer from the skin onto clothing, bedding, dressings, and other fabric. Once there, they can dry onto the fabric and build up over time. In the presence of a naked flame, fabric with emollient dried on is easily ignited. Although emollients are not flammable in themselves or when on the skin, when dried on to fabric they act as an accelerant, increasing the speed of ignition and intensity of the fire.
• Patient clothing and bedding should be changed regularly - preferably daily. Washing clothing or bedding at a high temperature may reduce the emollient build up but not totally remove it.
• Resources are available for health and social care professionals to support the safe use of emollients see MHRA guidance.
• A similar risk may apply for other products which are applied to the skin over large body areas, or in large volumes for repeated use for more than a few days.
• Content is available on the Dermatology pages of the Right Decision Service to provide an accessible resource for primary care practitioners to support the diagnosis and management of patients presenting with common skin conditions.
• The vehicle used in topical preparations influences skin hydration, has a mild anti-inflammatory effect and facilitates penetration of the active component.
• Creams are more cosmetically acceptable than ointments because they are less greasy and easier to apply and are useful in weeping skin conditions. Gels may be used on the face and scalp while lotions have a cooling effect and are used for moist conditions and hairy areas. Lotions in alcoholic basis can sting if used on broken skin. Ointments are greasy preparations and are much less likely to sensitise and are suitable for chronic dry lesions. Creams and lotions are absorbed into the skin more quickly than ointments or gels.
• Pastes can be used to protect inflamed, lichenified, or excoriated skin.
• Possible contact sensitivity to preservatives or antiseptics is the reason for the range of topical agents.
• Medicated bandages are flammable.
• All patients with eczema should use an emollient and soap substitute and/or bath oil.
• Emollients with antiseptics should be used in patients with infected eczema.
• Rarely, severe adverse effects can occur on stopping treatment with topical corticosteroids, often after long-term continuous or inappropriate use of moderate to high potency products. To reduce the risks of these events, prescribe the topical corticosteroid of lowest potency needed and ensure patients know how to use it safely and effectively. See MHRA warning - Topical corticosteroids: information on the risk of topical steroid withdrawal reactions.
• Exacerbation of eczema may represent secondary bacterial or viral infection (eczema herpeticum). Appropriate swabs should be taken, and appropriate anti-infective therapy prescribed.

Unlicensed / Special Manufacture Preparations

• The British Association of Dermatologists (BAD) list of preferred unlicensed dermatological preparations (‘Specials’) is available at the BAD website.
• Use a licensed product wherever available. Consider cost versus benefit of a licensed preparation versus an unlicensed preparation (often in excess of £100). If an unlicensed topical preparation is required, consider only those listed on the BAD list.
• If prescribing specials, prescribe appropriate quantities, as expiry dates are likely to be short for these unlicensed specials products. Do not put the special onto a repeat prescription and ensure that the condition is reviewed regularly.
• If a ‘Specials’ product is required Dermatologists in the East Region have agreed to use only BAD approved ‘Specials’ whenever possible.

Corticosteroid creams

Quantities are based on single daily application for 2 weeks. Estimates are based on the number of adult finger tips units (FTUs) of cream to treat the area. 2 FTUs are about the same as 1g of topical steroid.

(*) Qty = Estimated prescribable quantity of corticosteroid cream/ointment.

Quantities are based on twice daily application for 1 week in a child 12-18 years; smaller quantities will be required for children under 12 years:

Prescribing Notes:

• The choice of emollient should be based on the severity of the condition, patient preference, site of application and preparation cost.
• See general prescribing notes pathway above for information on fire risk with all paraffin based and paraffin free emollients.
• Emollients soothe, smooth and hydrate the skin and are indicated for all dry scaling disorders.
• Emollients should be applied regularly (up to 3-4 times per day) to maintain improvement; and are particularly effective applied after a shower or bath.
• Emollients should be applied in the direction of hair growth.
• Most emollients (apart from white soft paraffin 50%/liquid paraffin 50%) may be used as soap substitutes (hand washing and in bath/shower) by firstly wetting the skin, washing with the cream or ointment, then rinsing off. Alternatively, emollients can be put on the skin before bathing or showering and then washed off to reduce stinging from broken areas.
• If emollients are being applied to the whole body twice daily, children may need 250g per week and adults 500g per week.
• It is more cost-effective to prescribe emollients in large pack sizes and products that come in pump dispensers may be more suitable for long term use in order to reduce the risk of microbial contamination.
• Preparations containing antimicrobials or antiseptics should only be used when treating patients with infected eczema or when antisepsis is required.

Prescribing Notes:

• The choice of emollient should be based on the severity of the condition, patient preference, site of application and preparation cost.
• See general prescribing notes pathway above for information on fire risk with all paraffin based and paraffin free emollients.
• Emollients soothe, smooth and hydrate the skin and are indicated for all dry scaling disorders.
• Emollients should be applied regularly (up to 3-4 times per day) to maintain improvement; and are particularly effective applied after a shower or bath.
• Emollients should be applied in the direction of hair growth.
• Most emollients (apart from white soft paraffin 50%/liquid paraffin 50%) may be used as soap substitutes (hand washing and in bath/shower) by firstly wetting the skin, washing with the cream or ointment, then rinsing off. Alternatively, emollients can be put on the skin before bathing or showering and then washed off to reduce stinging from broken areas.
• If emollients are being applied to the whole body twice daily, children may need 250g per week and adults 500g per week.
• It is more cost-effective to prescribe emollients in large pack sizes and products that come in pump dispensers may be more suitable for long term use in order to reduce the risk of microbial contamination.
• Preparations containing antimicrobials or antiseptics should only be used when treating patients with infected eczema or when antisepsis is required.

Prescribing Notes:

• The choice of emollient should be based on the severity of the condition, patient preference, site of application and preparation cost.
• See general prescribing notes pathway above for information on fire risk with all paraffin based and paraffin free emollients.
• Emollients soothe, smooth and hydrate the skin and are indicated for all dry scaling disorders.
• Emollients should be applied regularly to maintain improvement; and are particularly effective applied after a shower or bath.
• Emollients should be applied in the direction of hair growth.

Prescribing Notes:

• Preparations containing urea are suitable for the treatment of very dry or hyperkeratotic, scaling skin conditions. Balneum plus is suitable for general skin care. Flexitol 10% Urea cream is suitable for skin lesions on the hands and feet. Dermatonics Once Heel Balm is suitable for use on the soles of the feet.

Prescribing Notes:

• Most emollients (apart from white soft paraffin 50%/liquid paraffin 50%) may be used as soap substitutes (hand washing and in bath/shower) by firstly wetting the skin, washing with the cream or ointment, then rinsing off. Alternatively, emollients can be put on the skin before bathing or showering and then washed off to reduce stinging from broken areas.
• Addition of emollient bath products can make baths slippy.
• A convenient way to apply emulsifying ointment and Hydromol ointment is as “soap balls”, which are made by putting a scoop of the ointment into tubinette or stockinette.
• The presence of antiseptics (e.g. benzalkonium chloride) in emollients can rarely cause allergic reactions or irritation - this should be considered if skin becomes irritated, and an alternative product prescribed.
• Dermol 500 lotion contains an antiseptic, so may be suitable for patients who specifically require an antiseptic soap substitute e.g. infected eczema.

Prescribing Notes:

• Topical corticosteroids should be tailed off and withdrawn as the condition settles (ideally over 1-3 weeks) but may need to be used intermittently in chronic eczema.
• Often local specialists recommend once daily application of a topical corticosteroid and if no benefit after review at 7-10 days, will consider a higher potency topical corticosteroid rather than increasing the frequency of application.
• To minimise the risk of side-effects, the smallest effective amount should be used, reducing strength and frequency of application as the condition settles. The risk of systemic side-effects increases with prolonged use particularly on thin, inflamed or raw skin surfaces, use in flexures, or use of more potent corticosteroids. Occlusion increases efficacy and side-effects. Only mild corticosteroids should generally be used on the face.
• There is no benefit in changing to a higher percentage strength of topical hydrocortisone. Instead, patients should be moved up the steroid potency ladder i.e. to a moderately potent steroid.
• The potency of the steroid should be stepped up or stepped down depending on the severity of symptoms.
• Water-miscible corticosteroid creams are suitable for moist areas e.g. axillae or groin or for weeping lesions.
• Ointments are generally chosen for dry, lichenified or scaly lesions or where a more occlusive effect is required. The occlusive effect of ointments increases penetration of the corticosteroid.
• Mixing topical preparations (e.g. steroid, emollient) on the skin should be avoided where possible; apply emollient and corticosteroid at different times of the day.
• Topical corticosteroids are not recommended in urticaria, rosacea, acne or when a primary infective disease is suspected.
• Topical corticosteroids should not be used on infected skin unless the infection is being treated.
• Topical corticosteroids should not routinely be added to repeat dispensing systems. For intermittent use in chronic eczema it may be appropriate to include topical steroids on repeat prescription provided there are clear instructions on intermittent use and regular review of therapy.
• Gloves should be worn during, or hands washed after, application of large quantities of steroid preparations.
• For the use of topical corticosteroids for lichen sclerosus, see the Obstetrics, gynaecology, and urinary-tract disorders chapter of the formulary.
• Loss of effect with time (tachyphylaxis) can occur with prolonged use of topical corticosteroids. Intermittent use is preferred to continuous use.
• Antibacterials and antifungals with corticosteroids may have a role if there is associated infection.

Prescribing Notes:

• Topical corticosteroids should be tailed off and withdrawn as the condition settles (ideally over 1-3 weeks) but may need to be used intermittently in chronic eczema.
• Often local specialists recommend once daily application of a topical corticosteroid and if no benefit after review at 7-10 days, will consider a higher potency topical corticosteroid rather than increasing the frequency of application.
• To minimise the risk of side-effects, the smallest effective amount should be used, reducing strength and frequency of application as the condition settles. The risk of systemic side-effects increases with prolonged use particularly on thin, inflamed or raw skin surfaces, use in flexures, or use of more potent corticosteroids. Occlusion increases efficacy and side-effects. Only mild corticosteroids should generally be used on the face and caution should be exercised.
• The potency of the steroid should be stepped up or stepped down depending on the severity of symptoms.
• Water-miscible corticosteroid creams are suitable for moist areas e.g. axillae or groin or for weeping lesions.
• Ointments are generally chosen for dry, lichenified or scaly lesions or where a more occlusive effect is required. The occlusive effect of ointments increases penetration of the corticosteroid.
• Mixing topical preparations (e.g. steroid, emollient) on the skin should be avoided where possible; apply emollient and corticosteroid at different times of the day.
• Topical corticosteroids are not recommended in urticaria, rosacea, acne or when a primary infective disease is suspected.
• Topical corticosteroids should not be used on infected skin unless the infection is being treated.
• Topical corticosteroids should not routinely be added to repeat dispensing systems. For intermittent use in chronic eczema it may be appropriate to include topical steroids on repeat prescription provided there are clear instructions on intermittent use and regular review of therapy.
• Gloves should be worn during, or hands washed after, application of large quantities of steroid preparations.
• For the use of topical corticosteroids for lichen sclerosus, see the Obstetrics, gynaecology, and urinary-tract disorders chapter of the formulary.
• Fludroxycortide tape can be used for localised areas that also require occlusion. It is applied for 12 hours each day. Please note this is a moderately potent steroid.
• Loss of effect with time (tachyphylaxis) can occur with prolonged use of topical corticosteroids. Intermittent use is preferred to continuous use.
• Antibacterials and antifungals with corticosteroids may have a role if there is associated infection.

Prescribing Notes:

• Topical corticosteroids should be tailed off and withdrawn as the condition settles (ideally over 1-3 weeks) but may need to be used intermittently in chronic eczema.
• Topical steroids should be applied once daily initially, if no benefit after 7-10 days, change to twice daily for a further 7-10 days.
• To minimise the risk of side-effects, the smallest effective amount should be used, reducing strength and frequency of application as the condition settles. The risk of systemic side-effects increases with prolonged use particularly on thin, inflamed or raw skin surfaces, use in flexures, or use of more potent corticosteroids. Occlusion increases efficacy and side-effects. Only mild corticosteroids should generally be used on the face.
• The potency of the steroid should be stepped up or stepped down depending on the severity of symptoms.
• Potent corticosteroids should generally be avoided on the face and skin flexures.
• In general, the most potent topical corticosteroids should be reserved for recalcitrant dermatoses such as chronic discoid lupus erythematosus, lichen simplex chronicus and hypertrophic lichen planus.
• Water-miscible corticosteroid creams are suitable for moist areas e.g. axillae or groin or for weeping lesions.
• Ointments are generally chosen for dry, lichenified or scaly lesions or where a more occlusive effect is required. The occlusive effect of ointments increases penetration of the corticosteroid.
• Mixing topical preparations (e.g. steroid, emollient) on the skin should be avoided where possible; apply emollient and corticosteroid at different times of the day.
• Topical corticosteroids are not recommended in urticaria, rosacea, acne or when a primary infective disease is suspected.
• Topical corticosteroids should not be used on infected skin unless the infection is being treated.
• Gloves should be worn during, or hands washed after, application of large quantities of steroid preparations.
• Palms of the hands and soles of the feet may require potent or very potent steroids.
• For the use of topical corticosteroids for lichen sclerosus, see the Obstetrics, gynaecology, and urinary-tract disorders chapter of the formulary.
• Loss of effect with time (tachyphylaxis) can occur with prolonged use of topical corticosteroids. Intermittent use is preferred to continuous use.
• Antibacterials and antifungals with corticosteroids may have a role if there is associated infection.

Prescribing Notes:

• Do not routinely offer either topical or oral antibiotic if not systemically unwell. Take skin swabs if there are clinical signs of infection. If an oral antibiotic is appropriate for empirical treatment see recommendations for cellulitis.
• Increasing concerns about the development of resistance have led to topical antibiotic therapy being discouraged.
• For more information see NICE NG190 ‘Secondary bacterial infection of eczema and other common skin conditions: antimicrobial prescribing’.
• Guidance on the treatment of skin infections including impetigo can be found in the Infections chapter of the formulary.

Prescribing Notes:

• Antibacterials and antifungals with corticosteroids may have a role if there is associated infection. Long term use of products containing antibacterials and antifungals increases the likelihood of resistance and sensitisation. Normally products should be used on a regular basis but for a short period only, usually 7 days.
• For more information see NICE NG190 ‘Secondary bacterial infection of eczema and other common skin conditions: antimicrobial prescribing’.
• Topical corticosteroids should be tailed off and withdrawn as the condition settles (ideally over 1-3 weeks). Where it is desirable to alter steroid frequency when treating an infection prescribe a separate topical antimicrobial to be applied regularly for a short duration to avoid the development of resistance.
• Occlusion increases efficacy and side-effects. Only mild corticosteroids should generally be used on the face.
• The potency of the steroid should be stepped up or stepped down depending on the severity of symptoms.
• Potent corticosteroids should generally be avoided on the face and skin flexures.
• In general, the most potent topical corticosteroids should be reserved for recalcitrant dermatoses such as chronic discoid lupus erythematosus, lichen simplex chronicus and hypertrophic lichen planus.
• Water-miscible corticosteroid creams are suitable for moist areas e.g. axillae or groin or for weeping lesions.
• Ointments are generally chosen for dry, lichenified or scaly lesions or where a more occlusive effect is required.
• Mixing topical preparations (e.g. steroid, emollient) on the skin should be avoided where possible; apply emollient and corticosteroid at different times of the day.
• Topical corticosteroids are not recommended in urticaria, rosacea, acne or when a primary infective disease is suspected.
• Topical corticosteroids should not be used on infected skin unless the infection is being treated.
• Topical corticosteroids with antimicrobials should not be put on repeat dispensing systems.
• Gloves should be worn during, or hands washed after, application of large quantities of steroid preparations.
• Palms of the hands and soles of the feet may require potent or very potent steroids.
• For the use of topical corticosteroids for lichen sclerosus, see the Obstetrics, gynaecology, and urinary-tract disorders chapter of the formulary.
• Loss of effect with time (tachyphylaxis) can occur with prolonged use of topical corticosteroids. Intermittent use is preferred to continuous use.
• Combination antifungal/ mild potency steroid can be used for seborrhoeic dermatitis affecting the face.

Prescribing Notes:

• For more information see NICE NG190 ‘Secondary bacterial infection of eczema and other common skin conditions: antimicrobial prescribing’.
• Potassium permanganate soaks are not suitable for dry skin conditions and may leave a brown stain on skin, nails and the bath or vessel holding the solution.
• The British Association of Dermatologists (BAD) have developed guidance on safe use of potassium permanganate soaks and an information leaflet for patients which can be found on their website.

Prescribing Notes:

• Ichthammol has anti-inflammatory properties and can be a useful addition to emollients and corticosteroid therapy.
• When ichthammol preparations are introduced as an add-on therapy there is increased absorption of topical corticosteroids, therefore the potency of concurrent steroid therapy may require reduction.
• 1% ichthammol in YSP is an option for easier application and wash off.
• ichthammol 1%/zinc oxide 15% in Yellow Soft Paraffin and ichthammol 1% in Yellow Soft Paraffin unlicensed specials are available from NHS Scotland specials service (formerly Tayside pharmaceuticals).
• See the Wound care section of the formulary for information on ichthopaste bandages for chronic lichenified skin conditions such as chronic eczema.

Prescribing Notes:

• For the purposes of this guidance, atopic eczema that has not been controlled by topical corticosteroids refers to disease that has not shown a satisfactory clinical response to adequate use of the maximum strength and potency that is appropriate for the patient's age and the area being treated.
• Tacrolimus and pimecrolimus can be initiated by a physician (including GPs) with a special interest and experience in dermatology, where eczema is uncomplicated and topical corticosteroid usage has not given sustained benefit or is considered likely to cause adverse effects. GPs are advised to seek advice from the dermatology department where support is required to initiate treatment and to support discussion with the patient on the risks and benefits of available alternative treatment options.

Prescribing Notes:

General notes

• Systemic treatments for moderate to severe eczema or atopic dermatitis are initiated by specialists and include methotrexate, ciclosporin or azathioprine. Alternative treatment includes systemic corticosteroids or biologic therapy. Biologic therapy should be offered in line with SMC advice, see the pathway for biologic treatment of moderate to severe atopic dermatitis for more details.
• For treatments continuing in primary care responsibility for monitoring to be agreed, refer to individual board shared care policies for more information.

Methotrexate

• Methotrexate can be prescribed, after specialist initiation, for severe atopic eczema unresponsive to conventional therapy.
• To avoid prescribing, dispensing and administration errors with tablets only the 2.5mg strength of methotrexate tablets should be prescribed and dispensed. The patient should be advised on the dose and frequency for taking methotrexate. New measures have been implemented to prompt healthcare professionals to record the day of the week for intake and to remind patients of the dosing schedule and the risks of overdose due to continued reports of inadvertent overdose. For further advice see MHRA Drug Safety Update September 2020.
• The patient should be advised to report immediately any signs of methotrexate toxicity.
• Regular monitoring of full blood count, renal function and liver function should be undertaken in line with local protocols.

Ciclosporin

• Ciclosporin can be prescribed, after specialist inititiation for atopic dermatitis where conventional therapy is ineffective or inappropriate. Preparations should be prescribed by brand name only due to differences in bio-availability.
• The formulary choice for ciclosporin is Capimune (10mg capsules and liquid formulation must be prescribed as Neoral).
• Patients on ciclosporin should be regularly monitored for adverse effects including hypertension and renal impairment.

Azathioprine

• Azathioprine (off-label) can be prescribed, after specialist initiation, for severe refractory eczema or as a steroid sparing agent in severe autoimmune bullous dermatoses. It is contraindicated if there is absent or very low thiopurine methyltransferase (TPMT) activity.

Prescribing Notes:

• Dupilumab is available for the treatment of moderate-to-severe atopic dermatitis for patients aged 6 months and over who are candidates for systemic therapy. Use is restricted to patients who have had an inadequate response to existing systemic immunosuppressants such as ciclosporin, or in whom such treatment is considered unsuitable.
• Upadicitinib is available for the treatment of moderate to severe atopic dermatitis in adults and adolescents 12 years and older who are candidates for systemic therapy. Use is restricted to patients who have had an inadequate response to at least one conventional systemic immunosuppressant such as ciclosporin, or in whom such treatment is considered unsuitable.
• Abrocitinib is available for the treatment of moderate-to-severe atopic dermatitis in adults and adolescents 12 years and older who are candidates for systemic therapy. Use is restricted to patients who have not responded to, or have lost response to, at least one systemic immunosuppressant therapy, or in whom these are contraindicated or not tolerated.
• Tralokinumab is available for treatment of moderate-to-severe atopic dermatitis in adults and adolescents 12 years and older who are candidates for systemic therapy. Use is restricted to patients who have had an inadequate response to an existing systemic immunosuppressant such as ciclosporin, or in whom such treatment is considered unsuitable.

Prescribing Notes:

• MHRA Drug Safety update information on risk of burns, is applicable to all emollients whether they contain paraffin or not.
• The choice of emollient is guided by individual patient tolerance, preference and ease of use.
• Emollients soothe, smooth and hydrate the skin and are indicated for all dry scaling disorders.
• Emollients should be applied regularly to maintain improvement; most are best applied after a shower or bath. Emollients should be applied in the direction of hair growth.
• Most emollients may be used as soap substitutes by firstly wetting the skin, washing with the cream or ointment, then rinsing off.
• Topical corticosteroids are not recommended in urticaria, rosacea, acne or undiagnosed, possibly infective, disorders.
• To minimise risk of side-effects with topical corticosteroids, the smallest effective amount should be used, reducing strength and frequency of application as the condition settles. The risk of systemic side-effects increases with prolonged use.
• When using topical corticosteroids wait 30 minutes before applying emollients to prevent diluting the steroid.
• Fragrance Free preparations are preferable to avoid irritation or sensitivity.
• Preparations containing antimicrobials are useful where an antiseptic would be of benefit.
• Aqueous cream is no longer recommended as a soap substitute or for use as an emollient. Aqueous cream contains sodium lauryl sulphate which can damage the skin barrier.
• Emollient bath additives make the bath slippy and patients should be warned of the risk of falling.
• Patients should be informed of the potential fire hazard when using paraffin based emollients.
• If emollients are being applied to the whole body twice daily, children may need 250g per week and adults 500g per week.

When to advise patient to contact GP
Once only trial of emollient, if need to use regularly or if no improvement.