Download Emollients and Sunscreens

Position Statement on Emollients/Use of Sunscreens

Practitioners are encouraged to adopt the cost-effective emollients in the BCCG formulary

Bath emollients/washes and shower gels not to be routinely available on prescription

Prescribers are requested to consider these products when initiating treatment in the absence of a
recommendation from a specialist or specific patient requirements

Aqueous cream is no longer recommended as an emollient

Sunscreens should not be routinely prescribed for other than the conditions detailed in the current
BNF
BACKGROUND
Evidence to inform the use of bath and shower emollients is lacking: there is no good evidence to recommend
a particular emollient over another and no published randomised controlled trials have assessed the efficacy
of bath and shower emollients in atopic eczema. Product selection is mostly based on patient preference
which is important to maximise adherence and minimise wastage.
The proposed emollient formulary is a guide to prescribing the most cost effective product and should not
override clinical judgement.
NHS guidance is that sunscreens should ONLY be prescribed on an FP10 for sun protection against UV
radiation in abnormal cutaneous photosensitivity resulting from genetic disorders or photodermatoses.
COST & PRESCRIBING DATA
For the financial year of 2014/15 Blackpool CCG spent £351,396,295 (60,284 items) on emollients and on
£7,803.44 (678 items) on sunscreens.
REFERENCES
www.nhs.uk/conditions/emollients/Pages/Introduction.aspx
Hoare C, Li Wan Po A, Williams H. Systematic review of treatments for atopic eczema. Health Technology Assessment 2000;4: (37)
National Institute for Health and Clinical Excellence (NICE): Atopic eczema in children – Management of atopic eczema in children from
birth up to the age of 12 years (CG57) London: National Collaborating Centre for Women’s and Children’s Health; 2007.Accessed via
http://www.nice.org.uk/guidance/cg57/chapter/1-Guidance Accessed 15/7/15
Scottish Intercollegiate Guidelines Network (SIGN). Management of atopic eczema in primary care SIGN no.125 March 2011. Accessed
via http://sign.ac.uk/pdf/sign125.pdf Accessed 15/7/15.
Eczema – atopic, Clinical Knowledge Summary, last revised March 2013.Accessed via http://cks.nice.org.uk/eczema-atopic Accessed
15/7/15.
With acknowledgment to Midlands and Lancashire CSU Medicines Commissioning
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Cost-Effective Emollients/Use of Sunscreens
Executive Summary
Introduction
Evidence to inform the use of bath and shower emollients is lacking. There is no good evidence to recommend
a particular emollient over another and no published randomised controlled trials have assessed the efficacy
of bath and shower emollients in atopic eczema. Product selection is mostly based on patient preference
which is important to maximise adherence and minimise wastage. Appendix 1 details products suitable for an
initial, cost-effective first choice.
The proposed emollient formulary is a guide to prescribing the most cost effective product and should not
override clinical judgement.
NHS guidance is that sunscreens should ONLY be prescribed on an FP10 for sun protection against UV
radiation in abnormal cutaneous photosensitivity resulting from genetic disorders or photodermatoses.
Background
In line with NICE guidance emollients should be prescribed according to the dryness of the skin, and individual
preference. The preparations in Appendix 1 are formulated as comparable products to commonly prescribed
emollients but are more cost effective. In addition, innovations in packaging used in the pumps and ‘top down’
bottles of these products can help to reduce waste.
The quantities of emollients deposited on the skin from bath and shower emollients are likely to be lower than
emollients used as soap substitutes applied directly to the skin before bathing then rinsing. However, NICE CG
57 does state that the additional use of bath emollients for some children may be appropriate in order to
ensure that adequate amounts of emollient are absorbed into the skin. If emollient bath additives are
prescribed, the BNF No.15 recommends that in order to improve hydration, patients should soak in the bath
for 10-20 minutes.
NHS guidance is that sunscreens should only be prescribed for sun protection against UV radiation in
abnormal cutaneous photosensitivity resulting from genetic disorders or photodermatoses, including vitiligo
and those resulting from radiotherapy; chronic or recurrent herpes simplex labialis. Photosensitive
dermatoses are made up of the following conditions: polymorphic light eruption (PLE), actinic prurigo, chronic
actinic dermatitis, solar urticaria, hydroa vacciniforme, xeroderma pigmentosum, porphyria, drug-induced
photosensitivity, photocontact allergic reactions and phytophoto dermatitis.
Key Points in Emollient Product Selection

Patient will not use a product if they think it does not work or unpleasant to apply

Correct hydration potency is a factor in selection: oily based products retain skin moisture and are better
moisturisers whereas high water based products are more pleasant to use but not as effective at retaining
moisture

Severity of affected skin: understanding severity will govern product selection

Quantities: it is important to use appropriate amounts to ensure adequate hydration/application
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
Trial of cost effective emollient options should be used (small packs). Larger quantity can be prescribed if it
suits the patient. They should be applied liberally and frequently, even when skin condition has improved,
and known irritants avoided

Children: it is important to spend time educating children with atopic eczema and parents/carers which
should cover how much treatment to use, how often to apply, when and how to stop treatment up or
down, and how to treat infected atopic eczema
Recommendations
1. As emollients are the mainstay of treatment for mild flares of atopic eczema this recommendation is to
bring to the attention of prescribers, cost effective alternatives to those products they are already familiar
with. Prescribers are requested to consider these products when initiating treatment in the absence of a
recommendation from a specialist or specific patient requirements.
N.B. Existing prescription recommendations from a dermatologist or specialist nurse should not be
substituted
2. Consideration should also be given to advising patients on the correct application technique and
prescribed in generous amounts and frequent and liberal use advised, even when the skin is clear. As the
effectiveness and acceptability of a particular emollient may vary with time and that a patient feels that a
particular product has become unsuitable for them (or if they have developed sensitivity to it), prescribing
an alternative emollient should be considered.
3. Bath emollients/washes and shower gels not to be routinely available on prescription
4. Aqueous cream is no longer recommended as an emollient.
5. Sunscreens should not be routinely prescribed.
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Appendix 1
EMOLLIENT FORMULARY
Emollients reduce water loss from the skin and are first-line
treatments in the management of dry skin conditions. They
should be used liberally and at least 2-4 times a day. In
general, the greasier the product, the more effective it is as
an emollient.
Patient preference (including sensitivities and previous
unsuccessful emollients), severity of condition and
application site should be considered when prescribing a
cost-effective emollient. These are key to ensuring
adherence.
Prescribe small quantities initially, then sufficient
amounts on repeat.
Ointments are the greasiest. They may be more
suitable for patients with sensitivities as most do not
contain preservatives however they should not be used
on infected skin. Some patients may find creams and
gels more acceptable as they are less greasy.
Ensure products for specialist use are prescribed
appropriately
and
reviewed
regularly
e.g.
antimicrobials and products containing urea.
Aqueous cream has a high risk of causing skin irritation
and should be reserved for use as a soap substitute
only.
N.B. Paraffin-based products are flammable – advise
patients using these products to stay away from fire or
flames and not to smoke.MHRA
VERY GREASY
1. Zeroderm
Ointment
2. Hydromol
Ointment
3. Cetraben
Ointment
GREASY
1. Zerodouble
gel
2. Doublebase
gel
3. Zeroguent
cream
CREAMY
1. Aquamax
cream
2. Zerocream
3. Oilatum
cream
LIGHT
1. Zero AQS
2. E45 lotion
3. Cetraben
lotion
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BATH AND SHOWER EMOLLIENTS
Soap is drying and can irritate the skin of patients with atopic eczema. These
patients should therefore be offered an alternative to soap with which to wash.
There are two options: the patient’s usual leave-on emollient used as a soap
substitute (provided it is miscible with water); a bath or shower emollient.
Neither option should replace the regular use of a leave-on emollient.
Evidence to inform the use of bath and shower emollients is lacking. No
published randomised controlled trials have assessed the efficacy of bath and
shower emollients in atopic eczema. The quantities of emollients deposited on
the skin from bath and shower emollients are likely to be lower than emollients
used as soap substitutes applied directly to the skin before bathing then rinsing.
However NICE CG 57 does state that the additional use of bath emollients for
some children may be appropriate in order to ensure that adequate amounts of
emollient are absorbed into the skin. If emollient bath additives are prescribed,
the BNF recommends that in order to improve hydration, patients should
soak in the bath for 10-20 minutes.BNF Extra care is required when
emollients are used in the bath or shower as surfaces may become
slippery.
SUNSCREENS ON FP10 PRESCRIPTION
Five sunscreen preparations are considered borderline substances when marked
with ACBS on the prescription. They are regarded as drugs when prescribed for
sun protection against UV radiation in abnormal cutaneous photosensitivity
resulting from genetic disorders or photodermatoses, including vitiligo and those
resulting from radiotherapy; chronic or recurrent herpes simplex labialis. BNF
Photosensitive dermatoses are made up of the following conditions: polymorphic
light eruption (PLE), actinic prurigo, chronic actinic dermatitis, solar urticaria,
hydroa vacciniforme, xeroderma pigmentosum, porphyria, drug-induced
photosensitivity, photocontact allergic reactions and phytophoto dermatitis.
http://www.pcds.org.uk/clinical-guidance/photodermatoses
The ACBS Sunscreen preparations are: LA Roche-Posay Anthelios SPF50+ Melt In
Cream; Sunsense Ultra (Ego) SPF 50+; Uvistat Lipscreen SPF 50; Uvistat Sunscreen
SPF 30 and Uvistat Sunscreen SPF 50.
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Patient Advice on bath oils and shower gels for dry skin conditions
There are many bath oils and shower gels (also known as moisturisers or emollients) available for people to
use to treat large areas of dry skin. We know that using moisturisers properly is a very important part of
treating dry skin conditions such as eczema, dermatitis and psoriasis.

Do bath oils and shower gels work?
The amount of moisturiser left on the skin during bathing or showering is usually much less than if oils,
moisturisers or ointments are put straight onto the skin.
By relying only on bath or shower oils, there is a real risk that people will under-treat the dry skin that is part
of their skin condition.

Are there any risks in using bath oils and shower gels?
As well as being less effective at moisturising the skin, oils and shower gels coat the bath or shower and make
it greasy and slippery, and so greatly increase the risk of falls. Using a bath mat or grab rails to reduce the risk
of slipping is strongly advised, as well as cleaning the bath or shower properly after use. Other people who
also use the bath or shower should be warned that it is likely to be very slippery.

What should you do to moisturise your skin when having a bath or shower if you don’t use bath
oils/shower gels?
Don’t use soap as this strips the natural oils out of your skin. Use your moisturiser applied directly to the skin
as a soap substitute to clean your skin. Massage the moisturiser between your hands and apply it to dry skin
in a downward direction. Parents of young children may prefer to apply the moisturiser onto a flannel, if so a
clean flannel should be used each time.
All moisturisers with the exception of Diprobase ointment, QV ointment and 50:50 LP:WSP, may be used as
soap substitutes.
After a bath or shower it is best to dry off by patting the skin lightly with a towel rather than by rubbing.
Rubbing can start the itch / scratch part of the eczema or dermatitis if that is causing the dry skin. Once the
skin is almost dry but still moist, immediately apply an oil or moisturiser to seal the moisture into the skin.

Why BCCG has asked GPs to stop prescribing bath oils, shower gels and washes
Following discussion with local Dermatology Consultants, GPs and Specialists have agreed not to issue
prescriptions for these products, because of concerns about the risk of falls and the evidence that these are
less effective moisturisers than those applied directly to the skin. People who choose to continue to use them
can buy them from their local community pharmacy (chemist) or supermarket.
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