Download emollients - Wandsworth CCG

EMOLLIENTS
There is good evidence to show that effective emollient therapy can reduce the need for steroid use by 75%. The following should be considered in order to optimise
emollient therapy;
 Emollients should be applied as frequently as possible at least three times daily and ideally four to six times a day (every three hours) and use continued even
when skin condition is improved
 Emollients should be applied gently in the direction of hair growth so that a visible sheen remains
 Apply emollients after bathing while water is still trapped in the skin to increase hydration
 Quantity: Appropriate application of emollient could be 500 - 1000 grams of emollient each week for an adult (half quantities for a child)
 There is no good evidence to recommend a particular emollient over another. Choice is based largely on patient preference, site of application and extent and
severity of condition therefore trial of cost effective emollient options should be used.
 Treatment should be initiated with a light emollient. Emollients should be tried in order of greasiness (starting with the least greasy emollient) so that patient is
provided with an emollient that is cosmetically acceptable to them and is greasy enough to control their skin condition.
 Avoid putting hands in large tubs, use a clean spatula to decant the emollient into a smaller clean container
 Antimicrobial products should be used as an adjunct to emollient therapy FOR SHORT TERM USE ONLY when there is evidence of high bacterial load.
 There is limited evidence to support the use of urea containing products if required they can be used for dry, thickened skin for short term use in adjunct to
emollient therapy.
Types
Lotions, creams and ointments: applied directly to the skin.
 Lotions (light preparations): more water, spread easily, absorb quickly, cooling, may be preferred for hairy areas, not very effective at moisturising the skin.
 Creams (medium preparations): mixture of water and fat and feel light and cool on the skin, well absorbed, generally acceptable preparation. All creams
contain preservatives which people can become sensitive too.
 Ointments (oily preparations): greasy and occlusive hence sometimes not cosmetically acceptable, usually no preservatives, useful for very dry and
thickened skin, not appropriate for weeping areas
Soap substitutes: soap can dry the skin. Soap substitutes are just as effective at cleansing the skin. Apply to dry or wet skin then wash off in shower or bath. May
reduce need for other emollients.
Bath and shower oils: bubble bath can be drying and irritant on the skin. A daily bath removes dirt and debris which could potentially lead to infection. Emollient
bath and shower oils can be added to the bath water or directly to the skin in the shower. WARNING, can cause bath or shower to become slippery.
*Acknowledgement: Nicola Watts, Medicines Information Pharmacist, Wessex Drug & Medicines Information Centre, prepared for National Eczema Week 18th – 25th September 2010, August 2010.
Prepared by Louise Maunick, GP Prescribing Support Pharmacist, November 2012 Approved at CEMMaG 12 December 2012
Excipients
Table: Excipients in topical preparations which may be associated with sensitisation
Beeswax
Benzyl alcohol
Butylated hydroxyanisole
Butylated hydroxytoluene
Cetostearyl alcohol (including cetyl and stearyl alcohol)
Chlorocresol
1.
Edetic acid (EDTA)
Ethylenediamine
Fragrances
Hydroxybenzoates (parabens)
Imidurea
Isopropyl palmitate
N-(3-Chloroallyl)hexaminium chloride (quaternium 15)
Polysorbates
Propylene glycol
Sodium metabisulphite
Sorbic acid
Wool fat and related substances including lanolin(1)
Purified versions of wool fat have reduced the problem.
Wandsworth CCG preferred emollients offering a broad selection of cost effective options that should cater to the majority of patients
Lotion (very light)
Cream
Ointment (greasy)
Soap Substitute
1st
E45 Lotion
Emulsifying ointment
ZeroAqs similar to
Aqueous Cream
2nd
QV Lotion
Aquamax (light) similar to
other light emollients such
as E45, Zeroaqs &
Zerocream
Aquamol (creamy)
Hydrous ointment
Aquamax similar to other
light emollients such as
E45, Zeroaqs & Zerocream
Zerobase (rich cream)
similar to Diprobase
Zeroderm ointment
similar to Epaderm or
Hydromol
3rd
Bath/Shower Emollient
(slippery)
Dermalo Bath emollient
similar to Zerolatum &
Oilatum
Hydromol bath & shower
emollient
Zeroneum Bath Oil similar
to Balneum
*Acknowledgement: Nicola Watts, Medicines Information Pharmacist, Wessex Drug & Medicines Information Centre, prepared for National Eczema Week 18th – 25th September 2010, August 2010.
Prepared by Louise Maunick, GP Prescribing Support Pharmacist, November 2012 Approved at CEMMaG 12 December 2012
Cost comparison for selection of popular emollients*
Aqueous Cream
Aquamax Cream
ZeroAQS Cream
OINTMENTS
Aveeno lotion
QV Skin Lotion
E45 lotion
Epaderm Ointment
50:50 Ointment
QV Intensive Ointment
Hydromol Ointment
Zeroderm Ointment
Hydrous ointment
Emulsifying ointment
CREAMS
LOTIONS
SOAP
SUBSTITUTES
BATH
EMOLLIENTS
QV Bath Oil
Oilatum Emollient Bath Additive
Zeroneum Bath Additive
Hydromol Bath & Shower emollient
Dermalo Bath Emollient
Aveeno Cream
Unguentum M cream
Zeroguent Cream
Epaderm Cream
Aquamol
Diprobase Cream
Cetraben cream
Doublebase emollient
QV Cream
E45 cream
Zerobase Cream
Oilatum Cream
Aquamax Cream
£0.00
£2.00
£4.00
£6.00
£8.00
£10.00
£12.00
*Prices per 500g/500ml as per Drug Tariff (November 2012), smaller pack sizes may be more expensive per gram due to economies of scale
*Acknowledgement: Nicola Watts, Medicines Information Pharmacist, Wessex Drug & Medicines Information Centre, prepared for National Eczema Week 18th – 25th September 2010, August 2010.
Prepared by Louise Maunick, GP Prescribing Support Pharmacist, November 2012 Approved at CEMMaG 12 December 2012
LOTIONS
Composition and excipients of preferred options in each category
Product Name
Composition
Excipients
E45 lotion*
Light liquid paraffin 4%, cetomacrogol, white soft paraffin 10%,
hypoallergenic anhydrous wool fat (hypoallogenic lanolin) 1% in glyceryl
monostearate
White soft paraffin 5%
Isopropyl palmitate, hydroxybenzoates (parabens), benzyl alcohol
Cetostearyl alcohol
Aquamol cream
Benzalkonium chloride 0.1%, chlorhexidine hydrochloride 0.1%, liquid
paraffin 2.5%, isopropyl myristate 2.5%
purified water Ph. Eur., white soft paraffin BP, cetostearyl alcohol, liquid
paraffin Ph. Eur., polysorbate 60 and phenoxyethanol.
liquid paraffin, white soft paraffin
Zerobase cream
liquid paraffin 11%
cetostearyl alcohol, chlorocresol
Dermol cream (with antimicrobials)
Benzalkonium chloride 0.1%, chlorhexidine hydrochloride 0.1%, isopropyl
myristate 10%, liquid paraffin 10%
Urea 10%
Cetostearyl alcohol
Hydrous ointment
Dried magnesium sulphate 0.5%, phenoxyethanol 1%, wool alcohols
ointment 50% in freshly boiled and cooled purified water
None as listed above
Emulsifying ointment
Emulsifying wax 30%, white soft paraffin 50%, liquid paraffin 20%
Cetostearyl alcohol
Zeroderm Ointment
Liquid paraffin 40%, white soft paraffin 30%
Cetostearyl alcohol, polysorbate 60
Zeroaqs cream
macrogol cetostearyl ether 1.8%, liquid paraffin 6%, white soft paraffin 15%
cetostearyl alcohol, chlorocresol
Aquamax cream
purified water Ph. Eur., white soft paraffin BP, cetostearyl alcohol, liquid
paraffin Ph. Eur., polysorbate 60 and phenoxyethanol.
Dermol 500 lotion (with anti-microbials)
Benzalkonium chloride 0.1%, chlorhexidine hydrochloride 0.1%, liquid
paraffin 2.5%, isopropyl myristate 2.5%
Cetostearyl alcohol
Hydromol bath & shower emollient
Isopropyl myristate 13%, light liquid paraffin 37.8%
None as listed above
Dermalo emollient bath additive
acetylated wool alcohols 5%, liquid paraffin 65%
Zeroneum bath oil
refined soya bean oil 83.35%
butylated hydroxytoluene, fragrance, propylene glycol
Dermol 600 Bath Emollient (with anti-microbials)
Benzalkonium chloride 0.5%, liquid paraffin 25%, isopropyl myristate 25%
Polysorbate 60
QV lotion
Dermol 500 lotion (with anti-microbials)
CREAMS
Aquamax cream
BATH / SHOWER
ADDITIVES
SOAP
SUBSTITUTES
OINTMENTS
#
Aquadrate cream
Cetostearyl alcohol, hydroxybenzoates (parabens)
cetostearyl alcohol, chlorocresol
None as listed above
*ACBS: for symptomatic relief of dry skin conditions, such as those associated with atopic eczema and contact dermatitis
#Caution: fire hazard with paraffin-based emollients, keep away from fire/flames
*Acknowledgement: Nicola Watts, Medicines Information Pharmacist, Wessex Drug & Medicines Information Centre, prepared for National Eczema Week 18th – 25th September 2010, August 2010.
Prepared by Louise Maunick, GP Prescribing Support Pharmacist, November 2012 Approved at CEMMaG 12 December 2012
References and useful information sources*
Evidence-based Guidance and Reviews
Patient Information
Clinical Knowledge Summary (CKS)
National Eczema Society (NES)




Atopic Eczema (2011) - An overview of management according to
severity. Includes information on emollients and topical
corticosteroids, infected eczema, trigger factors, prevention.
Contact Dermatitis (2011) - Includes management of acute and
infected dermatitis, prevention of recurrence and management of
occupational contact dermatitis.
Seborrhoeic dermatitis (2011) – Management information on scalp
and beard, face and body, severe and infantile scenarios.
British Association of Dermatologists (BAD)


Guidelines for the management of atopic eczema (last reviewed Jan
2010) - Includes diagnostic criteria, advice on management, and
guidance for referral to secondary care specialists.
Guidelines for the management of contact dermatitis (2009)
National Institute of Health and Clinical Evidence (NICE)




Eczema (chronic) – Alitretinoin (Aug 2009) – Recommended, within
its licensed indication, for adults with severe chronic hand eczema
Atopic eczema in children (Dec 2007) – From birth to 12 years.
Guidance on diagnosis, assessment, management, trigger factors,
and impact of education for children and carers.
Atopic dermatitis (eczema) – topical steroids (Aug 2004) - Topical
steroids should be applied once or twice daily only (but see BMJ
article in ‘Other useful information’ section).
Atopic dermatitis (eczema) – pimecrolimus and tacrolimus (Aug 2004)
- Tacrolimus and pimecrolimus should not be used to treat mild atopic
eczema. Even when atopic eczema is moderate or severe, they
should not be used ‘first-line’.
Cochrane Reviews

Probiotics for treating eczema (Oct 2008)

Topical pimecrolimus for eczema (Aug 2007)

Maternal dietary antigen avoidance during pregnancy or lactation, or
both, for preventing or treating atopic disease in the child (Apr 2006)


Wide variety of fact sheets on subjects including: emollients, topical steroids,
allergies, complementary medicine and sunscreens.
Information on different types of eczema as well as management and treatment.
Eczema in schools – information for teachers to help promote better
understanding of the condition and how it affects children.
NHS Choices (www.nhs.uk)

Eczema (atopic) includes information on diagnosis, treatment and helpful hints for
living with the disease, plus video interview with a doctor.
British Association of Dermatologists (BAD)

Patient information leaflets include: atopic eczema and contact dermatitis.
Medicines Guides
Patient information about specific medicines used in different conditions
 Eczema – includes topical steroids, tacrolimus and alitretinoin.
Other useful information

British National Formulary (BNF 64, Sept 2012).

NHS Evidence – eczema Includes sections on guidelines and medicines
available.

NPCi Skin – includes information, case studies, e-learning packages on eczema
as well as other skin conditions.

'Omega-3 can help control eczema' NHS Evidence Hitting the Headlines (Mar
2008). May be helpful, but the study was small.

Eczema in pregnancy BMJ 2007;335:152-4 – Discusses management and
implications in pregnancy. (Athens password or subscription required).

Established corticosteroid creams should be applied only once daily in patients
with atopic eczema BMJ 2007;334:1272 - (Athens password or subscription
required).

Systematic review of treatments for atopic eczema – health technology
assessment which reviews different products (2000)
*Acknowledgement: Nicola Watts, Medicines Information Pharmacist, Wessex Drug & Medicines Information Centre, prepared for National Eczema Week 18th – 25th September 2010, August 2010.
Prepared by Louise Maunick, GP Prescribing Support Pharmacist, November 2012 Approved at CEMMaG 12 December 2012