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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