Cobra Skin User & Service Manual PDF Guide (EN)

Chapter 13: Skin Table of contents 13.1 General principles 13.2 Emollients 13.2.1 Preparations containing urea 13.2.2 Emollient bath additives 13.2.3 Barrier preparations 13.3 Antipuritics 13.4. Topical corticosteroids 13.4.1 Topical corticosteroids with antimicrobials 13.5 Preparations for psoriasis 13.5.1 Drugs affecting the immune response . 13.6.1 & 13.6.2 Topical and oral preparations for acne 13.6.3 Topical and systemic preparations for rosacea 13.7 Preparations for warts, corns and calluses 13.8 Sunscreen preparations 13.8.1 Preparations for actinic keratosis 13.9.

Shampoos and other preparations for scalp and hair conditions 13.9.1 Preparation for Hirsutism 13.10.1 Topical antibacterial / antiseptic preparations 13.10.2 Antifungal preparations 13.10.3 Antiviral preparations 13.10.4 Parasiticidal preparations Appendix 1: Choice of emollients and soap substitutes Appendix 2: Suitable quantities for prescribing Appendix 3: Fingertip unit guide on quantity of topical corticosteroid to apply for children and Adults Appendix 4: Examples of OTC products Appendix 5: Rosacea: management 10 th edition January 2023; sections 13.2, 13.5, 13.8 and appendix 1 amended Jan 2023.

Minor update February 2023, Minor update 13.9 July 2023, Minor update July 2024 Next review: January 2026 1

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13.1 General principles Emollients are important in the management of atopic eczema and should be used regularly by all patients even when skin is clear. Choice of preparation should be based on severity of condition (a stepped approach), patient preference and site of application. Management can then be stepped up or down, according to the severity of symptoms. Prescribing of emollients for non-clinical cosmetic purposes is not recommended and should be reviewed. Mild dry skin can be managed via self-care. Promote patient self-care in the management of their skin conditions. See appendix 4 for further information on over the counter (OTC) products available from pharmacies.

Do not prescribe bath emollients or additives unless recommended by specialist dermatology services. See criteria in the Sheffield STOP guidance. Consider using emollients suitable as soap substitutes or bath additives instead. See choices below or in the abbreviated guide to emollients . People with eczema should be advised to wash with a regular leave-on emollient as a soap substitute. Note that leave-on emollients may make surfaces slippery. See warning information on fire hazards with emollient use. Topical steroids used intermittently to control exacerbations of atopic eczema are effective and rarely cause side effects.

However, see MHRA alert (September 2021) for information on the risk of topical steroid withdrawal reactions For detailed guidance refer to NICE CG57 Management of atopic eczema in children from birth up to the age of 12 years. 13.2 Emollients Preparations in bold indicate first line choices. 2 nd and 3 rd line options are given in case of shortage of first line treatment and for patient preference. All three are formulary choices and non- formulary alternatives are provided in abbreviated guide to emollients .

Emollient choices have been made by using multiple factors such as safety, cost-effectiveness, available ingredient information, supply availability and impact on greener NHS initiative. Choices will be checked on annual basis. Please refer to abbreviated guide to emollients used in primary care for more detailed choice, comparison and ingredient list, including paraffin-free, soap substitutes, bath additives and vegan options. Creams: Epimax ® original 500g Bottle (OTC) Epimax ® excetra cream 500ml bottle (OTC) ZeroAQS ® cream 500g Tub (OTC) Ointments: Fifty:50 ointment 500g Tub (OTC) Aproderm ® ointment 500g Tub (OTC) Zeroderm ® ointment 500g Tub (OTC) Gels:

Epimax ® isomol gel 500g Bottle (OTC) Aproderm ® gel 500g Tub (OTC) MyriBase ® gel 500ml pump (OTC) 10 th edition January 2023; sections 13.2, 13.5, 13.8 and appendix 1 amended Jan 2023. Minor update February 2023, Minor update 13.9 July 2023, Minor update July 2024 Next review: January 2026 2

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Lotions: QV ® skin lotion 500ml Pump (OTC) Cetraben ® lotion 500ml Pump (OTC) Colloidal oatmeal preparations: Epimax ® oatmeal cream 500ml Bottle (OTC) Miclaro ® oat cream 500ml Pump (OTC) AproDerm ® colloidal oat cream 500ml Pump (OTC) 10 th edition January 2023; sections 13.2, 13.5, 13.8 and appendix 1 amended Jan 2023. Minor update February 2023, Minor update 13.9 July 2023, Minor update July 2024 Next review: January 2026 3 Emollients should be the first line treatment for mild dry skin conditions. • There is no evidence that any one emollient is better than another but there is wide inter- patient variability in response to treatments.

The emollients of choice are therefore the least expensive ones that are effective and which the patient finds acceptable and is prepared to use. Encourage self-care. • If their current emollient causes irritation or is not acceptable, offer a different way to apply it or offer an alternative emollient. • Sufficient quantities should be prescribed - for more guidance see here. • Advise to use emollients liberally and frequently (at least two to four times a day; very dry skin may require application every two to three hours) • Children with atopic eczema should be prescribed sufficient quantities (250-500g weekly) of unperfumed emollients for daily use.

• Creams and gel emollients are easier to apply but ointments have a better emollient effect (the greasier the product the more effective it is at keeping the skin hydrated). • Atopic people are more likely to react to ingredients found in emollients compared with the general population, so it is important to anticipate potential sensitivity reactions. See abbreviated emollient guide and MIMS for more information. • Emollients should be applied in the direction of hair growth to reduce the risk of folliculitis. • Creams and ointments are suitable for use as soap substitutes for hand washing and in the bath.

Epimax® cream (light cream) is available is a squeezy bottle; it’s suitable for use in the shower or bath. Ointments (greasy) are available in tubs, therefore may be less suitable for use in a shower. When using as a soap substitute avoid application to and around eyes. • If emollient is available in a tub, then use a spatula to dispense the emollient. This helps with infection control. Patient education links: http://www.nhs.uk/conditions/emollients/pages/introduction.aspx http://www.eczema.org/emollients Booklets and factsheets for both healthcare professionals and patients covering a range of issues relating to eczema are available from The National Eczema Society.

http://www.eczema.org Fire hazard with emollients: Many patients use emollients containing paraffin for dry skin conditions. Care must be taken when creams are applied as these can be transferred to clothing, bedding, bandages and any other flammable material. Patients should be warned and advised of the fire risk when using emollients. MHRA provides a safety advice on emollients use. Please consider using fire safety information, on how to reduce the risk of fire from emollients.

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13.2.1 Preparations containing urea Imuderm ® cream (5% urea / 5 % glycerine) 500g pump pack (OTC) 13.2.2 Emollient bath additives 10 th edition January 2023; sections 13.2, 13.5, 13.8 and appendix 1 amended Jan 2023. Minor update February 2023, Minor update 13.9 July 2023, Minor update July 2024 Next review: January 2026 4 Urea is a keratin softener and hydrating agent used in the treatment of dry, scaling conditions (including ichthyosis). Preparations with urea should only be prescribed where standard emollients are ineffective. They should not be prescribed long term. Emollient products containing urea are generally not interchangeable.

The urea content of products varies, and some contain additional active ingredients such as salicylic acid, lactic acid or lauromacrogols. It is occasionally used with other topical agents such as corticosteroids to enhance penetration of the skin. Products containing urea tend to sting moderate to severe eczema skin and not tolerated well in younger children and babies due to irritation. Patients managed by Podiatry Services may require preparations other than Imuderm® for foot treatment, e.g., Flexitol 25% Urea Heel Balm® cream (urea 25% cream, pack size 500g). For training on Diabetic Foot Screen - see here. Sheffield Diabetes Footcare Pathway.

There is a lack of data on the clinical effectiveness of bath emollients, which are not substitutes for emollients applied directly to the skin. Do not offer bath emollients or additives to children with atopic eczema unless recommended by specialist dermatology services. NICE CG57 2023 update recommends in establishing a personalised advice on washing routine in children with eczema. NICE CG57 advises that health care professionals should offer children with atopic eczema a choice of unperfumed emollients for moisturising, washing and bathing. Many standard emollients (creams and ointments) can be used as a soap substitute.

Ointments that are completely immiscible with water (e.g., white soft paraffin alone) are not suitable. For more information see here. Leave-on emollients (creams / gels) should be applied to the skin before or during bathing / showering / washing and then rinsed off. Alternatively, melt approximately 4g (the size of a £2 coin) of ointment in hot water and add to the bath (best to do this under a running tap). Regular application of leave-on emollient is necessary after skin has been gently patted dry with a towel. Care with bath additives as they make skin and surfaces slippery. Some ointments can block drainage pipes. Routine use of antiseptic / emollient products is not recommended.

People who prefer to use emollient bath additives as a soap substitute should be advised to purchase it over the counter. Please see Sheffield STOP guideline.

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