Drug Action
Urea is a keratin softener and hydrating agent used in the treatment of dry, scaling conditions (including ichthyosis) and may be useful in elderly patients.
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Drug reference
Urea is a keratin softener and hydrating agent used in the treatment of dry, scaling conditions (including ichthyosis) and may be useful in elderly patients.
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AQUADRATE ® Dry, scaling, and itching skin ▶TO THE SKIN ▶Child: Apply twice daily, to be applied thinly ▶Adult: Apply twice daily, to be applied thinly BALNEUM ® CREAM Dry skin conditions ▶TO THE SKIN ▶Child: Apply twice daily ▶Adult: Apply twice daily BALNEUM ® PLUS CREAM Dry, scaling, and itching skin ▶TO THE SKIN ▶Child: Apply twice daily ▶Adult: Apply twice daily CALMURID ® Dry, scaling, and itching skin ▶TO THE SKIN ▶Child: Apply twice daily, apply a thick layer for 3–5 minutes, massage into area, and remove excess. Can be diluted with aqueous cream (life of diluted cream is 14 days). Half-strength cream can be used for 1 week if stinging occurs ▶Adult: Apply twice daily, apply a thick layer for 3–5 minutes, massage into area, and remove excess. Can be diluted with aqueous cream (life of diluted cream is 14 days). Half-strength cream can be used for 1 week if stinging occurs DERMATONICS ONCE HEEL BALM ® Dry skin on soles of feet ▶TO THE SKIN ▶Child 12–17 years: Apply once daily ▶Adult: Apply once daily E45 ® ITCH RELIEF CREAM Dry, scaling, and itching skin ▶TO THE SKIN ▶Child: Apply twice daily ▶Adult: Apply twice daily EUCERIN ® INTENSIVE CREAM Dry skin conditions including eczema, ichthyosis, xeroderma, and hyperkeratosis ▶TO THE SKIN ▶Child: Apply twice daily, to be applied thinly and rubbed into area ▶Adult: Apply twice daily, to be applied thinly and rubbed into area EUCERIN ® INTENSIVE LOTION Dry skin conditions including eczema, ichthyosis, xeroderma, and hyperkeratosis ▶TO THE SKIN ▶Child: Apply twice daily, to be applied sparingly and rubbed into area ▶Adult: Apply twice daily, to be applied sparingly and rubbed into area FLEXITOL ® Dry skin on soles of feet and heels ▶TO THE SKIN ▶Child 12–17 years: Apply 1–2 times a day ▶Adult: Apply 1–2 times a day HYDROMOL ® INTENSIVE Dry, scaling, and itching skin ▶TO THE SKIN ▶Child: Apply twice daily, to be applied thinly ▶Adult: Apply twice daily, to be applied thinly IMUDERM ® EMOLLIENT Dry skin conditions including eczema, psoriasis or dermatitis ▶TO THE SKIN ▶Adult: Apply to skin or use as a soap substitute NUTRAPLUS ® Dry, scaling, and itching skin ▶TO THE SKIN ▶Child: Apply 2–3 times a day ▶Adult: Apply 2–3 times a day
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MHRA/CHM ADVICE (UPDATED DECEMBER 2018): EMOLLIENTS: NEW INFORMATION ABOUT RISK OF SEVERE AND FATAL BURNS WITH PARAFFIN-CONTAINING AND PARAFFIN-FREE EMOLLIENTS See Emollient and barrier preparations p. 1286.
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Emollients should be applied immediately after washing or bathing to maximise the effect of skin hydration. Emollient preparations contained in tubs should be removed with a clean spoon or spatula to reduce bacterial contamination of the emollient. Emollients should be applied in the direction of hair growth to reduce the risk of folliculitis. Skin
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There can be variation in the licensing of different medicines containing the same drug. Cream CAUTIONARY AND ADVISORY LABELS 15 EXCIPIENTS: May contain Benzyl alcohol, cetostearyl alcohol (including cetyl and stearyl alcohol), hydroxybenzoates (parabens), isopropyl palmitate, polysorbates, propylene glycol, woolfat and related substances (including lanolin) ▶Aquadrate (Alliance Pharmaceuticals Ltd) Urea 100 mg per 1 gram Aquadrate 10% cream | 30 gram £1.64 | 100 gram £4.45 ▶Balneum (Almirall Ltd) Balneum cream | 50 gram £2.85 | 500 gram £9.97 ▶Balneum Plus (Almirall Ltd) Lauromacrogols 30 mg per 1 gram, Urea 50 mg per 1 gram Balneum Plus cream | 100 gram G £3.29 DT = £4.28 | 500 gram G £14.99 DT = £14.99 ▶E45 Itch Relief (Forum Health Products Ltd) Lauromacrogols 30 mg per 1 gram, Urea 50 mg per 1 gram E45 Itch Relief cream | 50 gram G £2.81 DT = £2.81 | 100 gram G £4.28 DT = £4.28 | 500 gram G £14.99 DT = £14.99 ▶Eucerin Intensive (Beiersdorf UK Ltd) Urea 100 mg per 1 gram Eucerin Intensive 10% cream | 100 ml G £7.59 ▶Hydromol Intensive (Alliance Pharmaceuticals Ltd) Urea 100 mg per 1 gram Hydromol Intensive 10% cream | 30 gram £1.67 | 100 gram £4.45 ▶imuDERM (CliniSupplies Ltd) imuDERM emollient | 500 gram £6.62 ▶Nutraplus (Galderma (UK) Ltd) Urea 100 mg per 1 gram Nutraplus 10% cream | 100 gram p £4.37 Liquid CAUTIONARY AND ADVISORY LABELS 15 EXCIPIENTS: May contain Benzyl alcohol, isopropyl palmitate ▶Eucerin Intensive (Beiersdorf UK Ltd) Urea 100 mg per 1 gram Eucerin Intensive 10% lotion | 250 ml G £7.93 DT = £7.93 Balm CAUTIONARY AND ADVISORY LABELS 15 EXCIPIENTS: May contain Beeswax, benzyl alcohol, cetostearyl alcohol (including cetyl and stearyl alcohol), fragrances, lanolin ▶Dermatonics Once (Dermatonics Ltd) Dermatonics Once Heel Balm | 75 ml £3.60 | 200 ml £8.50 ▶Flexitol (Thornton & Ross Ltd) Flexitol 25% Urea Heel Balm | 40 gram £2.75 | 75 gram £3.80 | 200 gram £9.40 | 500 gram £14.75 Infections of the skin Skin infections Antibacterial preparations for the skin Cellulitis, erysipelas, and leg ulcer infections require systemic antibacterial treatment, see Skin infections, antibacterial therapy p. 540. Impetigo requires topical antiseptic/antibacterial or systemic antibacterial treatment, see Skin infections, antibacterial therapy p. 540. Although many antibacterial drugs are available in topical preparations, some are potentially hazardous and frequently their use is not necessary if adequate hygienic measures can be taken. Moreover, not all skin conditions that are oozing, crusted, or characterised by pustules are actually infected. To minimise the development of resistant organisms it is Skin advisable to limit the choice of antibacterials applied topically to those not used systemically. Unfortunately some of these, for example neomycin sulfate p. 1296, may cause sensitisation, and there is cross-sensitivity with other aminoglycoside antibiotics, such as gentamicin p. 545. If large areas of skin are being treated, ototoxicity may also be a hazard with aminoglycoside antibiotics, particularly in children, in the elderly, and in those with renal impairment. Resistant organisms are more common in hospitals, and whenever possible swabs should be taken for bacteriological examination before beginning treatment. Mupirocin p. 1297 is not related to any other antibacterial in use; it is effective for skin infections, particularly those due to Gram-positive organisms but it is not indicated for pseudomonal infection. Although Staphylococcus aureus strains with low-level resistance to mupirocin are emerging, it is generally useful in infections resistant to other antibacterials. To avoid the development of resistance, mupirocin or fusidic acid p. 604 should not be used for longer than 10 days and local microbiology advice should be sought before using it in hospital. In the presence of mupirocin- resistant MRSA infection, a topical antiseptic such as povidone-iodine p. 1343, chlorhexidine p. 1344, or alcohol can be used; their use should be discussed with the local microbiologist. Tedizolid p. 606 is licensed for the treatment of acute bacterial skin and skin structure infections. Silver sulfadiazine p. 1297 is used in the treatment of infected burns. Antibacterial preparations also used systemically Fusidic acid is a narrow-spectrum antibacterial used for staphylococcal infections. An ointment containing fusidic acid is used in the fissures of angular cheilitis when associated with staphylococcal infection. See Oropharyngeal fungal infections p. 1283 for further information on angular cheilitis. Metronidazole p. 1296 is used topically for rosacea and to reduce the odour associated with anaerobic infections; oral metronidazole is used to treat wounds infected with anaerobic bacteria. Antifungal preparations for the skin Most localised fungal infections are treated with topical preparations. To prevent relapse, local antifungal treatment should be continued for 1–2 weeks after the disappearance of all signs of infection. Systemic therapy is necessary for scalp infection or if the skin infection is widespread, disseminated, or intractable; although topical therapy may be used to treat some nail infections, systemic therapy is more effective. Skin scrapings should be examined if systemic therapy is being considered or where there is doubt about the diagnosis. Dermatophytoses Ringworm infection can affect the scalp (tinea capitis), body (tinea corporis), groin (tinea cruris), hand (tinea manuum), foot (tinea pedis, athlete’s foot), or nail (tinea unguium). Scalp infection requires systemic treatment; additional application of a topical antifungal, during the early stages of treatment, may reduce the risk of transmission. A topical antifungal can also be used to treat asymptomatic carriers of scalp ringworm. Most other local ringworm infections can be treated adequately with topical antifungal preparations (including shampoos). The imidazole antifungals clotrimazole p. 1298, econazole nitrate p. 1298, ketoconazole p. 1298, and miconazole p. 1299 are all effective. Terbinafine cream p. 1300 is also effective but it is more expensive. Other topical antifungals include griseofulvin p. 1300 and the undecenoates. Compound benzoic acid ointment (Whitfield’s ointment) has been used for ringworm infections but it is cosmetically less acceptable than proprietary preparations. Topical preparations for athlete’s foot containing tolnaftate are on sale to the public. Antifungal dusting powders are of little therapeutic value in the treatment of fungal skin infections and may cause skin irritation; they may have some role in preventing re- infection. Antifungal treatment may not be necessary in asymptomatic patients with tinea infection of the nails. If treatment is necessary, a systemic antifungal is more effective than topical therapy. However, topical application of amorolfine p. 1299 or tioconazole p. 1299 may be useful for treating early onychomycosis when involvement is limited to mild distal disease, or for superficial white onychomycosis, or where there are contra-indications to systemic therapy. Pityriasis versicolor Pityriasis (tinea) versicolor can be treated with ketoconazole shampoo. Alternatively, selenium sulfide shampoo [unlicensed indication] can be used as a lotion (diluting with a small amount of water can reduce irritation) and left on the affected area for 10 minutes before rinsing off; it should be applied once daily for 7 days, and the course repeated if necessary. Topical imidazole antifungals such as clotrimazole, econazole nitrate, ketoconazole, and miconazole, or topical terbinafine are alternatives, but large quantities may be required. If topical therapy fails, or if the infection is widespread, pityriasis versicolor is treated systemically with a triazole antifungal. Relapse is common, especially in the immunocompromised. Candidiasis Candidal skin infections can be treated with a topical imidazole antifungal, such as clotrimazole, econazole nitrate, ketoconazole, or miconazole; topical terbinafine is an alternative. Topical application of nystatin p. 1284 is also effective for candidiasis but it is ineffective against dermatophytosis. Refractory candidiasis requires systemic treatment generally with a triazole such as fluconazole p. 630; systemic treatment with terbinafine is not appropriate for refractory candidiasis. Angular cheilitis Miconazole cream is used in the fissures of angular cheilitis when associated with Candida. Compound topical preparations Combination of an imidazole and a mild corticosteroid (such as hydrocortisone 1% p. 1313) may be of value in the treatment of eczematous intertrigo and, in the first few days only, of a severely inflamed patch of ringworm. Combination of a mild corticosteroid with either an imidazole or nystatin may be of use in the treatment of intertrigo associated with candida. Antiviral preparations for the skin Aciclovir cream p. 1303 is licensed for the treatment of initial and recurrent labial and genital herpes simplex infections; treatment should begin as early as possible. Systemic treatment is necessary for buccal or vaginal infections and for herpes zoster (shingles). Herpes labialis Aciclovir cream can be used for the treatment of initial and recurrent labial herpes simplex infections (cold sores). It is best applied at the earliest possible stage, usually when prodromal changes of sensation are felt in the lip and before vesicles appear. Penciclovir cream is also licensed for the treatment of herpes labialis; it needs to be applied more frequently than aciclovir cream p. 1303. Systemic treatment is necessary if cold sores recur frequently or for infections in the mouth. Parasiticidal preparations for the skin Suitable quantities of parasiticidal preparations Area of body Skin creams Lotions Cream rinses 50–100 mL 50–100 mL Scalp (head lice) 30–60 g 100 mL Body (scabies) 30–60 g 100 mL Body (crab lice) These amounts are usually suitable for an adult for single application. Scabies Permethrin p. 1303 is used for the treatment of scabies (Sarcoptes scabiei); malathion p. 1302 can be used if permethrin is inappropriate. Benzyl benzoate p. 1302 is an irritant and should be avoided in children; it is less effective than malathion and permethrin. Ivermectin p. 640 (available on a named patient basis from ‘special-order’ manufacturers or specialist importing companies) by mouth has been used, in combination with topical drugs, for the treatment of hyperkeratotic (crusted or ‘Norwegian’) scabies that does not respond to topical treatment alone; further doses may be required. Application Although acaricides have traditionally been applied after a hot bath, this is not necessary and there is even evidence that a hot bath may increase absorption into the blood, removing them from their site of action on the skin. All members of the affected household should be treated simultaneously. Treatment should be applied to the whole body including the scalp, neck, face, and ears. Particular attention should be paid to the webs of the fingers and toes and lotion brushed under the ends of nails. It is now recommended that malathion and permethrin should be applied twice, one week apart; in the case of benzyl benzoate in adults, up to 3 applications on consecutive days may be needed. It is important to warn users to reapply treatment to the hands if they are washed. Patients with hyperkeratotic scabies may require 2 or 3 applications of acaricide on consecutive days to ensure that enough penetrates the skin crusts to kill all the mites. Itching The itch and eczema of scabies persists for some weeks after the infestation has been eliminated and treatment for pruritus and eczema may be required. Application of crotamiton p. 1333 can be used to control itching after treatment with more effective acaricides. A topical corticosteroid may help to reduce itch and inflammation after scabies has been treated successfully; however, persistent symptoms suggest that scabies eradication was not successful. Oral administration of a sedating antihistamine at night may also be useful. Head lice Dimeticone p. 1302 is effective against head lice (Pediculus humanus capitis). It coats head lice and interferes with water balance in lice by preventing the excretion of water; it is less active against eggs and treatment should be repeated after 7 days. Malathion, an organophosphorus insecticide, is an alternative, but resistance has been reported. Benzyl benzoate is licensed for the treatment of head lice but it is less effective than other drugs and not recommended for use in children. Permethrin is active against head lice but the formulation and licensed methods of application of the current products make them unsuitable for the treatment of head lice. Head lice infestation (pediculosis) should be treated using lotion or liquid formulations only if live lice are present. Shampoos are diluted too much in use to be effective. A contact time of 8–12 hours or overnight treatment is Skin recommended for lotions and liquids; a 2-hour treatment is not sufficient to kill eggs. In general, a course of treatment for head lice should be 2 applications of product 7 days apart to kill lice emerging from any eggs that survive the first application. All affected household members should be treated simultaneously. MHRA/CHM advice: Head lice eradication products: risk of serious burns if treated hair is exposed to open flames or other sources of ignition (March 2018) Some products for the eradication of head lice infestations are combustible/flammable when on the hair and can ignite and cause serious harm in the presence of an open flame or other source of ignition such as when lighting cigarettes. Patients and carers should be advised on the safe and correct use of head lice eradication treatments and if appropriate, should be advised that they should not smoke around treated hair and that it should be kept away from open flames or other sources of ignition, including in the morning after overnight application until hair is washed. Wet combing methods Head lice can be mechanically removed by combing wet hair meticulously with a plastic detection comb (probably for at least 30 minutes each time) over the whole scalp at 4-day intervals for a minimum of 2 weeks, and continued until no lice are found on 3 consecutive sessions; hair conditioner or vegetable oil can be used to facilitate the process. Several devices for the removal of head lice such as combs and topical solutions, are available and some are prescribable on the NHS. The Drug Tariffs can be accessed online at: . National Health Service Drug Tariff for England and Wales: www.ppa.org.uk/ppa/edt_intro.htm . Health and Personal Social Services for Northern Ireland Drug Tariff: www.hscbusiness.hscni.net/services/2034.htm . Scottish Drug Tariff: www.isdscotland.org/Health-topics/ Prescribing-and-Medicines/Scottish-Drug-Tariff/ Crab lice Permethrin and malathion are used to eliminate crab lice (Pthirus pubis). An aqueous preparation should be applied, allowed to dry naturally and washed off after 12 hours; a second treatment is needed after 7 days to kill lice emerging from surviving eggs. All surfaces of the body should be treated, including the scalp, neck, and face (paying particular attention to the eyebrows and other facial hair). A different insecticide should be used if a course of treatment fails. 2.1 Bacterial skin infections ANTIBACTERIALS › AMINOGLYCOSIDES
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Apply twice daily, to be applied thinly
First-line fragment. Read the complete Indications and Dose section above.
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Apply twice daily
First-line fragment. Read the complete Indications and Dose section above.
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Apply twice daily
First-line fragment. Read the complete Indications and Dose section above.
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Apply twice daily, apply a thick layer for
First-line fragment. Read the complete Indications and Dose section above.
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Apply once daily
First-line fragment. Read the complete Indications and Dose section above.
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Apply twice daily
First-line fragment. Read the complete Indications and Dose section above.
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Apply twice daily, to be applied thinly and
First-line fragment. Read the complete Indications and Dose section above.
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Apply twice daily, to be applied sparingly and
First-line fragment. Read the complete Indications and Dose section above.
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Apply 1–2 times a day
First-line fragment. Read the complete Indications and Dose section above.
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Apply twice daily, to be applied thinly
First-line fragment. Read the complete Indications and Dose section above.
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Apply 2–3 times a day
First-line fragment. Read the complete Indications and Dose section above.
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