Formulary


	NHS Bath and North East Somerset, Swindon and Wiltshire CCG Royal United Hospitals Bath NHS Foundation Trust Great Western Hospitals NHS Foundation Trust Salisbury NHS Foundation Trust

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Formulary Chapter 13: Skin - Full Chapter

Notes:

Only high cost medicines to be supplied within our health economy are listed on BSW Formulary, but patients may also have access to more specialised, high cost medicines via other specialist centres, if eligible.

Dermatology-related Prescribing Guidance

Please see our Prescribing Guidelines page for all prescribing guidance relating to this chapter.

Dermatology-related Shared Care Agreements

Please see our Shared Care Agreements page for all shared care agreements (SCAs) relating to this chapter.

Self-care

Many of the products in this chapter are available for purchase over-the-counter, and patients are encouraged to self-care, with the support of their community pharmacist, in the first instance.

For further information on self-care & the NHS, please refer to https://www.england.nhs.uk/medicines/conditions-for-which-over-the-counter-items-should-not-routinely-be-prescribed/

Dermatology Specials Approved List: see section 13.14

Please note that any specials listed in the BAD list are deemed to be RED on this formulary, so that specialists can prescribe them only.

Details...

13.06

Acne and rosacea

Please refer to BSW Acne Prescribing Guidance for recommended treatment pathway in primary care

Metronidazole 0.75% (Cream)

First Choice

Cream 0.75% 30g, 40g
Treatment of pustules and erythema of rosacea
Notes: Topical metronidazole preparations are licensed for different indications: rosacea (Rozex^®) and malodorous tumours and skin ulcers (Anabact^®). Therefore, it is important to prescribe the appropriate branded product.

Ivermectin
(Cream)

Second Choice

Cream 1% 30g
Treatment of moderate to severe inflammatory lesions of rosacea
Second line to metronidazole

Azelaic Acid
(Topical gel)

Formulary

Non-antibiotic treatment option for rosacea (adults only) and mild to moderate papular-pustular acne of the facial area (age 12 upwards).
Gel 15% 30g
Apply twice daily discontinue if no improvement after 1 month (acne) or 2 months (rosacea)

BSW Acne Prescribing Guidelines

13.06.01

Topical preparations for acne

13.06.01

Benzoyl peroxide and azelaic acid

Benzoyl Peroxide
(Topical)

Formulary

Aqueous gel 5%

BSW Acne Prescribing Guidelines

NHS patient information benozyl peroxide

Benzoyl Peroxide 5% with Clindamycin 1%
(Topical gel)

Formulary

Gel benzoyl peroxide 5%, clindamycin 1% 25g, 50g
Apply once daily in the evening.

BSW Acne Prescribing Guideline

13.06.01

Topical antibacterials for acne

Clindamycin 1%
(Aqueous solution)

Formulary

10% aqueous Solution
Topical antibiotics should not be used in isolation; use in combination with retinoids or benzoyl peroxide topically if possible.
Resistance is more likely with topical antibiotics and topical clindamycin can cause resistance to oral erythromycin. Only use topical clindamycin if retinoids/BPO aren't tolerated and the patient does not want to take an oral antibiotic (or has contra-indications).

BSW Acne Prescribing Guidelines

Clindamycin/ tretinoin (Gel)

Formulary

Gel Tretinoin 0.025% and Clindamycin 1% 30g

BSW Acne Prescribing Guidelines

Erythromycin 40mg with Zinc Acetate 12mg/mL
(Topical lotion)

Formulary

Topical lotion, powder for reconstitution, erythromycin 40mg/ml, Zinc acetate 12mg/ml 30ml, 90ml
Apply twice daily
Note that this product is not in local acne guidance due to high resistance levels. It was on the 3Ts and SFT formularies for children under 12 with acne only.

13.06.01

Topical retinoids and related preparations for acne

Adapalene
(Topical)

First Choice

Cream 0.1% 45g
Gel 0.1% 45g
For the prevention of relapse.

BSW Acne Prescribing Guidelines

Adapalene + Benzoyl peroxide
(Topical gel)

Formulary

Gel Adapalene 0.1% and Benzoyl Peroxide 2.5% 45g
Gel Adapalene 0.3% and Benzoyl Peroxide 2.5% 45g

BSW Acne Prescribing Guidelines

13.06.01

Other topical preparations for acne

13.06.02

Oral preparations for acne

Always combine systemic antibiotic with a topical anti-acne agent such as a retinoid or Benzoyl peroxide to reduce resistance and improve outcome
The need for continued antibiotic treatment should be reviewed at 3 months due to risk of resistance.
Erythromycin is best reserved for patients in whom other antibiotics are unsuitable as resistance is common
Tetracyclines can cause photosensitivity.

13.06.02

Oral antibiotics for acne

Doxycycline
(Capsule)

Formulary

Capsules 100mg
100mg once a day for 3 months then review

BSW Acne Prescribing Guidelines

Lymecycline
(Capsule)

Formulary

Capsules 408mg
408mg once a day for 3 months then review
Better compliance due to once daily dose.

BSW Acne Prescribing Guidelines

Oxytetracycline
(Tablet)

Formulary

Tablets 250mg
500mg twice a day for 3 months then review (two tablets twice daily)

BSW Acne Prescribing Guidelines

Trimethoprim
(Tablet)

Formulary

Dermatologist recommendation only
300mg Twice daily(off label)

Erythromycin
(Tablet)

Formulary

Tablets 250mg
First line children less than 12 years of age and in pregnant or breastfeeding women
500mg twice a day for 3 months then review (two tablets twice daily)

BSW Acne Prescribing Guidelines

MHRA DSU Dec 2020 Erythromycin: caution required due to cardiac risks (QT interval prolongation); drug interaction with rivaroxaban

13.06.02

Hormone treatment for acne

Co-Cyprindiol 2000/35
(Cyproterone Acetate 2mg with Ethinylestradiol 35micrograms)
(Tablet)

Formulary

Tablets cyproterone 2000mcg ethinyl estradiol 35mcg per tablet (prescribe generically, previous brand name Dianette)

June 2020 - Cyproterone acetate: new advice to minimise risk of meningioma

MHRA DSU APril 2008: Cyproterone acetate with ethinylestradiol (co-cyprindiol): recommended duration of use

MHRA DSU Dec 2014: Cyproterone acetate with ethinylestradiol (co-cyprindiol): balance of benefits and risks remains positive

13.06.02

Oral retinoid for acne

Note: Isotretinoin is a toxic drug that should only be prescribed by, or under the supervision of a consultant dermatologist.

This medicinal product is TERATOGENIC

Isotretinoin is contraindicated in women of childbearing potential unless all of the following conditions of the Pregnancy Prevention Programme are met. Further information and risk materials can be found on the Electronic Medicines Compendium website: https://www.medicines.org.uk/emc/search?q=isotretin

It is usually given for 16 weeks; repeat courses are not normally required. Side effects of isotretinoin include severe dryness of the skin and mucous membranes, nosebleeds and joint pains.

June 2019 DSU: Oral retinoid medicines▼: revised and simplified pregnancy prevention educational materials for healthcare professionals and women

Isotretinoin
(Capsule)

Formulary

Capsules 5mg, 10mg, 20mg
Women of child bearing age must be enrolled in the pregnancy prevention program.
Note: As a RED TLS drug, isotretinoin should be supplied by secondary care. A local exception to this is for Wiltshire patients under the care of the consultant-led integrated community dermatology service at Spa GP practice, Melksham - Cotswold Surgical Partners (CSP) and the BEMS community dermatology clinic. Wiltshire community pharmacies can dispense FP10s for isotretinoin from CSP where it is clear that the prescription has been issued within the context of a Pregnancy Prevention Programme. Do not dispense 7 days beyond issue date of FP10. Further information on P6 of this newsletter.

Pharmacist Checklist – Guidance for dispensing Roaccutane® (isotretinoin)

June 2019 DSU: Oral retinoid medicines¥: revised and simplified pregnancy prevention educational materials for healthcare professionals and women

MHRA DSU Dec 2014: Isotretinoin: risk of serious skin reactions

13.06.03

Ocular rosacea

....

Non Formulary Items

Abrasive Agents
(Brasivol^®)

Non Formulary

Antibacterials
(Stiemycin^®)

Non Formulary

Antibacterials
(Zindaclin^®)

Non Formulary

Brimonidine gel
(Mirvaso^®)
(rosacea)

Non Formulary

Corticosteroids
(Actinac^®)

Non Formulary

Isotretinoin
(Isotrex^® gel)

Non Formulary

Isotretinoin with antibacterial
(Isotrexin^®)

Non Formulary

Salicylic Acid
(Acnisal^®)

Non Formulary

Tretinoin (Retin-A^®)

Non Formulary

Tretinoin with antibacterial
(Aknemycin^® Plus)

Non Formulary

Key

	Notes
	Section Title (top level)
	Section Title (sub level)
	First Choice item
	Non Formulary section
	Restricted Drug
	Unlicensed
	Display tracking information
	Link to adult BNF
	Link to SPCs
	Scottish Medicines Consortium

	Cytotoxic Drug
	Controlled Drug
	High Cost Medicine
	Cancer Drugs Fund
	NHS England
	Homecare
	CCG
	High Cost Drug Approval System

Traffic Light Status Information

Status	Description
	RED - Hospital only – to be prescribed by a specialist and supplied from secondary care ONLY throughout treatment.
	Amber medicines are considered suitable for GP prescribing following specialist initiation or recommendation.
	Shared Care - these medicines require specialist initiation and stabilisation. Ongoing division of responsibility for drug and disease monitoring between specialist and GP by a Shared Care Guideline (SCG). If no SCG in place status reverts to red.
	These medicines are appropriate for initiation in both primary and secondary care. Prescribing is appropriate within licensed or local recommendations.
	Suitable for patient to be directed to buy themselves
	Not currently used. We intend to include this TLS in future to highlight where a decision to use this medicine is under review.
	(In use from Oct 2020) Used where a decision has been made by the BSW APC not to routinely commission this preparation for its licensed indications. Do not prescribe.
	Not currently used. We intend to include this TLS in future to highlight where this medicine and indication is ONLY available through a Specialist Centre according to a NICE Highly Specialised Technology or NHSE Specialised Commission Circular / Policy.