Emollient prescribing guidelines 2023

Bath emollients support document 2023

Moisture Associated Skin Damage (MASD) Pathway

Emollient pathway

Fire risk with paraffin-containing products

Greasy preparations (ointments) are often preferable to creams in most circumstances because:

However, patient preference or activity may necessitate a combination of ointments and creams, for example, patients may prefer to apply creams during the day and use ointments at night, or different preparations on different parts of the body.

Application technique: It is important to educate patients with the correct application technique. Ointments and creams should be applied down the direction of hair growth. They should also be smeared on and not rubbed in.

Pot Hygiene: When supplying patients with pots of emollient, it is important to educate them about the hygiene required. Patients should be advised to decant from the pot onto plate/bowl etc. using a spoon or a spatula. Hands should not be put into the pot as this will lead to the introduction of foreign particles.

In many cases generic prescribing will be difficult because products contain a combination of active ingredients. In this chapter brand names are used for products which should not be prescribed generically.

Extemporaneous preparations: A product should only be extemporaneously prepared when there is no product with a marketing authorisation available. Depending on the formulation this may be done in a pharmacy, or by a specials manufacturer, usually depending on the formulation. Where a specials manufacturer prepares the product, additional charges will be incurred. The cost can, and usually does, exceed £100 for a cream. The cost is usually the same whether 500 g or 50 g of a product is ordered. Specials all have a very short shelf life with an expiry date of a maximum of 28 days from manufacture.

A range (but not all) of specials preferred by the British Association of Dermatologists has been approved for use within Cornwall mainly for prescribing by secondary care.

2. The least expensive emollient that is effective should be prescribed, which is cosmetically acceptable and that the patient is prepared to use regularly.

3. Generally, ‘greasy’ preparations provide the best emollient effect. However, for cosmetic reasons, patients may prefer a less oily preparation for daytime use, or for use on exposed areas such as the face.

4. Careful explanation of how to use emollients, as well as how much to use, may encourage compliance. Sufficient quantities should be prescribed once the agent of choice is established.

5. For adults, if a large part of the body has dry skin, 500 g per week of emollient should be prescribed.

6. Patients with atopic eczema often find emollients cause stinging or irritation of the skin. Therefore an alternative preparation must be considered taking into account excipients.

7. Patients may require a smaller sized tube for use at school or home.

8. If necessary, topical steroids should be applied 10 - 15 minutes after emollients.

9. Aqueous cream should only be used as a soap substitute rather than a “leave on” emollient.

NPSA Alert (November 2007) Managing the Fire Hazard with Paraffin Based Skin Products on Dressings and Clothing

Emulsifying ointment or 50% Liquid Paraffin and 50% White Soft Paraffin Ointment in contact with dressings and clothing is easily ignited by a naked flame. The risk is greater when these preparations are applied to large areas of the body, and clothing or dressings become soaked with the ointment. Patients should be told to keep away from fire or flames, and not to smoke when using these preparations. The fire risk should be considered when using large quantities of any paraffin based emollients.

 The following commonly prescribed products contain White Soft Paraffin at concentrations of over 50% (note this list is not exhaustive):

• Diprobase Ointment   -   95%
• Liquid Paraffin 50% / White Soft Paraffin 50%   -   50%
• Zinc and Salicylic Acid Paste BP   -   50%
• Emulsifying Ointment   -   50%
• White Soft Paraffin   -   100%
• Zinc Ointment BP   -   72.25%

Paraffin products can also be found as constituents in some commonly prescribed ‘specials’ creams and ointments, for example emulsifying ointment is often used as a diluent to lower the strength of a ready prepared ointment. The evidence currently only relates to White Soft Paraffin and there is currently no evidence of a risk of fire hazard with preparations containing concentrations of WSP lower than 50%, however the NPSA has taken the view that this risk could apply to any paraffin ‘based’ product. In this respect the guidance should also apply to the following products (noting that this list is not exhaustive).