Self-Care: Those people with dry skin without a diagnosed dermatological condition requesting a general dry skin moisturiser should purchase these over the counter.

NHS England (NHSE) has published new prescribing guidance for various common conditions for which over the counter (OTC) items should not be routinely prescribed in primary care (quick reference guide). These conditions include mild irritant dermatitis and mild dry skin.

Many of these products are cheap to buy and are readily available OTC along with advice from pharmacies. Some self-care medicines are available from shops and supermarkets. Please click here for further information, exceptions, and a patient leaflet.

Emollients are essential in the management of diagnosed dermatological conditions, such as eczema or psoriasis, and their regular use can alleviate symptoms and reduce flare ups; prescribing of emollients should be reserved for these patients.

Emollients should be used as a soap substitute, as normal soap tends to dry the skin. It is important to use a product which suits the patient and is effective for them. Evidence from randomised controlled trials to support the use of one emollient over another is lacking, therefore selection is based on the known physiological properties of emollients, patient acceptability, dryness of the skin, area of skin involved and lowest acquisition cost.

Careful explanation of how to use emollients, as well as how much to use, may encourage compliance. Emollients should be smoothed on in the direction of hair growth. They should not be rubbed in. They should be continued to be used even after the skin condition has cleared, if the clinical condition justifies continued use.

Sufficient quantities should be prescribed to allow liberal application as frequently as required, once patient preference is established:

• Adults would normally require at least 250g of emollients per week
• Children would normally require at least 125g of emollients per week

MHRA Drug Safety Update (April 2016): Fire risk with paraffin-based skin emollients on dressings or clothing:

• Patients are advised not to: smoke; use naked flames (or be near people who are smoking or using naked flames); or go near anything that may cause a fire while emollients are in contact with their medical dressings or clothing
• Patients should change clothing and bedding regularly—preferably daily—because emollients soak into fabric and can become a fire hazard
• The risk is greater when these preparations are applied to large areas of the body, or when dressings or clothing become soaked with emollient

MHRA Drug Safety Update (December 2018): Emollients: new information about risk of severe and fatal burns with paraffin-containing and paraffin-free emollients:

• There is a fire risk with all paraffin-containing emollients, regardless of paraffin concentration, and it also cannot be excluded with paraffin-free emollients. A similar risk may apply for other products which are applied to the skin over large body areas, or in large volumes for repeated use for more than a few days
• Be aware that washing clothing or fabric at a high temperature may reduce emollient build-up but not totally remove it

MHRA Drug Safety Update (August 2020): Emollients and risk of severe and fatal burns: new resources available. The MHRA has launched a campaign to raise awareness of this important risk. A toolkit of resources is now available for health and social care professionals to support the safe use of emollients (see Drug Safety Update for weblinks)

MHRA Drug Safety Update (July 2024): Epimax Ointment and Epimax Paraffin-Free Ointment: reports of ocular surface toxicity and ocular chemical injury
(included for information, these particular Epimax products are non-formulary)

• Do not prescribe or advise use of Epimax Ointment or Epimax Paraffin-Free Ointment on the face.
• Be aware that if Epimax Ointment or Epimax Paraffin-Free Ointment comes into contact with the eyes, patients may present with pain, swelling, redness or watering of eyes, sensitivity to light, blurred vision, burning or grittiness.
• Symptoms should resolve with discontinuation of the product around the eyes and can be treated with topical lubricants, topical antibiotics or topical steroids as required.
• Follow the advice in the manufacturer’s Field Safety Notice:
  • The ingredients and consistency of Epimax Ointment and Epimax Paraffin-Free Ointment are likely to lead to them taking longer to remove/ wash out, if inadvertently introduced into the eye, compared to the rest of the products in the Epimax range.
  • The product labelling has been amended to restrict use to the body and not to use on the face, to wash hands after use and to avoid contact with the eyes.
• Advice for healthcare professionals to provide to patients:
  • Do not use Epimax Ointment or Epimax Paraffin-Free Ointment on your face as it has been reported to cause serious symptoms if it comes into contact with your eyes. It is only for use on the body.
  • Wash your hands thoroughly after applying Epimax Ointment or Epimax Paraffin-Free Ointment and avoid touching your eyes after using these products.
  • If the product accidentally gets into your eyes, rinse well with water and seek medical advice.

Pot Hygiene: Where possible, prescribe an emollient with a pump dispenser to minimize the risk of bacterial contamination. 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 using a spoon. Hands should not be put into the pot as this will lead to the introduction of foreign particles.

All primary and secondary care prescribers should where possible select the emollient with the lowest acquisition cost from the range available in the agreed preferred product list.

For most types of emollient, several products have been included to allow for patients to try a number of options, before clinicians consider non-formulary options.

Ointments

Ointments are good for very dry, thickened skin and night-time use as they are greasy, thick and very moisturising; however, they are not always acceptable to patients due to their greasiness. They should be applied every 6–8 hours.

Zeroderm

• Ointment (£4.29 = 500g tub) [OTC]
• Paraffin content: 70% (White soft paraffin 30%, Liquid Paraffin 40%)
• Potential sensitisers: Cetostearyl alcohol
• Similar in formulation to Epaderm ointment (non-formulary)

Hydromol

• Ointment (£5.50 = 500g tub) [OTC]
• Paraffin content: 70% (Yellow soft paraffin 30%, Liquid paraffin 40%)
• Potential sensitisers: Cetostearyl alcohol

Cetraben

• Ointment (£5.67 = 450g tub) [OTC]
• Paraffin content: 80% (White soft paraffin 35%, Liquid paraffin 45%)
• Potential sensitisers: Cetostearyl alcohol

White soft paraffin BP

• Ointment (also known as 'White Petroleum Jelly') (£4.16 = 500g tub) [OTC]
• Paraffin content: 100% (White soft paraffin 100%)
• Potential sensitisers: No known sensitisers
• Not suitable as a soap substitute

Liquid and White Soft Paraffin

• Ointment 50/50 (£4.57 = 500g tub) [OTC]
• Paraffin content: 100% (White soft paraffin 50%, Liquid paraffin 50%)
• Potential sensitisers: No known sensitisers
• Not suitable as a soap substitute
  

Gels

Gels are relatively light and non-greasy, despite having reasonably high oil content. They should be applied every 3–4 hours.

Epimax Isomol

• Gel (£3.14 = 500g flexi-dispenser), (£2.06 = 100g tube) [OTC]
• Paraffin content = 15% (Liquid paraffin 15%)
• Potential sensitisers: Isopropyl myristate, Phenoxyethanol, Triethanolamine

Zerodouble

• Gel (£5.14 = 500g pump dispenser) (£2.34 = 100g tube) [OTC]
• Paraffin content = 15% (Liquid paraffin 15%)
• Potential sensitisers: Isopropyl myristate, Phenoxyethanol, Triethanolamine
• Similar in formulation to Doublebase gel

Doublebase

• Gel (£5.83 = 500g pump dispenser), (£2.65 = 100g tube) [OTC]
• Paraffin content = 15% (Liquid paraffin 15%)
• Potential sensitisers: Isopropyl myristate, Phenoxyethanol, Triethanolamine

Doublebase Dayleve

• Gel (£6.29 = 500g pump dispenser), (£2.65 = 100g tube) [OTC]
• Paraffin content = 15% (Liquid paraffin 15%)
• Potential sensitisers: Isopropyl myristate, Phenoxyethanol, Triethanolamine
• Contains povidone to prolong emollient action compared to Doublebase gel, less frequent application may be possible

Doublebase Once Gel

• Doublebase Once Gel is not included in the Devon Formulary, following consideration by the Formulary Interface Group in September 2023. This is due to higher acquisition costs and a lack of evidence of clinical benefit compared to alternatives.

Creams

Creams are not greasy and are quite easy to spread over sore and weeping skin; so many patients prefer them to ointments for daytime use. They should be applied every 3–4 hours.

Epimax Original

• Cream (£2.72 = 500g flexi-dispenser), (£0.81 = 100g tube) [OTC]
• Paraffin content: 21% (White soft paraffin 15%, Liquid paraffin 6%)
• Potential sensitisers: Cetostearyl alcohol, Phenoxyethanol

ZeroCream

• Cream (£4.30 = 500g pump dispenser) [OTC]
• Paraffin content: 27.1% (White soft paraffin 14.5%, Liquid paraffin 12.6%)
• Potential sensitisers: Cetostearyl alcohol, Lanolin, Parabens, Phenoxyethanol
• Similar in formulation to E45 cream (non-formulary)

Zerobase

• Cream (£5.58 = 500g pump dispenser) [OTC]
• Paraffin content: 21% (White soft paraffin 10%, Liquid paraffin 11%)
• Potential sensitisers: Cetostearyl alcohol
• Similar in formulation to Diprobase cream (non-formulary)

Cetraben

• Cream (£6.29 = 500g pump dispenser) [OTC]
• Paraffin content: 23.7% (White soft paraffin 13.2% / Light liquid paraffin 10.5%)
• Potential sensitisers: Cetostearyl alcohol, Parabens, Phenoxyethanol

Creams - colloidal oatmeal-containing

Some patients may prefer an emollient cream containing colloidal oatmeal.

Epimax Oatmeal Cream

• Cream (£3.16 = 500g pump dispenser), (£2.10 = 100g tube) [OTC]
• Paraffin content = 4.25% (White soft paraffin 0.75% / Liquid paraffin 3.5%)
• Potential sensitisers: Benzyl alcohol, Cetylstearyl alcohol, Isopropyl palmitate, Phenoxyethanol

AproDerm Colloidal Oat Cream

• Cream (£5.80 = 500ml pump dispenser), (£2.74 = 100ml tube) [OTC]
• Paraffin-free
• Potential sensitisers: Ceteryl alcohol, Phenoxyethanol

Creams - urea-containing

Urea, which acts as a humectant, draws water into the skin. These products are not indicated for routine use as they are more expensive but may be useful for very dry conditions such as ichthyoses and for keratosis pilaris (used sparingly). 5% and 10% urea-containing creams should be applied every 6-8 hours.

Patients can be advised that smaller volumes of urea-based emollients can be purchased OTC, please see guidance above.

5% Urea content

ImuDERM

• Emollient (£6.85 = 500g pump dispenser) (contains urea 5% & glycerine 5%) [OTC]
• Paraffin content: Less than 20% (Liquid paraffin less than 20%)
• Potential sensitisers: Benzyl alcohol, Cetostearyl alcohol, Cetrimonium bromide, Phenoxyethanol

10% Urea content

Hydromol Intensive 10%

• Cream (£4.66 = 100g tube) (contains urea 10%) [OTC]
• Paraffin content: 28.15% (White soft paraffin 28.15%)
• Potential sensitisers: Isopropyl myristate
• For larger volumes of 10% urea containing creams (i.e 500g) prescribe Flexitol 10% Urea, as this represents better value for money

Flexitol 10% Urea

• Cream (£12.36 = 500g pump dispenser) (contains urea 10%) [OTC]
• Paraffin content: 1%-10% (Light liquid paraffin 1%-10%)
• Potential sensitisers: Benzyl alcohol, Butylated hydroxytoluene, Cetosteraryl alcohol, Lanolin/derivatives, Phenoxyethanol
• For smaller volumes of 10% urea containing creams (i.e 100g) prescribe Hydromol Intensive 10%, as this represents better value for money

25% Urea content

Skin and footcare specialists recommend high percentage urea (25%) as the initial starting treatment for callused, anhidrotic, fissured, and hard foot skin.

Patients should decrease to the low percentage urea (10%) for maintenance treatment when there has been improvement in the skin condition; then further stepping down to standard emollient preparations when hydration has returned.

If there is no improvement in skin condition after 6 weeks continual use of urea preparations, please seek further advice from skin and footcare specialists.

Local specialists have indicated that 25% urea preparations are considered suitable options for patients with diabetes who suffer from neuropathy where the skin is very dry with callus; in these patients continuous use would be recommended.

For all patients with hydrated heels with little or no drying skin with no callus, a standard emollient should be used.

Dermatonics Once Heel Balm

• Heel balm (£3.83 = 75ml tube), (£9.52 = 200ml tube) (contains urea 25%)
• Paraffin content: 11% (White soft paraffin 11%)
• Potential sensitisers: Beeswax, Lanolin/derivatives, Phenoxyethanol, Triethanolamine

Indications and dose

• For the treatment of callused, anhidrotic, fissured, and hard foot skin conditions
  • Apply once daily

Notes

1. Only to be used after initial assessment by a skin or footcare specialist
2. Not recommended for use in children under 12 years of age
3. For larger volumes of 25% urea containing creams (i.e 500g) prescribe Flexitol 25% Urea, as this represents better value for money

Flexitol 25% Urea Heel Balm

• Heel balm (£15.55 = 500g tub) (contains 25% urea)
• Paraffin content: 6.9% (Light liquid paraffin 4%, Hard paraffin 2.9%)
• Potential sensitisers: Benzyl alcohol, Cetosteraryl alcohol, Lanolin/derivatives, Phenoxyethanol

Indications and dose

• For the treatment of callused, anhidrotic, fissured, and hard foot skin conditions
  • Apply once or twice daily

Notes

1. Only to be used after initial assessment by a skin or footcare specialist
2. Not recommended for use in children under 12 years of age
3. For smaller volumes of 25% urea containing creams (i.e 75ml, 200ml) prescribe Dermatonics Once 25% Urea, as this represents better value for money

Lotions and Sprays

Lotions are quick to apply but take a little longer to dry. Useful for hair-bearing areas prone to folliculitis. They should be applied every 6-8 hours.

E45

• Lotion (£6.13 = 500ml pump dispenser) [OTC]
• Paraffin content: 14% (White soft paraffin 10%, Liquid paraffin 4%)
• Potential sensitisers: Benzyl alcohol, Lanolin, Parabens

Sprays are an option for some patients where the emollient can be applied without touching the skin; this may be an advantage where the patient cannot reach the affected area or where touching the skin may be detrimental.

Emollin

• Aerosol spray (£7.73 = 240ml) [OTC]
• Paraffin content: 100% (White soft paraffin 50%, Liquid Paraffin 50%)
• Potential sensitisers: No known sensitisers

Bath and shower preparations

Following national guidance from NHS England, bath and shower preparations for dry and pruritic skin conditions are not recommended for use due to a lack of robust evidence of clinical effectiveness. Click here for more information. Prescribers should not initiate bath and shower preparations for dry and pruritic skin conditions for any new patient.

A multicentre pragmatic parallel group RCT looking at emollient bath additives for the treatment of childhood eczema (BATHE, 2018) showed that there was no evidence of clinical benefit for including emollient bath additives in the standard management of childhood eczema. NHS England has stated that in the absence of other good quality evidence "it is acceptable to extrapolate this to apply to adults until good quality evidence emerges".

Emollients can still be used for treating eczema and these emollients can still be used as soap substitutes. Any emollient listed in the formulary (except White Soft Paraffin 100%, and Liquid Paraffin 50% & White Soft Paraffin 50%) can be applied before bathing, showering or washing, or while in the water.

Patients should be aware of the potential dangers of slipping when using emollients in a bath or shower, or on a tiled floor. Parents may also wish to be cautious when removing children from the bath.

Products for specific clinical conditions

Antimicrobials

Use only when skin is infected or if infection is a frequent complication; i.e. folliculitis or secondary infection of eczema. Antimicrobial emollients are not for prolonged use.

Creams are not greasy and are quite easy to spread over sore and weeping skin.

Dermol

• Cream (£7.19 = 500g pump dispenser), (£3.08 = 100g tube) [OTC]
• Paraffin content: 10% (Liquid paraffin 10%)
• Potential sensitisers: Benzalkonium chloride, Cetostearyl alcohol, Chlorhexidine, Isopropyl myristate, Phenoxyethanol

Lotions are quick to apply but take a little longer to dry. They may be useful for hair-bearing areas.

Dermol 500

• Lotion (£6.52 = 500ml pump dispenser) [OTC]
• Paraffin content: 2.5% (Liquid paraffin 2.5%)
• Potential sensitisers: Benzalkonium chloride, Cetostearyl alcohol, Chlorhexidine, Isopropyl myristate, Phenoxyethanol