The National Dermatology Patient Pathways (available at www.dermatology.nhs.scot/dermatology-pathways/pathways and via the NHS Highland Intranet under Shared Clinical Guidelines) should be used in association with drug recommendations and guidance in this chapter to inform the management of acne, alopecia, atopic eczema, benign skin lesions, generalised and local pruritus, hand and foot eczema, molluscum contagiosum, nail dystrophy, non-melanoma skin cancers, psoriasis, rosacea, scabies, solar (actinic) keratoses and Bowen’s Disease, suspicious pigmented lesions, urticaria, and viral warts. Also refer to the British Association of Dermatologists Clinical Guidelines at http://www.bad.org.uk/healthcare-professionals/clinical-standards/clinical-guidelines.
For use of dermatologicals in children, refer to BNF for Children.
Choice of vehicle is very personal; it can mean the difference between treatment success and failure. Skin treatments are ‘worn’, like clothes. Patients will not use a topical therapy that irritates their skin, and will be reluctant to use one that does not ‘feel right’.
Ointments are recommended as the first choice of formulation for most skin diseases and are particularly useful for dry, scaly conditions. Ointments are greasy and generally insoluble in water so can be difficult to wash off; they do not suit all patients and may be less acceptable to some patients.
Creams, emulsions of oil and water, often contain an antimicrobial preservative and are therefore more likely to cause both irritant and allergic reactions. For this reason creams are often best avoided as first-line treatment, but can be better than ointments for some acute conditions due to a cooling effect as they evaporate. Creams may be more cosmetically acceptable for some patients in some body sites and are often the agents of choice for moist, flexural areas such as axillae.
Lotions also have a cooling effect, and may be preferable to treat hairy sites. They can be made up in either water or alcohol. Alcoholic lotions will sting if applied to broken or acutely inflamed skin.
Gels have a high water content, and are especially suitable for the face and scalp; however, gels may irritate in some circumstances.
Refer to guidance on Adverse reactions to topical therapy.