Greater Glasgow and Clyde Medicines

Formulary Update - Emollients

The emollients section of the NHSGGC Adult Medicines Formulary has been updated in line with recommendations from a SLWG of dermatologists, GPs, specialist nurses and pharmacists.

Key messages

• Emollients are typically under-prescribed and under-used. This results in suboptimal treatment of dermatological conditions, and may increase the occurrence of flares.

• Patients should be advised to use emollients liberally and frequently, even when their skin appears to return to normal. For guidance on appropriate quantities to supply on prescription see below.

• Evidence from randomised controlled trials to support the use of one emollient over another is lacking. The best emollient is the one the patient will use. Patients will often prefer a cream or a gel for use during the day and an ointment at night.

• Many standard emollients can be used as soap substitutes. The range of bath and shower emollients on formulary has been reduced to encourage use of daily emollients in this way as opposed to prescribing additional bath and shower products.

• Dermol 500 lotion should only be prescribed when skin is infected or if infection is a frequent complication; i.e. folliculitis or secondary infection of eczema. It should not be prescribed for prolonged use unless clinically indicated or advised by Dermatology. It should therefore not be added to repeat prescriptions.

• Some patients under the care of Dermatology may require emollients which are non-formulary; primary care teams will receive timely communication with details of the request to facilitate prescribing in primary care.

• All paraffin based emollients are associated with a risk of flammability. See Medicines Update blog.

Background

Emollients (moisturisers) are essential in the management of dermatological conditions. Emollients work by trapping moisture in the skin by forming a protective oily layer on the outer surface. This can help skin to repair and improve skin hydration.

Creams are water based emollients/emulsions of oil and water and are generally well absorbed into the skin. Generally, creams are cosmetically more acceptable than ointments because they are less greasy and easier to apply.

Lotions are lighter water based emollients which may be useful for hair bearing areas or use on the face.

Ointments are oil-based greasy preparations which are normally anhydrous and insoluble in water, and are more occlusive than creams. They are particularly suitable for chronic, dry lesions. However, they can be poorly tolerated compared with cream; this may affect patient acceptability and compliance.

Gels consist of active ingredients in suitable hydrophilic or hydrophobic bases; they generally have a high water content. Gels are particularly suitable for application to the face and scalp.

Bath and shower products: Patients with chronic skin conditions should be offered an emollient (soap substitute) to wash with. Standard emollients can be used in this way e.g by applying it to the skin before showering then rinsing off. Alternatively 1-2 tablespoons of any ointment (except 50:50) can be dissolved in some hot water and added to bath water, as a bath additive. Bath products will coat the bath and make it slippery, patients should be advised of this and take extra care.

Suitable quantities of dermatological preparations to be prescribed for specific areas of the body, these amounts are usually suitable for an adult for twice daily application for 1 week:

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Summary of formulary changes and advice

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Published 08/09/2021. Amended 06/06/23 to reflect the removal of Epimax original cream, ExCetra cream, isomol gel and ointment from the NHSGGC Adult Medicines Formulary. A full emollient formulary section review is planned for 2023. Medicines Update blogs are correct at the time of publication.