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Herpes simplex infection (local treatment)
▶ Child: Apply 5 times a day for 5–10 days, to be applied
to lesions approximately every 4 hours, starting at first
▶ Adult: Apply 5 times a day for 5–10 days, to be applied
to lesions approximately every 4 hours, starting at first
▶ In children Cream licensed for use in children (age range
not specified by manufacturer).
l CAUTIONS Avoid cream coming in to contact with eyes and
l INTERACTIONS → Appendix 1: aciclovir
l PREGNANCY Limited absorption from topical aciclovir
Medicines for Children leaflet: Aciclovir cream for herpes
www.medicinesforchildren.org.uk/aciclovir-cream-herpes-0
l PROFESSION SPECIFIC INFORMATION
Dental practitioners’ formulary
Aciclovir Cream may be prescribed.
l EXCEPTIONS TO LEGAL CATEGORY A 2-g tube and a pump
pack are on sale to the public for the treatment of cold
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
EXCIPIENTS: May contain Cetostearyl alcohol (including cetyl and
stearyl alcohol), propylene glycol
▶ Zovirax (GlaxoSmithKline Consumer Healthcare, GlaxoSmithKline UK
Aciclovir 50 mg per 1 gram Zovirax 5% cream | 2 gram P £4.63
DT = £1.09 | 10 gram P £13.96 DT = £5.45
Eczema (dermatitis) has several causes, which may influence
treatment. The main types of eczema are irritant, allergic
complicate any chronic eczema. Atopic eczema is the most
common type and it usually involves dry skin as well as
infection and lichenification.
Management of eczema involves the removal or treatment of
contributory factors including occupational and domestic
irritants. Known or suspected contact allergens should be
avoided. Rarely, ingredients in topical medicinal products
may sensitise the skin; the BNF lists active ingredients
together with excipients that have been associated with skin
Skin dryness and the consequent irritant eczema requires
emollients applied regularly (at least twice daily) and
liberally to the affected area; this can be supplemented with
bath or shower emollients. The use of emollients should
continue even if the eczema improves or if other treatment is
Topical corticosteroids are also required in the
management of eczema; the potency of the corticosteroid
should be appropriate to the severity and site of the
condition. Mild corticosteroids are generally used on the face
and on flexures; potent corticosteroids are generally
required for use on adults with discoid or lichenified eczema
or with eczema on the scalp, limbs, and trunk. Treatment
should be reviewed regularly, especially if a potent
corticosteroid is required. In patients with frequent flares
(2–3 per month), a topical corticosteroid can be applied on
2 consecutive days each week to prevent further flares.
Bandages (including those containing ichthammol with
zinc oxide p. 1253) are sometimes applied over topical
corticosteroids or emollients to treat eczema of the limbs.
Dry-wrap dressings can be used to provide a physical barrier
to help prevent scratching and improve retention of
emollients. See Wound management products and elasticated
garments for details of elasticated viscose stockinette tubular
bandages and garments, and silk clothing.
See Eczema and psoriasis, drugs affecting the immune
response p. 1240 for the role of topical pimecrolimus p. 1255
and tacrolimus p. 1256 in atopic eczema.
Bacterial infection (commonly with Staphylococcus aureus
and occasionally with Streptococcus pyogenes) can exacerbate
eczema and requires treatment with topical or systemic
antibacterial drugs. Antibacterial drugs should be used in
short courses (typically 1 week) to reduce the risk of drug
resistance or skin sensitisation. Associated eczema is treated
simultaneously with a topical corticosteroid which can be
combined with a topical antimicrobial.
Eczema involving widespread or recurrent infection
requires the use of a systemic antibacterial that is active
against the infecting organism. Products that combine an
antiseptic with an emollient application and with a bath
emollient can also be used; antiseptic shampoos can be used
Intertriginous eczema commonly involves candida and
bacteria; it is best treated with a mild or moderately potent
topical corticosteroid and a suitable antimicrobial drug.
Widespread herpes simplex infection may complicate
atopic eczema and treatment with a systemic antiviral drug
Management of other features of eczema
Lichenification, which results from repeated scratching is
treated initially with a potent corticosteroid. Bandages
containing ichthammol paste p. 1252 (to reduce pruritus)
and other substances such as zinc oxide can be applied over
the corticosteroid or emollient. Coal tar and ichthammol
can be useful in some cases of chronic eczema.
A non-sedating antihistamine may be of some value in
relieving severe itching or urticaria associated with eczema.
A sedating antihistamine can be used if itching causes sleep
Exudative (‘weeping’) eczema requires a potent
corticosteroid initially; infection may also be present and
require specific treatment. Potassium permanganate
solution (1 in 10,000) p. 1276 can be used in exudating
1238 Inflammatory skin conditions BNF 78
eczema for its antiseptic and astringent effects; treatment
should be stopped when exudation stops.
Severe refractory eczema is best managed under specialist
supervision; it may require phototherapy or drugs that act on
the immune system. Alitretinoin p. 1262 is licensed for the
treatment of severe chronic hand eczema refractory to
potent topical corticosteroids; patients with hyperkeratotic
features are more likely to respond to alitretinoin than those
Seborrhoeic dermatitis (seborrhoeic eczema) is associated with
species of the yeast Malassezia and affects the scalp,
paranasal areas, and eyebrows. Shampoos active against the
yeast (including those containing ketoconazole p. 1233 or
coal tar p. 1253) and combinations of mild corticosteroids
with suitable antimicrobials are used.
Psoriasis is characterised by epidermal thickening and
scaling. It commonly affects extensor surfaces and the scalp.
Occasionally, psoriasis is provoked or exacerbated by
drugs such as lithium, chloroquine and hydroxychloroquine,
beta-blockers, non-steroidal anti-inflammatory drugs, and
ACE inhibitors. Psoriasis may not be seen until the drug has
been taken for weeks or months.
Emollients, in addition to their effects on dryness, scaling
and cracking, may have an anti-proliferative effect in
psoriasis, and may be the only treatment necessary for mild
psoriasis. They are particularly useful in inflammatory
psoriasis and in plaque psoriasis of palms and soles, in which
irritant factors can perpetuate the condition. Emollients are
useful adjuncts to other more specific treatment.
More specific topical treatment for chronic stable plaque
psoriasis on extensor surfaces of trunk and limbs involves the
use of vitamin D analogues, coal tar p. 1253, dithranol
p. 1253, and the retinoid tazarotene p. 1262. However, they
can irritate the skin and they are not suitable for the more
inflammatory forms of psoriasis; their use should be
suspended during an inflammatory phase of psoriasis. The
efficacy and the irritancy of each substance varies between
patients. If a substance irritates significantly, it should be
stopped or the concentration reduced; if it is tolerated, its
effects should be assessed after 4 to 6 weeks and treatment
Scalp psoriasis is usually scaly, and the scale may be thick
and adherent; this will require softening with an emollient
cream, ointment, or oil. A tar-based shampoo is first-line
treatment for scalp psoriasis; a keratolytic, such as salicylic
acid, should also be used if there is significant scaling, to
allow other treatments to work.
Some preparations prescribed for psoriasis affecting the
scalp, combine salicylic acid with coal tar or sulfur. The
product should be applied generously, and an adequate
quantity should be prescribed. It should be left on for at least
an hour, often more conveniently overnight, before washing
off. The use of scalp preparations containing a potent
corticosteroid or a vitamin D analogue, either alone or in
combination, can also be helpful.
Facial, flexural and genital psoriasis can be managed with
short-term use of a mild or moderate potency topical
corticosteroid (a mild potency topical corticosteroid is
preferred for the initial treatment of facial psoriasis).
potency topical corticosteroids is inadequate; calcipotriol
p. 1263 is more likely to cause irritation. Low strength tar
preparations can also be used. Pimecrolimus p. 1255 or
tacrolimus p. 1256 by topical application [unlicensed
indication] can be used short-term, under specialist
supervision, in patients whose condition has not responded
adequately to other treatments, or who are intolerant of
Widespread unstable psoriasis of erythrodermic or
generalised pustular type requires urgent specialist
assessment. Initial topical treatment should be limited to
using emollients frequently and generously; emollients
should be prescribed in quantities of 1 kg or more. More
localised acute or subacute inflammatory psoriasis with hot,
spreading or itchy lesions, should be treated topically with
emollients or with a corticosteroid of moderate potency.
Calcipotriol and tacalcitol are analogues of vitamin D that
affect cell division and differentiation. Calcitriol is an active
form of vitamin D. Vitamin D and its analogues are used
first-line for the long-term treatment of plaque psoriasis;
they do not smell or stain and they may be more acceptable
than tar or dithranol products. Of the vitamin D analogues,
tacalcitol and calcitriol are less likely to irritate.
Coal tar has anti-inflammatory properties that are useful
in chronic plaque psoriasis; it also has antiscaling properties.
Crude coal tar (coal tar, BP) is the most effective form,
typically in a concentration of 1 to 10% in a soft paraffin
base, but few outpatients tolerate the smell and mess.
Cleaner extracts of coal tar included in proprietary
preparations, are more practicable for home use but they are
less effective and improvement takes longer. Contact of coal
tar products with normal skin is not normally harmful and
they can be used for widespread small lesions; however,
irritation, contact allergy, and sterile folliculitis can occur.
The milder tar extracts can be used on the face and flexures.
Tar baths and tar shampoos are also helpful.
Dithranol is effective for chronic plaque psoriasis. Its
major disadvantages are irritation (for which individual
susceptibility varies) and staining of skin and of clothing.
Dithranol is not generally suitable for widespread small
lesions nor should it be used in the flexures or on the face.
Proprietary preparations are more suitable for home use;
they are usually washed off after 5 to 60 minutes (‘short
contact’). Specialist nurses may apply intensive treatment
with dithranol paste which is covered by stockinette
dressings and usually retained overnight. Dithranol should
be discontinued if even a low concentration causes acute
inflammation; continued use can result in the psoriasis
Tazarotene, a retinoid, has a similar efficacy to vitamin D
and its analogues, but is associated with a greater incidence
of irritation. Although irritation is common, it is minimised
by applying tazarotene sparingly to the plaques and avoiding
normal skin; application to the face and in flexures should
also be avoided. Tazarotene does not stain and is odourless.
psoriasis; any early improvement is not usually maintained
and there is a risk of the condition deteriorating or of
precipitating an unstable form of psoriasis (e.g.
erythrodermic psoriasis or generalised pustular psoriasis) on
withdrawal. Topical use of potent corticosteroids on
widespread psoriasis can also lead to systemic as well as local
such as the face or flexures (with a mild or moderate
corticosteroid), and psoriasis of the scalp, palms, and soles
(with a potent corticosteroid). Very potent corticosteroids
should only be used under specialist supervision.
Combining the use of a corticosteroid with another specific
topical treatment may be beneficial in chronic plaque
psoriasis; the drugs may be used separately at different times
of the day or used together in a single formulation. Eczema
co-existing with psoriasis may be treated with a
corticosteroid, or coal tar, or both.
BNF 78 Eczema and psoriasis 1239
Phototherapy is available in specialist centres under the
supervision of a dermatologist. Ultraviolet B (UVB)
radiation is usually effective for chronic stable psoriasis and
for guttate psoriasis. It may be considered for patients with
moderately severe psoriasis in whom topical treatment has
failed, but it may irritate inflammatory psoriasis.
Photochemotherapy combining long-wave ultraviolet A
radiation with a psoralen (PUVA) is available in specialist
centres under the supervision of a dermatologist. The
psoralen, which enhances the effect of irradiation, is
administered either by mouth or topically. PUVA is effective
in most forms of psoriasis, including localised palmoplantar
pustular psoriasis. Early adverse effects include phototoxicity
and pruritus. Higher cumulative doses exaggerate skin
ageing, increase the risk of dysplastic and neoplastic skin
lesions, especially squamous cancer, and pose a theoretical
Phototherapy combined with coal tar, dithranol,
tazarotene, topical vitamin D or vitamin D analogues, or oral
acitretin, allows reduction of the cumulative dose of
phototherapy required to treat psoriasis.
Systemic treatment is required for severe, resistant,
unstable or complicated forms of psoriasis, and it should be
initiated only under specialist supervision. Systemic drugs
for psoriasis include acitretin and drugs that affect the
immune response (such as ciclosporin p. 838 and
Systemic corticosteroids should be used only rarely in
psoriasis because rebound deterioration may occur on
Acitretin p. 1261, a metabolite of etretinate, is a retinoid
(vitamin A derivative); it is prescribed by specialists. The
main indication for acitretin is psoriasis, but it is also used in
disorders of keratinisation such as severe Darier’s disease
(keratosis follicularis), and some forms of ichthyosis.
Although a minority of cases of psoriasis respond well to
acitretin alone, it is only moderately effective in many cases
and it is combined with other treatments. A therapeutic
effect occurs after 2 to 4 weeks and the maximum benefit
after 4 months. Consideration should be given to stopping
acitretin if the response is inadequate after 4 months at the
optimum dose. The manufacturers of acitretin do not
recommend continuous treatment for longer than 6 months.
However, some patients may benefit from longer treatment,
provided that the lowest effective dose is used, patients are
monitored carefully for adverse effects, and the need for
treatment is reviewed regularly.
Apart from teratogenicity, which remains a risk for 3 years
after stopping, acitretin is the least toxic systemic treatment
for psoriasis; in women with a potential for child-bearing,
the possibility of pregnancy must be excluded before
treatment and effective contraception must be used during
treatment and for at least 3 years afterwards (oral
progestogen-only contraceptives not considered effective).
The vitamin D and analogues, calcipotriol p. 1263, calcitriol
p. 1263, and tacalcitol p. 1264 are used for the management
of plaque psoriasis. They should be avoided by those with
calcium metabolism disorders, and used with caution in
generalised pustular or erythrodermic exfoliative psoriasis
(enhanced risk of hypercalcaemia).
Drugs affecting the immune response are used for eczema or
psoriasis. Systemic drugs acting on the immune system are
used under specialist supervision.
Pimecrolimus p. 1255 by topical application is licensed for
mild to moderate atopic eczema. Tacrolimus p. 1256 is
licensed for topical use in moderate to severe atopic eczema.
Both are drugs whose long-term safety is still being
reduce the use of topical corticosteroids. Treatment of atopic
eczema with topical pimecrolimus or topical tacrolimus
should be initiated only by prescribers experienced in
managing the condition. Topical tacrolimus and
pimecrolimus have a role in the treatment of psoriasis.
A short course of a systemic corticosteroid can be given for
eczema flares that have not improved despite appropriate
Ciclosporin p. 838 by mouth can be used for severe
psoriasis and for severe eczema. Azathioprine p. 836 or
mycophenolate mofetil p. 846 are used for severe refractory
eczema [unlicensed indication]. Dupilumab p. 1257 is
licensed for the treatment of moderate to severe atopic
eczema in patients requiring systemic therapy. Dimethyl
fumarate p. 853 is licensed for the treatment of moderate to
Methotrexate p. 913 can be used for severe psoriasis, the
dose being adjusted according to severity of the condition
and haematological and biochemical measurements. Folic
once weekly [unlicensed indication], on a different day from
the methotrexate; alternative regimens of folic acid may be
Etanercept p. 1113, adalimumab p. 1108, and infliximab
p. 1116 inhibit the activity of tumour necrosis factor (TNFa).
They are used for severe plaque psoriasis either refractory to
at least 2 standard systemic treatments and
photochemotherapy, or when standard treatments cannot be
used because of intolerance or contra-indications; while
either etanercept or adalimumab is considered to be the first
choice in stable disease, infliximab or adalimumab may be
useful when rapid disease control is required. Secukinumab
p. 1100 and ixekizumab p. 1259 inhibit the activity of
interleukin-17A, brodalumab p. 1257 inhibits the activity of
interleukin-17RA and guselkumab p. 1258 inhibits the
activity of interleukin-23. They are used for moderate to
severe plaque psoriasis in patients who are candidates for
systemic therapy. Secukinumab is also licensed for psoriatic
arthritis and ankylosing spondylitis. Ustekinumab p. 1103 (a
monoclonal antibody that inhibits interleukins 12 and 23)
can be used for severe plaque psoriasis that has not responded
to at least 2 standard systemic treatments and
photochemotherapy, or when these treatments cannot be
used because of intolerance or contra-indications.
Adalimumab is also licensed for the treatment of active
moderate to severe hidradenitis suppurativa (acne inversa)
in patients who have had inadequate response to
conventional systemic therapy. Adalimumab, etanercept,
infliximab, ixekizumab and ustekinumab are also licensed
Other drugs used for Eczema and psoriasis Apremilast,
p. 1119 . Certolizumab pegol, p. 1111
1240 Inflammatory skin conditions BNF 78
Topical corticosteroids are used for the treatment of
inflammatory conditions of the skin (other than those
arising from an infection), in particular eczema, contact
dermatitis, insect stings, and eczema of scabies.
Corticosteroids suppress the inflammatory reaction during
use; they are not curative and on discontinuation a rebound
exacerbation of the condition may occur. They are generally
used to relieve symptoms and suppress signs of the disorder
when other measures such as emollients are ineffective.
Topical corticosteroids are not recommended in the
routine treatment of urticaria; treatment should only be
initiated and supervised by a specialist. They should not be
used indiscriminately in pruritus (where they will only
benefit if inflammation is causing the itch) and are not
recommended for acne vulgaris.
Systemic or very potent topical corticosteroids should be
avoided or given only under specialist supervision in
psoriasis because, although they may suppress the psoriasis
in the short term, relapse or vigorous rebound occurs on
withdrawal (sometimes precipitating severe pustular
psoriasis). See the role of topical corticosteroids in the
In general, the most potent topical corticosteroids should
be reserved for recalcitrant dermatoses such as chronic
discoid lupus erythematosus, lichen simplex chronicus,
hypertrophic lichen planus, and palmoplantar pustulosis.
Potent corticosteroids should generally be avoided on the
face and skin flexures, but specialists occasionally prescribe
them for use on these areas in certain circumstances.
When topical treatment has failed, intralesional
corticosteroid injections may be used. These are more
effective than the very potent topical corticosteroid
preparations and should be reserved for severe cases where
there are localised lesions such as keloid scars, hypertrophic
lichen planus, or localised alopecia areata.
Hydrocortisone cream 1% p. 1247 can be used for up to
7 days to treat uninfected inflammatory lesions on the lips.
Hydrocortisone with miconazole cream or ointment p. 1252
is useful where infection by susceptible organisms and
inflammation co-exist, particularly for initial treatment (up
to 7 days) e.g. in angular cheilitis. Organisms susceptible to
miconazole include Candida spp. and many Gram-positive
bacteria including streptococci and staphylococci.
Water-miscible corticosteroid creams are suitable for moist
or weeping lesions whereas ointments are generally chosen
for dry, lichenified or scaly lesions or where a more occlusive
effect is required. Lotions may be useful when minimal
application to a large or hair-bearing area is required or for
the treatment of exudative lesions. Occlusive polythene or
hydrocolloid dressings increase absorption, but also increase
the risk of side effects; they are therefore used only under
supervision on a short-term basis for areas of very thick skin
(such as the palms and soles). The inclusion of urea or
salicylic acid also increases the penetration of the
In the BNF publications topical corticosteroids for the skin
are categorised as ‘mild’, ‘moderately potent’, ‘potent’ or
‘very potent’; the least potent preparation which is effective
should be chosen but dilution should be avoided whenever
Mild and moderately potent topical corticosteroids are
associated with few side-effects but care is required in the
use of potent and very potent corticosteroids. Absorption
through the skin can rarely cause adrenal suppression and
even Cushing’s syndrome, depending on the area of the body
being treated and the duration of treatment. Absorption is
greatest where the skin is thin or raw, and from
intertriginous areas; it is increased by occlusion.
Suitable quantities of corticosteroid
preparations to be prescribed for specific areas
Area of body Creams and Ointments
Groins and genitalia 15 to 30 g
These amounts are usually suitable for an adult for a single daily
The advantages of including other substances (such as
antibacterials or antifungals) with corticosteroids in topical
preparations are uncertain, but such combinations may have
a place where inflammatory skin conditions are associated
with bacterial or fungal infection, such as infected eczema.
In these cases the antimicrobial drug should be chosen
according to the sensitivity of the infecting organism and
used regularly for a short period (typically twice daily for
1 week). Longer use increases the likelihood of resistance
The keratolytic effect of salicylic acid p. 1286 facilitates the
absorption of topical corticosteroids; however, excessive and
prolonged use of topical preparations containing salicylic
Topical corticosteroid preparation potencies
Potency of a topical corticosteroid preparation is a result of
the formulation as well as the corticosteroid. Therefore,
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