Skin cleansers, antiseptics and
Skin cleansers and antiseptics
Soap or detergent is used with water to cleanse intact skin;
emollient preparations such as aqueous cream or
emulsifying ointment can be used in place of soap or
detergent for cleansing dry skin.
An antiseptic is used for skin that is infected or that is
susceptible to recurrent infection. Detergent preparations
containing chlorhexidine p. 1277 or povidone-iodine below,
which should be thoroughly rinsed off, are used. Emollients
Antiseptics such as chlorhexidine or povidone-iodine are
used on intact skin before surgical procedures; their
antiseptic effect is enhanced by an alcoholic solvent.
Antiseptic solutions containing cetrimide can be used if a
detergent effect is also required.
Hydrogen peroxide p. 1278, an oxidising agent, can be
used in solutions of up to 6% for skin disinfection, such as
cleansing and deodorising wounds and ulcers. Hydrogen
peroxide is also available as a cream for superficial bacterial
For irrigating ulcers or wounds, lukewarm sterile sodium
chloride 0.9% solution is used, but tap water is often
Potassium permanganate below solution 1 in 10 000, a
mild antiseptic with astringent properties, can be used for
exudative eczematous areas; treatment should be stopped
Alginate, hydrogel and hydrocolloid dressings are effective
at wound debridement. Sterile larvae (maggots) (available
from BioMonde) are also used for managing sloughing
wounds and are prescribable on the NHS.
Desloughing solutions and creams are of little clinical
value. Substances applied to an open area are easily
absorbed and perilesional skin is easily sensitised.
Gravitational dermatitis may be complicated by
superimposed contact sensitivity to substances such as
neomycin sulfate p. 1230 or lanolin.
Cleansing and deodorising suppurating eczematous
▶ Adult: For wet dressings or baths, use approximately
l CAUTIONS Irritant to mucous membranes
l DIRECTIONS FOR ADMINISTRATION Potassium
permanganate 0.1% solution to be diluted 1 in 10 to
provide a 0.01% (1 in 10 000) solution. With potassium
permanganate tablets for solution, 1 tablet dissolved in
4 litres of water provides a 0.01% (1 in 10 000) solution.
l PATIENT AND CARER ADVICE Can stain clothing, skin and
nails (especially with prolonged use).
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug. Forms available
from special-order manufacturers include: liquid
▶ Permitabs (Alliance Pharmaceuticals Ltd)
Potassium permanganate 400 mg Permitabs 400mg tablets for
cutaneous solution | 30 tablet £19.25 DT = £19.25
ANTISEPTICS AND DISINFECTANTS › ALCOHOL
(Industrial methylated spirit)
Skin preparation before injection
l CAUTIONS Avoid broken skin . flammable . patients have
suffered severe burns when diathermy has been preceded
by application of alcoholic skin disinfectants
Overdose Features of acute alcohol intoxication include
ataxia, dysarthria, nystagmus, and drowsiness, which may
progress to coma, with hypotension and acidosis.
For details on the management of poisoning,
see Alcohol, under Emergency treatment of poisoning
l PRESCRIBING AND DISPENSING INFORMATION Industrial
methylated spirits defined by the BP as a mixture of 19
volumes of ethyl alcohol of an appropriate strength with 1
volume of approved wood naphtha.
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
Industrial methylated spirit 70% | 600 ml £6.56–£7.01
ANTISEPTICS AND DISINFECTANTS › IODINE
▶ Child: (consult product literature)
▶ Adult: (consult product literature)
Skin disinfection, particularly minor wounds and
▶ Adult: Not for use in serous cavities (consult product
▶ Child: Apply undiluted in pre-operative skin
disinfection and general antisepsis
▶ Adult: Apply undiluted in pre-operative skin
disinfection and general antisepsis
1276 Skin cleansers, antiseptics and desloughing agents BNF 78
▶ Child: Use as a pre-operative scrub for hand and skin
▶ Adult: Use as a pre-operative scrub for hand and skin
▶ Adult: Apply undiluted in pre-operative skin
l CONTRA-INDICATIONS Avoid regular use in patients with
l CAUTIONS Broken skin . large open wounds
▶ Large open wounds The application of povidone–iodine to
large wounds or severe burns may produce systemic
adverse effects such as metabolic acidosis, hypernatraemia
and impairment of renal function.
VIDENE ® TINCTURE Procedures involving hot wire cautery
▶ Rare or very rare Eye erythema . punctate keratitis
▶ Frequency not known Cytotoxicity . eye discolouration
l PREGNANCY Sufficient iodine may be absorbed to affect
the fetal thyroid in the second and third trimester.
l BREAST FEEDING Avoid regular or excessive use.
l RENAL IMPAIRMENT Avoid regular application to inflamed
l EFFECT ON LABORATORY TESTS May interfere with thyroid
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug. Forms available
from special-order manufacturers include: liquid
▶ Betadine (Aspire Pharma Ltd)
Povidone-Iodine 25 mg per 1 gram Betadine 2.5% dry powder spray
CAUTIONARY AND ADVISORY LABELS 15 (Only for use with alcoholic
▶ Videne (Ecolab Healthcare Division)
Povidone-Iodine 75 mg per 1 ml Videne 7.5% surgical scrub solution
Povidone-Iodine 100 mg per 1 ml Videne 10% antiseptic solution | 500 ml G £7.97 DT = £7.97
ANTISEPTICS AND DISINFECTANTS › OTHER
▶ Child: (consult product literature)
▶ Adult: (consult product literature)
▶ Child: (consult product literature)
▶ Adult: (consult product literature)
HIBITANE ® PLUS 5% CONCENTRATE SOLUTION
General and pre-operative skin disinfection
▶ Child: (consult product literature)
Pre-operative hand and skin disinfection | General hand
▶ Child: Use as alternative to soap (consult product
▶ Adult: Use as alternative to soap (consult product
For use in obstetrics and gynaecology as an antiseptic and
▶ Adult: To be applied to skin around vulva and
perineum and to hands of midwife or doctor
▶ Child: To be used undiluted (consult product literature)
▶ Adult: To be used undiluted (consult product
For pre-operative skin disinfection
▶ Child: (consult product literature)
▶ Adult: (consult product literature)
For pre-operative hand and skin disinfection | General
▶ Child: (consult product literature)
▶ Adult: (consult product literature)
For cleansing and disinfecting wounds and burns and
▶ Child: (consult product literature)
▶ Adult: (consult product literature)
In preterm neonates, use sparingly, monitor for skin
reactions, and do not allow solution to pool—risk of
l CONTRA-INDICATIONS Alcoholic solutions not suitable
before diathermy . not for use in body cavities
l CAUTIONS Avoid contact with brain . avoid contact with
eyes . avoid contact with meninges . avoid contact with
l DIRECTIONS FOR ADMINISTRATION
alcohol 70%. For general skin disinfection, dilute 1 in 100
(0.05%) with water. Alcoholic solutions not suitable for use
before diathermy or on neonatal skin.
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
▶ Hibitane Obstetric (Derma UK Ltd)
Chlorhexidine gluconate 10 mg per 1 gram Hibitane Obstetric 1%
BNF 78 Skin cleansers, antiseptics and desloughing agents 1277
CAUTIONARY AND ADVISORY LABELS 15 (For ethanolic solutions (e.g.
ChloraPrep ® and Hydrex ® only)
EXCIPIENTS: May contain Fragrances
▶ Cepton (Boston Healthcare Ltd)
Chlorhexidine gluconate 10 mg per 1 ml Cepton 1% medicated skin
wash | 150 ml G £34.75 DT = £34.75
▶ HiBiTane Plus (Molnlycke Health Care Ltd)
Chlorhexidine gluconate 50 mg per 1 ml HiBiTane Plus 5%
concentrate solution | 5000 ml G £14.50 DT = £14.50
▶ Hibi (Molnlycke Health Care Ltd)
Chlorhexidine gluconate 5 mg per 1 ml HiBi Liquid Hand Rub+ 0.5%
solution | 500 ml G £5.25 DT = £5.25
▶ Hibiscrub (Molnlycke Health Care Ltd)
▶ Hydrex (Ecolab Healthcare Division)
Chlorhexidine gluconate 5 mg per 1 ml Hydrex pink chlorhexidine
gluconate 0.5% solution | 600 ml G £4.91 DT = £4.91
Hydrex clear chlorhexidine gluconate 0.5% solution | 600 ml G £4.91 DT = £4.91
Chlorhexidine gluconate 40 mg per 1 ml Hydrex 4% Surgical Scrub
| 250 ml G £4.47 DT = £4.25 | 500 ml G £4.96 DT = £5.25
▶ Sterets Unisept (Molnlycke Health Care Ltd)
Chlorhexidine gluconate 500 microgram per 1 ml Sterets Unisept
0.05% solution 25ml sachets | 25 sachet p £5.54 DT = £5.54
Sterets Unisept 0.05% solution 100ml sachets | 10 sachet p £6.83
The properties listed below are those particular to the
combination only. For the properties of the components
please consider, chlorhexidine p. 1277.
Skin disinfection before invasive procedures
▶ Child 2 months–17 years: (consult product literature)
▶ Adult: (consult product literature)
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug. Forms available
from special-order manufacturers include: liquid
CAUTIONARY AND ADVISORY LABELS 15
▶ ChloraPrep (CareFusion U.K. Ltd)
Chlorhexidine gluconate 20 mg per 1 ml, Isopropyl alcohol
ChloraPrep with Tint solution 26ml applicators | 25 applicator G £170.75 DT = £162.50
ChloraPrep solution 3ml applicators | 25 applicator G £21.25 DT =
ChloraPrep solution 1.5ml applicators | 20 applicator G £11.00 DT
ChloraPrep with Tint solution 3ml applicators | 25 applicator G £22.31 DT = £21.25
ChloraPrep solution 0.67ml applicators | 200 applicator G £60.00
ChloraPrep solution 10.5ml applicators | 25 applicator G £73.00
ChloraPrep solution 26ml applicators | 25 applicator G £162.50
The properties listed below are those particular to the
combination only. For the properties of the components
please consider, chlorhexidine p. 1277.
Skin disinfection such as wound cleansing and obstetrics
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
▶ Chlorhexidine with cetrimide (Non-proprietary)
Chlorhexidine gluconate 1 mg per 1 gram, Cetrimide 5 mg per
1 gram Savlon antiseptic cream | 15 gram G £0.90 |
30 gram G £1.19 | 60 gram G £1.91 | 100 gram G £2.78
▶ Chlorhexidine with cetrimide (Non-proprietary)
Chlorhexidine acetate 150 microgram per 1 ml, Cetrimide 1.5 mg
per 1 ml Chlorhexidine acetate 0.015% / Cetrimide 0.15% irrigation
solution 1litre bottles | 1 bottle p s
▶ Sterets Tisept (Molnlycke Health Care Ltd)
Chlorhexidine gluconate 150 microgram per 1 ml, Cetrimide
1.5 mg per 1 ml Sterets Tisept solution 25ml sachets | 25 sachet p
Sterets Tisept solution 100ml sachets | 10 sachet p £6.85 DT = £6.85
Skin preparation before injection
▶ Adult: Apply to the area to be disinfected
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
CAUTIONARY AND ADVISORY LABELS 15
▶ Diethyl phthalate with methyl salicylate (Non-proprietary)
Methyl salicylate 5 ml per 1 litre, Diethyl phthalate 20 ml per
1 litre, Castor oil 25 ml per 1 litre, Industrial methylated spirit
950 ml per 1 litre Surgical spirit | 200 ml G £1.17 DT = £1.17 | 1000 ml G £3.95
l DRUG ACTION Hydrogen peroxide is an oxidising agent.
For skin disinfection, particularly cleansing and
▶ Adult: Use 3% and 6% solutions (consult product
Superficial bacterial skin infection
▶ Child: Apply 2–3 times a day for up to 3 weeks
▶ Adult: Apply 2–3 times a day for up to 3 weeks
▶ In children Licensed for use in children (age range not
1278 Skin cleansers, antiseptics and desloughing agents BNF 78
disinfection agent for surgical instruments (in adults). use
as enema (in adults). use during surgery (in adults)
l CAUTIONS Avoid on eyes . avoid on healthy skin . incompatible with products containing iodine or
l PRESCRIBING AND DISPENSING INFORMATION The BP
directs that when hydrogen peroxide is prescribed,
hydrogen peroxide solution 6% (20 vols) should be
Strong solutions of hydrogen peroxide which contain
27% (90 vols) and 30% (100 vols) are only for the
preparation of weaker solutions.
l HANDLING AND STORAGE Hydrogen peroxide bleaches
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug. Forms available
from special-order manufacturers include: liquid
EXCIPIENTS: May contain Edetic acid (edta), propylene glycol
▶ Crystacide (Reig Jofre UK Ltd)
▶ Hydrogen peroxide (Non-proprietary)
Hydrogen peroxide 60 mg per 1 ml Hydrogen peroxide 6% solution
| 200 ml G £0.67 | 500 ml G £3.02 | 2000 ml G £9.33
Hydrogen peroxide 90 mg per 1 ml Hydrogen peroxide 9% solution
Hydrogen peroxide 30 ml per 1 litre Hydrogen peroxide 3%
Infected wounds | Infected burns
▶ Adult: (consult product literature)
l PATIENT AND CARER ADVICE Stains clothing.
l MEDICINAL FORMS Forms available from special-order
Flowfusor sodium chloride 0.9% irrigation solution 120ml
Irriclens sodium chloride 0.9% irrigation solution aerosol
spray (ConvaTec Ltd) Sodium chloride 9 mg per 1 ml 240 ml . NHS
indicative price = £3.60 . Drug Tariff (Part IXa)
Normasol sodium chloride 0.9% irrigation solution 100ml
sachets (Molnlycke Health Care Ltd) Sodium chloride 9 mg per 1 ml
10 unit dose . NHS indicative price = £7.97 . Drug Tariff (Part IXa)
Normasol sodium chloride 0.9% irrigation solution 25ml
sachets (Molnlycke Health Care Ltd) Sodium chloride 9 mg per 1 ml
25 unit dose . NHS indicative price = £6.46 . Drug Tariff (Part IXa)
Sodium chloride 0.9% irrigation solution 20ml Clinipod unit
dose (Mayors Healthcare Ltd) Sodium chloride 9 mg per 1 ml 25 unit
dose . NHS indicative price = £4.80 . Drug Tariff (Part IXa)
Sodium chloride 0.9% irrigation solution 20ml ISO-POD unit
dose (St Georges Medical Ltd) Sodium chloride 9 mg per 1 ml 25 unit
dose . NHS indicative price = £4.95 . Drug Tariff (Part IXa)
Sodium chloride 0.9% irrigation solution 20ml Irripod unit
Sodium chloride 0.9% irrigation solution 20ml Sal-e Pods unit
dose (Ennogen Healthcare Ltd) Sodium chloride 9 mg per 1 ml 25 unit
dose . NHS indicative price = £4.80 . Drug Tariff (Part IXa)
Sodium chloride 0.9% irrigation solution 20ml Salipod unit
dose (Sai-Meds Ltd) Sodium chloride 9 mg per 1 ml 25 unit dose . NHS
indicative price = £4.99 . Drug Tariff (Part IXa)
Sodium chloride 0.9% irrigation solution 20ml Steripod unit
dose (Molnlycke Health Care Ltd) Sodium chloride 9 mg per 1 ml
25 unit dose . NHS indicative price = £7.96 . Drug Tariff (Part IXa)
Sodium chloride 0.9% irrigation solution 20ml Sterowash unit
dose (Steroplast Healthcare Ltd) Sodium chloride 9 mg per 1 ml
25 unit dose . NHS indicative price = £5.40 . Drug Tariff (Part IXa)
Sodium chloride 0.9% irrigation solution 20ml unit dose (Alissa
Sodium chloride 0.9% irrigation solution 20ml unit dose (Bell,
Sodium chloride 0.9% irrigation solution 20ml unit dose (Crest
Medical Ltd) Sodium chloride 9 mg per 1 ml 25 unit dose . NHS
indicative price = £4.99 . Drug Tariff (Part IXa)
Sodium chloride 0.9% irrigation solution 20ml unit dose
(Mylan) Sodium chloride 9 mg per 1 ml 25 unit dose . NHS indicative
price = £5.50 . Drug Tariff (Part IXa)
Stericlens sodium chloride 0.9% irrigation solution aerosol
spray (C D Medical Ltd) Sodium chloride 9 mg per 1 ml 100 ml . NHS
indicative price = £2.07 . Drug Tariff (Part IXa)240 ml . NHS indicative
price = £3.15 . Drug Tariff (Part IXa)
Many preparations traditionally used to manage minor
burns, and abrasions have fallen out of favour. Preparations
containing camphor and sulfonamides should be avoided.
Preparations such as magnesium sulfate paste are now rarely
used to treat carbuncles and boils as these are best treated
Cetrimide is used to treat minor cuts and abrasions and
proflavine above may be used to treat infected wounds or
burns, but its use has now been largely superseded by other
antispetics or suitable antibacterials. The effervescent effect
of hydrogen peroxide p. 1278 is used to clean minor cuts and
Flexible collodion (see castor oil with collodion and
colophony p. 1280) may be used to seal minor cuts and
wounds that have partially healed; skin tissue adhesives are
used similarly, and also for additional suture support.
ANTISEPTICS AND DISINFECTANTS › OTHER
Glycerol with magnesium sulfate and
▶ Adult: To be applied under dressing
l DIRECTIONS FOR ADMINISTRATION Paste should be stirred
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
▶ Glycerol with magnesium sulfate and phenol (Non-proprietary)
Phenol 5 mg per 1 gram, Magnesium sulfate dried 450 mg per
BNF 78 Minor cuts and abrasions 1279
DERMATOLOGICAL DRUGS › COLLODIONS
Used to seal minor cuts and wounds that have partially
▶ Child: (consult product literature)
▶ Adult: (consult product literature)
l ALLERGY AND CROSS-SENSITIVITY Contra-indicated if
patient has an allergy to colophony in elastic adhesive
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
▶ Castor oil with collodion and colophony (Non-proprietary)
Castor oil 25 mg per 1 ml, Colophony 25 mg per 1 ml, Collodion
methylated 950 microlitre per 1 ml Flexible collodion methylated
| 100 ml £13.81–£14.09 | 500 ml £29.47
Derma+Flex skin adhesive (Chemence Ltd)
0.5 ml . NHS indicative price = £5.36 . Drug Tariff (Part IXa)
Dermabond ProPen skin adhesive (Ethicon Ltd)
0.5 ml . NHS indicative price = £19.46 . Drug Tariff (Part IXa)
Histoacryl L skin adhesive (B.Braun Medical Ltd)
0.5 ml . NHS indicative price = £6.72 . Drug Tariff (Part IXa)
Histoacryl skin adhesive (B.Braun Medical Ltd)
0.5 ml . NHS indicative price = £6.50 . Drug Tariff (Part IXa)
Indermil skin adhesive (Covidien (UK) Commercial Ltd)
0.5 gram . NHS indicative price = £6.50 . Drug Tariff (Part IXa)
LiquiBand flow control tissue adhesive (Advanced Medical
0.5 gram . NHS indicative price = £5.50 . Drug Tariff (Part IXa)
LiquiBand tissue adhesive (Advanced Medical Solutions Ltd)
0.5 gram . NHS indicative price = £5.50 . Drug Tariff (Part IXa)
Disfigurement of the skin can be very distressing to patients
and may have a marked psychological effect. In skilled
hands, or with experience, camouflage cosmetics can be very
effective in concealing scars and birthmarks. The
depigmented patches in vitiligo are also very disfiguring and
camouflage creams are of great cosmetic value.
Opaque cover foundation or cream is used to mask skin
pigment abnormalities; careful application using a
combination of dark- and light-coloured cover creams set
with powder helps to minimise the appearance of skin
The preparations marked ‘ACBS’ can be prescribed on the
NHS for postoperative scars and other deformities and as
adjunctive therapy in the relief of emotional disturbances
due to disfiguring skin disease, such as vitiligo.
Covermark classic foundation (Derma UK Ltd)
15 ml(ACBS) . NHS indicative price = £11.86
Covermark finishing powder (Derma UK Ltd)
25 gram(ACBS) . NHS indicative price = £11.86
Covermark removing cream (Derma UK Ltd)
200 ml . No NHS indicative price available
Deep Skin Cleanser (SkinKind Ltd)
100 ml . NHS indicative price = £19.50
Dermablend Dermasmooth Corrective Foundation (Vichy)
30 ml . No NHS indicative price available
Dermacolor Creme Effectiv (Kryolan UK Ltd)
50 ml . NHS indicative price = £5.73
Dermacolor body camouflage (Kryolan UK Ltd)
50 ml . NHS indicative price = £8.94
Dermacolor camouflage creme (Kryolan UK Ltd)
30 gram . NHS indicative price = £11.00
Dermacolor cleansing cream (Kryolan UK Ltd)
75 gram . No NHS indicative price available
Dermacolor fixing powder (Kryolan UK Ltd)
60 gram(ACBS) . NHS indicative price = £9.85
Keromask finishing powder (Bellava Ltd)
20 gram(ACBS) . NHS indicative price = £6.27
Keromask masking cream (Bellava Ltd)
15 ml(ACBS) . NHS indicative price = £6.27
Veil cleansing cream (Thomas Blake Cosmetic Creams Ltd)
50 gram . NHS indicative price = £2.45 | 100 gram . NHS indicative price =
Veil cover cream (Thomas Blake Cosmetic Creams Ltd)
19 gram(ACBS) . NHS indicative price = £22.42 | 44 gram(ACBS) . NHS
indicative price = £33.35 | 70 gram(ACBS) . NHS indicative price = £42.10
Veil finishing powder (Thomas Blake Cosmetic Creams Ltd)
35 gram(ACBS) . NHS indicative price = £24.58
Solar ultraviolet irradiation can be harmful to the skin. It is
responsible for disorders such as polymorphic light eruption,
solar urticaria, and it provokes the various cutaneous
porphyrias. It also provokes (or at least aggravates) skin
lesions of lupus erythematosus and may aggravate rosacea
and some other dermatoses. Certain drugs, such as
demeclocycline, phenothiazines, or amiodarone, can cause
photosensitivity. All these conditions (as well as sunburn)
may occur after relatively short periods of exposure to the
sun. Solar ultraviolet irradiation may provoke attacks of
recurrent herpes labialis (but it is not known whether the
effect of sunlight exposure is local or systemic).
The effects of exposure over longer periods include ageing
changes and more importantly the initiation of skin cancer.
Solar ultraviolet radiation is approximately 200–400 nm in
wavelength. The medium wavelengths (290–320 nm, known
as UVB) cause sunburn. The long wavelengths (320–400 nm,
known as UVA) are responsible for many photosensitivity
reactions and photodermatoses. Both UVA and UVB
contribute to long-term photodamage and to the changes
responsible for skin cancer and ageing.
Sunscreen preparations contain substances that protect
the skin against UVA and UVB radiation, but they are no
substitute for covering the skin and avoiding sunlight. The
sun protection factor (SPF, usually indicated in the
preparation title) provides guidance on the degree of
1280 Skin disfigurement BNF 78
protection offered against UVB; it indicates the multiples of
protection provided against burning, compared with
unprotected skin; for example, an SPF of 8 should enable a
person to remain 8 times longer in the sun without burning.
However, in practice, users do not apply sufficient sunscreen
product and the protection is lower than that found in
Some manufacturers use a star rating system to indicate
the protection against UVA relative to protection against
UVB for sunscreen products. However, the usefulness of the
star rating system remains controversial. The EU
Commission (September 2006) has recommended that the
achieve this requirement will be labelled with a UVA logo
alongside the SPF classification. Preparations that also
contain reflective substances, such as titanium dioxide,
provide the most effective protection against UVA.
Sunscreen preparations may rarely cause allergic
For optimum photoprotection, sunscreen preparations
should be applied thickly and frequently (approximately
2 hourly). In photodermatoses, they should be used from
spring to autumn. As maximum protection from sunlight is
desirable, preparations with the highest SPF should be
Ingredient nomenclature in sunscreen
amiloxate isoamyl p-methoxycinnamate
avobenzone butyl methoxydibenzoylmethane
bemotrizinol bis-ethylhexyloxyphenol
bisoctrizole methylene bis-benzotriazolyl
ecamsule terephthalylidene dicamphor
ensulizole phenylbenzimidazole sulfonic acid
enzacamene 4-methylbenzylidene camphor
octinoxate octyl (or ethylhexyl)
The European Commission Cosmetic Products Regulation (EC)
1223/2009 requires the use of INCI (International Nomenclature
of Cosmetic Ingredients) for cosmetics and sunscreens. This table
includes the rINN and the INCI synonym for the active ingredients
of sunscreen preparations in the BNF
Anthelios ® XL SPF 50+ Melt-in cream; Sunsense ® Ultra;
Uvistat ® Lipscreen SPF 50; and Uvistat ® Suncream SPF 30
and 50 (see Borderline substances) are regarded as drugs
when prescribed for skin protection against ultraviolet
radiation in abnormal cutaneous photosensitivity.
Preparations with SPF less than 30 should not normally be
Patients should be advised to use a high-SPF sunscreen and
to minimise exposure of the skin to direct sunlight or sun
Topical treatments can be used for actinic keratosis. An
emollient may be sufficient for mild lesions. Diclofenac
sodium gel below is suitable for the treatment of superficial
lesions in mild disease. Fluorouracil cream p. 1282 is
effective against most types of non-hypertrophic actinic
keratosis; a solution containing fluorouracil with salicylic
acid p. 1282 is available for the treatment of low or
moderately thick hyperkeratotic actinic keratosis.
Imiquimod p. 1285 is used for lesions on the face and scalp
when cryotherapy or other topical treatments cannot be
used. Fluorouracil and imiquimod produce a more marked
inflammatory reaction than diclofenac sodium but lesions
resolve faster. A short course of ingenol mebutate p. 1282 is
licensed for the treatment of non-hypertrophic actinic
keratosis; response to treatment can usually be assessed
8 weeks after the course. Photodynamic therapy in
combination with methyl-5-aminolevulinate cream
(Metvix ®, available from Galderma) or 5-aminolaevulinic
acid gel (Ameluz ®, available from Spirit Healthcare) is used
in specialist centres for treating superficial and confluent,
non-hypertrophic actinic keratosis when other treatments
are inadequate or unsuitable; it is particularly suitable for
multiple lesions, for periorbital lesions, or for lesions located
Imiquimod or topical fluorouracil is used for treating
superficial basal cell carcinomas. Photodynamic therapy in
combination with methyl-5-aminolevulinate cream is used
in specialist centres for treating superficial, nodular basal
cell carcinomas when other treatments are unsuitable.
ANALGESICS › NON-STEROIDAL ANTIINFLAMMATORY DRUGS
▶ Adult: Apply twice daily for 60–90 days, to be applied
l CAUTIONS Avoid contact with eyes . avoid contact with
inflamed or broken skin . avoid contact with mucous
membranes . not for use with occlusive dressings .topical
application of large amounts can result in systemic effects,
including hypersensitivity and asthma (renal disease has
l INTERACTIONS → Appendix 1: NSAIDs
▶ Common or very common Conjunctivitis . muscle tone
increased . oedema .rash (discontinue). sensation
abnormal . skin reactions . skin ulcer
▶ Frequency not known Hair colour changes
SIDE-EFFECTS, FURTHER INFORMATION Topical application
of large amounts of diclofenac can result in systemic
l ALLERGY AND CROSS-SENSITIVITY Contra-indicated in
patients with a history of hypersensitivity to aspirin or any
other NSAID—which includes those in whom attacks of
asthma, angioedema, urticaria or rhinitis have been
precipitated by aspirin or any other NSAID.
l PREGNANCY Patient packs for topical preparations carry a
warning to avoid during pregnancy.
l BREAST FEEDING Patient packs for topical preparations
carry a warning to avoid during breast-feeding.
BNF 78 Sun protection and photodamage 1281
l DIRECTIONS FOR ADMINISTRATION For topical
preparations, apply with gentle massage only.
l PATIENT AND CARER ADVICE For topical preparations,
patients and their carers should be advised to wash hands
Photosensitivity Patients should be advised against
excessive exposure to sunlight of area treated in order to
avoid possibility of photosensitivity.
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
EXCIPIENTS: May contain Benzyl alcohol, fragrances, propylene glycol
ANTINEOPLASTIC DRUGS › ANTIMETABOLITES
Superficial malignant and pre-malignant skin lesions
▶ Adult: Apply 1–2 times a day for 3–4 weeks (usual
duration of initial therapy), apply thinly to the affected
area, maximum area of skin 500 cm2 (e.g. 23 cm 6
23 cm) treated at one time, alternative regimens may
l CAUTIONS Avoid contact with eyes and mucous
membranes . dihydropyrimidine dehydrogenase deficiency . do not apply to bleeding lesions
l INTERACTIONS → Appendix 1: fluorouracil
▶ Uncommon Dizziness . headache
▶ Rare or very rare Abdominal pain . chills . diarrhoea
haemorrhagic . fever. leucocytosis . pancytopenia . skin
irritation (use a topical corticosteroid for severe
discomfort associated with inflammatory reactions). skin
▶ Frequency not known Conjunctival irritation . excessive
tearing . keratitis .taste altered
l CONCEPTION AND CONTRACEPTION Contraceptive advice
required, see Pregnancy and reproductive function in
l PREGNANCY Manufacturers advise avoid (teratogenic).
l BREAST FEEDING Manufacturers advise avoid.
l HANDLING AND STORAGE Caution in handling—irritant to
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), hydroxybenzoates (parabens), polysorbates, propylene
▶ Efudix (Meda Pharmaceuticals Ltd)
Fluorouracil 50 mg per 1 gram Efudix 5% cream | 40 gram P £32.90 DT = £32.90
Fluorouracil with salicylic acid
The properties listed below are those particular to the
combination only. For the properties of the components
please consider, fluorouracil above, salicylic acid p. 1286.
Low or moderately thick hyperkeratotic actinic keratosis
▶ Adult: Apply once daily for up to 12 weeks, reduced to
3 times a week if severe side effects occur and until
side-effects improve, to be applied to the affected area,
if treating area with thin epidermis, reduce frequency
of application and monitor response more often;
maximum area of skin treated at one time, 25 cm2 (e.g.
l INTERACTIONS → Appendix 1: fluorouracil
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
CAUTIONARY AND ADVISORY LABELS 15
Fluorouracil 5 mg/g, Salicylic acid 100 mg/g Actikerall 5mg/g /
100mg/g cutaneous solution | 25 ml P £38.30 DT = £38.30
Actinic keratosis on face and scalp
▶ Adult: Apply once daily for 3 days, use the
Actinic keratosis on trunk and extremities
▶ Adult: Apply once daily for 2 days, use the
l CAUTIONS Avoid contact with broken skin . avoid contact
with eyes . avoid contact with inside of ears . avoid contact
with inside of nostrils . avoid contact with lips . avoid
occlusive dressings on treated area
▶ Common or very common Headache . infection . local
reaction . oedema . pain . skin reactions
▶ Uncommon Paraesthesia . skin ulcer
l PREGNANCY Not absorbed from skin, but manufacturer
l BREAST FEEDING Not absorbed from skin; ensure infant
does not come in contact with treated area for 6 hours
l DIRECTIONS FOR ADMINISTRATION One tube covers skin
. Allow gel to dry on treatment area for
15 minutes. Avoid washing or touching the treated area for
6 hours after application; after this time, area may be
washed with mild soap and water. Avoid use immediately
after shower or less than 2 hours before bedtime.
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
CAUTIONARY AND ADVISORY LABELS 15
EXCIPIENTS: May contain Benzyl alcohol
Ingenol mebutate 150 microgram per 1 gram Picato
150micrograms/g gel | 1.41 gram P £65.00 DT = £65.00
Ingenol mebutate 500 microgram per 1 gram Picato
500micrograms/g gel | 0.94 gram P £65.00 DT = £65.00
1282 Sun protection and photodamage BNF 78
Topical circulatory preparations
These preparations are used to improve circulation in
conditions such as bruising, superficial thrombophlebitis,
chilblains and varicose veins but are of little value. Chilblains
are best managed by avoidance of exposure to cold; neither
systemic nor topical vasodilator therapy is established as
Superficial thrombophlebitis | Bruising | Haematoma
▶ Adult: Apply up to 4 times a day
l CONTRA-INDICATIONS Should not be used on large areas of
skin, broken or sensitive skin, or mucous membranes
l LESS SUITABLE FOR PRESCRIBING Hirudoid ® is less
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), hydroxybenzoates (parabens)
▶ Hirudoid (Genus Pharmaceuticals Ltd)
Heparinoid 3 mg per 1 gram Hirudoid 0.3% cream | 50 gram p
EXCIPIENTS: May contain Fragrances, propylene glycol
▶ Hirudoid (Genus Pharmaceuticals Ltd)
Heparinoid 3 mg per 1 gram Hirudoid 0.3% gel | 50 gram p £3.99
Warts (verrucas) are caused by a human papillomavirus,
which most frequently affects the hands, feet (plantar warts),
and the anogenital region; treatment usually relies on local
tissue destruction. Warts may regress on their own and
treatment is required only if the warts are painful, unsightly,
persistent, or cause distress.
Preparations of salicylic acid p. 1286, formaldehyde
p. 1284, glutaraldehyde p. 1284 or silver nitrate p. 1285 are
available for purchase by the public; they are suitable for the
removal of warts on hands and feet. Salicylic acid is a useful
keratolytic which may be considered first-line; it is also
suitable for the removal of corns and calluses. Preparations of
salicylic acid in a collodion basis are available but some
patients may develop an allergy to colophony in the
formulation; collodion should be avoided in children allergic
to elastic adhesive plaster. Cryotherapy causes pain,
swelling, and blistering, and may be no more effective than
topical salicylic acid in the treatment of warts.
The treatment of anogenital warts (condylomata acuminata)
should be accompanied by screening for other sexually
transmitted infections. Podophyllotoxin p. 1284 (the major
number of external warts or keratinised lesions may be better
treated with cryotherapy or other forms of physical ablation.
Imiquimod cream p. 1285 is licensed for the treatment of
external anogenital warts; it may be used for both
keratinised and non-keratinised lesions. It is also licensed
for the treatment of superficial basal cell carcinoma and
actinic keratosis. Camellia sinensis ointment below is
licensed for the treatment of external anogenital warts.
Inosine pranobex p. 633 is licensed for adjunctive
treatment of genital warts but it has been superseded by
ANTINEOPLASTIC DRUGS › PLANT ALKALOIDS
l DRUG ACTION Camellia sinensis is an extract from green
tea leaves. The exact mechanism of action is not known;
non-clinical studies have shown inhibition of the growth
of activated keratinocytes, and anti-oxidative effects at the
Warts (external genital and perianal) in
▶ Adult: Apply up to 250 mg 3 times a day until complete
clearance of warts (maximum 16 weeks), do not exceed
treatment period even if new warts develop; maximum
DOSE EQUIVALENCE AND CONVERSION
▶ 250 mg is equivalent to 0.5 cm of ointment.
contact with nostrils . avoid inflamed skin . uncircumcised
males (risk of phimosis). vulvar region
intercourse . phimosis . skin reactions . urinary disorders
▶ Frequency not known Urinary tract stenosis . vaginal
l CONCEPTION AND CONTRACEPTION Manufacturer advises
Catephen ® may weaken condoms and vaginal
diaphragms—alternative methods of contraception should
l PREGNANCY Manufacturer advises avoid—toxicity in
l BREAST FEEDING Manufacturer advises risk to infant
cannot be excluded—no information available.
l HEPATIC IMPAIRMENT Manufacturer advises avoid in
severe impairment (limited information available).
l DIRECTIONS FOR ADMINISTRATION Manufacturer advises
apply to each wart, ensuring a thin layer is left on the wart.
It is not necessary to wash off the ointment from the area
l PATIENT AND CARER ADVICE Manufacturer advises the
ointment should be washed off before sexual activity.
Manufacturer advises female patients using tampons
should insert tampon before applying the ointment.
l NATIONAL FUNDING/ACCESS DECISIONS
Scottish Medicines Consortium (SMC) decisions
The Scottish Medicines Consortium has advised (April 2016)
that camellia sinensis (green tea) leaf extract (Catephen ®)
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