not successful. Oral administration of a sedating
antihistamine at night may also be useful.
Dimeticone p. 1236 is effective against head lice (Pediculus
humanus capitis). It coats head lice and interferes with water
balance in lice by preventing the excretion of water; it is less
active against eggs and treatment should be repeated after
7 days. Malathion, an organophosphorus insecticide, is an
alternative, but resistance has been reported. Benzyl
benzoate is licensed for the treatment of head lice but it is
less effective than other drugs and not recommended for use
in children. Permethrin is active against head lice but the
formulation and licensed methods of application of the
current products make them unsuitable for the treatment of
Head lice infestation (pediculosis) should be treated using
lotion or liquid formulations only if live lice are present.
Shampoos are diluted too much in use to be effective. A
contact time of 8–12 hours or overnight treatment is
recommended for lotions and liquids; a 2-hour treatment is
In general, a course of treatment for head lice should be 2
applications of product 7 days apart to kill lice emerging
from any eggs that survive the first application. All affected
household members should be treated simultaneously.
MHRA/CHM advice: Head lice eradication products: risk of serious
burns if treated hair is exposed to open flames or other sources of
Some products for the eradication of head lice infestations
are combustible/flammable when on the hair and can ignite
and cause serious harm in the presence of an open flame or
other source of ignition such as when lighting cigarettes.
Patients and carers should be advised on the safe and
correct use of head lice eradication treatments and if
appropriate, should be advised that they should not smoke
around treated hair and that it should be kept away from
open flames or other sources of ignition, including in the
morning after overnight application until hair is washed.
Head lice can be mechanically removed by combing wet hair
meticulously with a plastic detection comb (probably for at
least 30 minutes each time) over the whole scalp at 4-day
intervals for a minimum of 2 weeks, and continued until no
lice are found on 3 consecutive sessions; hair conditioner or
vegetable oil can be used to facilitate the process.
Several devices for the removal of head lice such as combs
and topical solutions, are available and some are
The Drug Tariffs can be accessed online at:
. National Health Service Drug Tariff for England and Wales:
www.ppa.org.uk/ppa/edt_intro.htm
. Health and Personal Social Services for Northern Ireland
Drug Tariff: www.hscbusiness.hscni.net/services/2034.htm
. Scottish Drug Tariff: www.isdscotland.org/Health-topics/
Prescribing-and-Medicines/Scottish-Drug-Tariff/
Permethrin and malathion are used to eliminate crab lice
(Pthirus pubis). An aqueous preparation should be applied,
allowed to dry naturally and washed off after 12 hours; a
second treatment is needed after 7 days to kill lice emerging
from surviving eggs. All surfaces of the body should be
treated, including the scalp, neck, and face (paying particular
attention to the eyebrows and other facial hair). A different
insecticide should be used if a course of treatment fails.
ANTIBACTERIALS › AMINOGLYCOSIDES
▶ Child: Apply up to 3 times a day, for short-term use
▶ Adult: Apply up to 3 times a day, for short-term use
▶ In children Neomycin Cream BPC—no information available.
l CAUTIONS If large areas of skin are being treated
ototoxicity may be a hazard, particularly in children, in the
elderly, and in those with renal impairment.
l INTERACTIONS → Appendix 1: neomycin
l SIDE-EFFECTS Sensitisation (cross sensitivity with other
l RENAL IMPAIRMENT Ototoxicity may be a hazard if large
l LESS SUITABLE FOR PRESCRIBING Neomycin sulfate cream
is less suitable for prescribing.
l MEDICINAL FORMS Forms available from special-order
ANTIBACTERIALS › NITROIMIDAZOLE
l DRUG ACTION Metronidazole is an antimicrobial drug with
high activity against anaerobic bacteria and protozoa.
Acute inflammatory exacerbation of rosacea
▶ Adult: Apply twice daily for 8 weeks, to be applied
Malodorous fungating tumours and malodorous
gravitational and decubitus ulcers
▶ Adult: Apply 1–2 times a day, to be applied to clean
wound and covered with non-adherent dressing
Acute inflammatory exacerbation of rosacea
▶ Adult: Apply twice daily for 8–9 weeks, to be applied
▶ Adult: Apply 1–2 times a day, to be applied to clean
wound and covered with non-adherent dressing
▶ Adult: Apply twice daily for up to 8 weeks, to be applied
1230 Infections of the skin BNF 78
Inflammatory papules and pustules of rosacea
▶ Adult: Apply twice daily for 6 weeks (longer if
Inflammatory papules, pustules and erythema of rosacea
▶ Adult: Apply twice daily for 3–4 months
Inflammatory papules, pustules and erythema of rosacea
▶ Adult: Apply twice daily for 3–4 months
Acute inflammatory exacerbation of rosacea
▶ Adult: Apply twice daily for 8–9 weeks, to be applied
l CAUTIONS Avoid exposure to strong sunlight or UV light
l INTERACTIONS → Appendix 1: metronidazole
▶ Common or very common Skin reactions
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
EXCIPIENTS: May contain Benzyl alcohol, disodium edetate,
hydroxybenzoates (parabens), propylene glycol
▶ Acea (Ferndale Pharmaceuticals Ltd)
Metronidazole 7.5 mg per 1 gram Acea 0.75% gel | 40 gram P £9.95 DT = £22.63
▶ Anabact (Cambridge Healthcare Supplies Ltd)
Metronidazole 7.5 mg per 1 gram Anabact 0.75% gel | 15 gram P £4.47 DT = £4.47 | 30 gram P £7.89 |
▶ Metrogel (Galderma (UK) Ltd)
Metronidazole 7.5 mg per 1 gram Metrogel 0.75% gel | 40 gram P £22.63 DT = £22.63
▶ Metrosa (M & A Pharmachem Ltd)
Metronidazole 7.5 mg per 1 gram Metrosa 0.75% gel | 30 gram P £12.00 | 40 gram P £19.90 DT = £22.63
Metronidazole 7.5 mg per 1 gram Rozex 0.75% gel | 30 gram P £6.60 | 40 gram P £9.88 DT = £22.63
Metronidazole 7.5 mg per 1 gram Zyomet 0.75% gel | 30 gram P £12.00
EXCIPIENTS: May contain Benzyl alcohol, isopropyl palmitate, propylene
▶ Rosiced (Pierre Fabre Dermo-Cosmetique)
Metronidazole 7.5 mg per 1 gram Rosiced 0.75% cream | 30 gram P £6.60 DT = £6.60
▶ Adult: Apply twice daily, may be applied more
l CAUTIONS If large areas of skin are being treated
nephrotoxicity and neurotoxicity may be a hazard,
particularly in children, in the elderly, and in those with
l INTERACTIONS → Appendix 1: polymyxins
l MEDICINAL FORMS No licensed medicines listed.
Prophylaxis and treatment of infection in burn wounds
▶ Child: Apply daily, may be applied more frequently if
▶ Adult: Apply daily, may be applied more frequently if
For conservative management of finger-tip injuries
▶ Child: Apply every 2–3 days, consult product literature
▶ Adult: Apply every 2–3 days, consult product literature
Adjunct to prophylaxis of infection in skin graft donor
▶ Adult: (consult product literature)
Adjunct to short-term treatment of infection in pressure
▶ Adult: Apply once daily or on alternate days
As an adjunct to short-term treatment of infection in leg
▶ Adult: Apply once daily or on alternate days, not
recommended if ulcer is very exudative
▶ In children No age range specified by manufacturer.
l CONTRA-INDICATIONS Not recommended for neonates
CAUTIONS, FURTHER INFORMATION Plasma-sulfadiazine
l INTERACTIONS → Appendix 1: silver sulfadiazine
▶ Common or very common Leucopenia . skin reactions
▶ Rare or very rare Argyria (following treatment of large
areas of skin or long term use).renal failure
SIDE-EFFECTS, FURTHER INFORMATION Leucopenia
developing 2–3 days after starting treatment of burns
patients is reported usually to be self-limiting and silver
sulfadiazine need not usually be discontinued provided
blood counts are monitored carefully to ensure return to
l ALLERGY AND CROSS-SENSITIVITY Contra-indicated in
patients with sensitivity to sulfonamides.
l PREGNANCY Risk of neonatal haemolysis and
methaemoglobinaemia in third trimester.
l BREAST FEEDING Small risk of kernicterus in jaundiced
infants and of haemolysis in G6PD-deficient infants.
l HEPATIC IMPAIRMENT Manufacturer advises caution in
significant hepatic impairment.
l RENAL IMPAIRMENT Manufacturer advises caution if
l MONITORING REQUIREMENTS Monitor for leucopenia.
l DIRECTIONS FOR ADMINISTRATION Apply with sterile
BNF 78 Bacterial skin infections 1231
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), polysorbates, propylene glycol
▶ Flamazine (Smith & Nephew Healthcare Ltd)
Bacterial skin infections, particularly those caused by
Gram-positive organisms (except pseudomonal
▶ Child: Apply up to 3 times a day for up to 10 days
▶ Adult: Apply up to 3 times a day for up to 10 days
▶ In children Mupirocin ointment licensed for use in children
(age range not specified by manufacturer). Bactroban ®
cream not recommended for use in children under 1 year.
▶ Common or very common Skin reactions
l PREGNANCY Manufacturer advises avoid unless potential
benefit outweighs risk—no information available.
l BREAST FEEDING No information available.
l RENAL IMPAIRMENT Manufacturer advises caution when
mupirocin ointment used in moderate or severe
impairment because it contains macrogols (polyethylene
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
Mupirocin 20 mg per 1 gram Mupirocin 2% ointment | 15 gram P £12.50 DT = £5.26
▶ Bactroban (GlaxoSmithKline UK Ltd)
Mupirocin 20 mg per 1 gram Bactroban 2% ointment |
EXCIPIENTS: May contain Benzyl alcohol, cetostearyl alcohol (including
▶ Bactroban (GlaxoSmithKline UK Ltd)
Mupirocin (as Mupirocin calcium) 20 mg per 1 gram Bactroban
2% cream | 15 gram P £5.26 DT = £5.26
Other drugs used for Fungal skin infections
Hydrocortisone with clotrimazole, p. 1251
ANTIFUNGALS › IMIDAZOLE ANTIFUNGALS
▶ Child: Apply 2–3 times a day
▶ Adult: Apply 2–3 times a day
l CAUTIONS Contact with eyes and mucous membranes
l INTERACTIONS → Appendix 1: antifungals, azoles
l SIDE-EFFECTS Oedema . pain . paraesthesia . skin reactions . syncope
l PREGNANCY Minimal absorption from skin; not known to
l PRESCRIBING AND DISPENSING INFORMATION Spray may
be useful for application of clotrimazole to large or hairy
Medicines for Children leaflet: Clotrimazole for fungal infections
www.medicinesforchildren.org.uk/clotrimazole-fungalinfections
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
EXCIPIENTS: May contain Benzyl alcohol, cetostearyl alcohol (including
cetyl and stearyl alcohol), polysorbates
▶ Clotrimazole (Non-proprietary)
▶ Canesten (clotrimazole) (Bayer Plc)
Clotrimazole 10 mg per 1 gram Canesten 1% cream | 20 gram p
£2.20 DT = £0.95 | 50 gram p £3.64 DT = £2.38
Canesten Antifungal 1% cream | 20 gram p £1.85 DT = £0.95
Clotrimazole 20 mg per 1 gram Canesten 2% thrush cream | 20 gram p £4.76 DT = £4.76
▶ Canesten (clotrimazole) (Bayer Plc)
Clotrimazole 10 mg per 1 ml Canesten 1% solution | 20 ml p
Combinations available: Hydrocortisone with clotrimazole,
▶ Child: Apply once daily, applied under occlusive
▶ Adult: Apply once daily, applied under occlusive
l CAUTIONS Avoid contact with eyes and mucous
▶ Common or very common Pain . skin reactions
▶ Frequency not known Angioedema
SIDE-EFFECTS, FURTHER INFORMATION Treatment should
be discontinued if side-effects are severe.
l PREGNANCY Minimal absorption from skin; not known to
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
EXCIPIENTS: May contain Butylated hydroxyanisole, fragrances
Econazole nitrate 10 mg per 1 gram Pevaryl 1% cream |
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