Big Sky Specialty Compounding Pharmacy 1600 Whitefish Stage Rd Ste 2, Kalispell MT 59901 (Located SW Corner of Reserve across from Glacier Bank) Phone 406-752-0499 Fax 406-752-0498
Date______Phone ______D.O.B. ______
Patient Name______Allergies______
Rx: Enhanced Dermatology Formulations (Check Selection(s))
Acne ☐ Clindamycin/Azelaic Acid 2/5% in Clarifying Cream ☐ Clindamycin/Benzoyl Peroxide/Niacinamide 1/5/5% in Clarifying Cream ☐ Retinoic Acid/Erythromycin 0.025/3% in Clarifying Cream ☐ Retinoic Acid/Clindamycin 0.02/1% in Clarifying Cream ☐ Retinoic Acid/Azelaic Acid 0.025/2.5% in Clarifying Cream ☐ Dapsone/Niacinamide 5/4% in Clarifying Cream
Anti-Aging ☐ Retinoic Acid/Hyaluronic Acid/Niacinamide 0.5/0.7/4% W06 Cream ☐ Retinoic Acid/Hyaluronic Acid 0.05/0.7% W06 Cream
Melasma ☐ Hydroquinone/Retinoic Acid/Kojic Acid/Hydrocortisone 2//0.025/4/0.5% in Pracasil Plus
Psoriasis/Eczema ☐ Clobetasol/Zinc Pyrithione/B17 0.05/0.2/0.07% in Xematop Cream
Eczema ☐ Betamthasone/Mupirocin 0.012/0.15% in Xematop Cream Apply to affected area 4 to 5 times daily then taper down every 7 days.
Atopic Dermatitis ☐ Ketotifen/Vitamin B12 0.05/0.07% in Xematop Cream
Rosacea ☐ Metronidazole/Niacinamide 1/4% in Clarifying Cream
Scar ☐ Scar Therapy: Frankincense, Helichrysum, Lavender in Pracasil Plus Silicone Base
Cold Sores ☐ Acyclovir/Lidocaine 5/2% Lip Cream ☐ Acyclovir/Deoxy-D Glucose 5/0.2% Lip Cream (Option add Lidocaine)
Seborrheic Dermatitis ☐ Ketoconazole/Salicylic Acid/Zinc Pyrithione 2/2/0.2% in Xematop Cream
Nail Fungus ☐ Ketoconazole/Ibuprofen/Tea Tree Oil in DMSO 2/2/10%
Customized Formula ☐ ______
1 Month QTY: _____gm Refills ____ Sig:______
______PRINT Prescriber Prescriber’s signature (required) Prescriber Phone
We are limiting dermatology prescriptions to an estimated 1 Month (30 day) supply due to new regulations and lack of extended dating data for FDA regulations.
Enhanced Dermatology Bases
Clarifying Cream: Acne, all skin types (especially oily), red/blotchy, rosacea, reduces irritation from acne medications. Ingredients derived from: Avocado (reduces sebum production, balances DHT), chamomile (anti- inflammatory)
Pracasil Plus: 100% improvement in Scar texture/smoothness (new or old), excellent moisturizer. Ingredients: Silicone, Vitamin E, Fatty Acids
Xematop: For eczema, psoriasis, dry skin, irritation, reduces IL-6, restores skin barrier to prevent water loss. Ingredients derived from: Ceramides, Oat Beta Glucans, Chamomile, phosphatidyl glycerol, Boswellia.
Enhanced Ingredient Uses
Azelaic Acid 5-15%: Acne, Rosacea, Skin Pigmentation, Anti-microbial, Anti-inflammatory, 5-alpha reductase activity (DHT), reduces keratin, reduces melanin. Higher concentrations can cause irritation
Niacinamide 4%: lower sebum extraction rate, anti-inflammatory, Rosacea Do not use with Vitamin C (can trigger Acne)
Vitamin B12: (methylcobalamin, cyanocobalamin): Studies for Eczema & regeneration of skin cels
Ketotifen: anti-histamine, mast cell stabilizer
Kojic Acid: Skin lightener
Hyaluronic Acid: Retains Water and Moisture in Skin, reduces wrinkles, reduces redness
Additional or Alternative Options available at Big Sky Specialty Compounding
Acne: Cyclic Nano Silver Soap to skin care regimen
Eczema, Seborrheic Dermatitis, Psoriasis, Yeast: Neem Cream/Lotion
Rosacea: Neem Lotion
Cold Sores: Environmental Lip Balm (Lysine, Zinc and Essential Oils)
Melasma: Vitamin C 10-15% added to skin care regimen
Anti-Aging: Vitamin C serum added to skin care lotion or as a treatment Hyaluronic Acid Serum added to skin care lotion or regimen