Prescribing of Medicines That Are Available for Purchase (Self-Care)

Prescribing of Medicines that are Available for Purchase (Self-Care)

Funding of medicines available to purchase to treat self-limiting conditions and minor ailments and self-care is a personal responsibility.

It is expected that patients will purchase such medicines (see overleaf for examples and table), after seeking appropriate advice if required, from a healthcare professional.

All patients, regardless of where they live, should be able to access and purchase such medicines. There is a range of resources for advice on medicines use, e.g. community pharmacists, NHS 111, NHS website, which can be used to enable self-care before seeking advice from a GP or a Nurse.

Individuals are expected, where possible, to try to alter their diet and lifestyle if it is probable that this is the cause of a minor health problem, e.g. dyspepsia.

Medicines can be purchased over the counter (OTC) from community pharmacies (P)*, supermarkets (GSL)** or health food shops. These often have extended opening times therefore allowing rapid access and early treatment, rather than delaying treatment by attending a GP appointment for a prescription. The range of medicines available increases regularly and a community pharmacist would be best placed to give advice on the most appropriate product to use. Many minor ailments are not of a serious nature and will resolve within a short time-frame without the need for treatment. Please note that there may be restrictions on certain products that community pharmacists can sell OTC or for certain patient groups, dependent on the licensed status of the product (please refer to the table for further information).

Community pharmacists are able to advise and signpost patients in situations where they should seek medical advice.

Community pharmacists should not advise patients to request their GP to prescribe medicines available for self-limiting conditions and minor health problems where these are available to purchase.

If patients are regularly using OTC medicines for a long term condition e.g. regular full dose paracetamol for chronic pain, it would not be unreasonable to prescribe.

It is important to check that the OTC medicine is licensed for the indication that is it is to be used for, otherwise requests for purchasing OTC medicines for unlicensed indications will be refused by community pharmacies.

* P – Pharmacy medicines (products that can only be purchased at a pharmacy) ** GSL – General Sales List medicines (products that can be bought without consultation / supervision of a pharmacist) Note: Some products are available as both P and GSL (usually smaller pack sizes are available GSL)

General exceptions to the guidance

1. Patients prescribed an OTC treatment for a long term condition (e.g. regular pain relief for chronic arthritis or treatments for inflammatory bowel disease).

2. For the treatment of more complex forms of minor illnesses (e.g. severe migraines that are unresponsive to OTC medicines).

3. For those patients that have symptoms that suggest the condition is not minor (i.e. those with red flag symptoms, for example indigestion with very bad pain).

4. Treatment for complex patients (e.g. immunosuppressed patients).

5. Patients on prescription only treatments.

6. Patients prescribed OTC products to treat an adverse effect or symptom of a more complex illness and/or prescription only medications should continue to have these products prescribed on the NHS.

7. Circumstances where the product licence does not allow the product to be sold OTC to certain groups of patients. This may vary by medicine, but could include babies, children and/or women who are pregnant for example or breast-feeding. Community Pharmacists will be aware of what these are and can advise accordingly.

8. Patients with a minor condition suitable for self-care that has not responded sufficiently to treatment with an OTC product.

9. Patients where the clinician considers that the presenting symptom is due to a condition that would not be considered a minor condition.

10. Circumstances where the prescriber believes that in their clinical judgement, exceptional circumstances exist that warrant deviation from the recommendation to self-care.

11. Individual patients where the clinician considers that their ability to self-manage is compromised as a consequence of medical, mental health or significant social vulnerability to the extent that their health and/or wellbeing could be adversely affected, if reliant on self-care. To note that being exempt from paying a prescription charge does not automatically warrant an exception to the guidance. Consideration should also be given to safeguarding issues.

Medications for minor ailments and self-limiting conditions which should be purchased - seek advice from community pharmacists (list not exhaustive)

Items of Limited Clinical Effectiveness  PROBIOTICS  VITAMINS AND MINERALS (please refer to position statements Prescribing of vitamins and minerals, Vitamin D low dose with OTC products and Vitamin B complex)

Self-limiting Conditions  COLD SORES OF THE LIP (INFREQUENT)  CONJUNCTIVITIS  COUGHS AND COLDS AND NASAL CONGESTION  CRADLE CAP (SEBORRHOEIC DERMATITIS – INFANTS)  CYSTITIS (MILD)  HAEMORRHOIDS  INFANT COLIC (please refer to position statement Infantile Colic)  SORE THROAT (ACUTE)

Minor Conditions Suitable for Self-Care  ACNE (MILD)  ATHLETE’S FOOT / RINGWORM  BURNS AND SCALDS (MINOR)  CONSTIPATION (INFREQUENT)  DANDRUFF  DIARRHOEA IN ADULTS (ONE-OFF / NON SERIOUS)  DRY EYES / SORE TIRED EYES  DRY SKIN (MILD) (please refer to Emollient guidelines and formulary)  EARWAX  EXCESSIVE SWEATING (HYPERHIDROSIS)  HAY FEVER / SEASONAL RHINITIS (MILD TO MODERATE SYMPTOMS)  HEAD LICE  INDIGESTION AND HEARTBURN  INSECT BITES AND STINGS  IRRITABLE BOWEL SYNDROME (MILD OCCASIONAL SYMPTOMS)  IRRITANT DERMATITIS (MILD)  MIGRAINE (INFREQUENT)  MINOR CONDITIONS ASSOCIATED WITH PAIN, DISCOMFORT AND/OR FEVER (please refer to Good Practice guide for the Prescribing of Paracetamol and refer to position statement Rubefacients)  MOUTH ULCERS  NAPPY RASH  ORAL THRUSH  PREVENTION OF DENTAL CARIES (TOOTH DECAY) (please refer to position statement High strength fluoride toothpaste, mouthwashes and tablets)  SCABIES  SUNBURN DUE TO EXCESSIVE SUN EXPOSURE  SUN PROTECTION (please refer to position statement Sunscreen)  TEETHING / MILD TOOTHACHE  THREADWORMS  TOPICAL FUNGAL NAIL INFECTIONS (please refer to position statement Fungal Nail Infection)  TRAVEL SICKNESS (please refer to Travel advice)  VAGINAL THRUSH  WARTS AND VERRUCAE

Products not Suitable for GP Prescribing  Antiseptic creams / gels / ointments (e.g. Savlon, Germolene)  Complementary medicines / health supplements  Creams / gels for:  abrasions / irritated skin (minor)  hair removal (e.g. Veet, Nair)  bruising (e.g. Arnica)  scars (please refer to position statement Silicone dressings)  tattoos  varicose veins (e.g. Hirudoid)  Dietetic products (e.g. gluten free foods – please refer to local guidance)  Infant formula (e.g. soya, anti-reflux, lactose free – please refer to local guidance)  Gargles  Lozenges  Mouthwashes  Sip feeds / oral nutritional supplements (unless meeting ACBS criteria – please refer to local guidance)  Swimming preparations  Toiletries  Tonics (e.g. Metatone, Floravital)  Throat sprays  Toothpastes  Tubigrip / plasters / bandages for sprains and sports injuries

Position Statement No. 28 Title Prescribing of Medicines that are Available for Purchase (Self-Care) References 1. C+D Guide to OTC Spring & Summer 2019 2. OTC Directory September 2019 3. OTC Directory online: https://www.otcdirectory.co.uk/ (accessed January 2020) 4. www.nhs.uk (accessed December 2019 and January 2020) 5. NHS England: ‘Conditions for which OTC items should not routinely be prescribed in primary care: Guidance for CCGs’ (March 2018): https://www.england.nhs.uk/wp-content/uploads/2018/03/otc-guidance-for- ccgs.pdf Acknowledgements Mid Essex CCG Medicines Management Team Version 3 Author Medicines Management Team Approved by Basildon and Brentwood CCG: Prescribing Subgroup, Patient Quality and Safety Committee, Board Thurrock CCG: Medicines Management and Safety Group, Patient Quality and Safety Committee, Transformation and Sustainability Committee, Board Basildon and Brentwood CCG and Thurrock CCG Virtual Prescribing Group Date Approved May 2020 Review Date May 2022

PROBIOTICS There is currently insufficient clinical evidence to support the prescribing of probiotics (e.g. VSL#3 and Vivomixx) within the NHS for the treatment or prevention of diarrhoea of any cause.

Public Health England C.difficile guidance and NICE CG 84 recommend that probiotics cannot be recommended currently and that “Good quality randomised controlled trials should be conducted in the UK to evaluate the effectiveness and safety of a specific probiotic using clearly defined treatment regimens and outcome measures before they are routinely prescribed.”

Exceptions No routine exceptions have been identified

VITAMINS AND MINERALS There is insufficient high quality evidence to demonstrate the clinical effectiveness of vitamins and minerals.

Vitamins and minerals are essential nutrients which most people can and should get from eating a healthy, varied and balanced diet. In most cases, dietary supplementation is unnecessary.

Many vitamin and mineral supplements are classified as foods and not medicines. They therefore do not have to go through the strict criteria laid down by the Medicines and Healthcare products Regulatory Agency (MHRA) to confirm their quality, safety and efficacy before reaching the market. It is therefore not deemed appropriate for such preparations to be routinely funded on the NHS.

Any prescribing not in-line with listed exceptions should be discontinued.

Exceptions  Medically diagnosed deficiency, including for those patients who may have a lifelong or chronic condition or have undergone surgery that results in malabsorption. Continuing need should however be reviewed on a regular basis. N.B. maintenance or preventative treatment is not an exception.  Calcium and vitamin D for osteoporosis.  Malnutrition including alcoholism.

COLD SORES OF THE LIP (INFREQUENT) Illness Cold sores caused by the herpes simplex virus usually clear up without treatment within seven to ten days.

 Antiviral creams are available OTC from pharmacies and supermarkets without a prescription. If used correctly, they can help ease symptoms and speed up the healing time Advice to patients  To be effective, apply as soon as the first signs of a cold sore appear

 Using an antiviral cream after this initial period is unlikely to have much of an effect

Examples of medicines  Aciclovir 5% cream (P and GSL) (brands include: Zovirax / Virasorb / Clearsore / Cymex Ultra) available OTC

 Immunocompromised and terminally ill OTC restrictions  Only for face and lips

 Immunocompromised patients Exceptions  ‘Red flag’ symptoms

CONJUNCTIVITIS Treatment is not usually needed for conjunctivitis as the symptoms usually clear within a week. There are several self-care measures that may help with symptoms. If treatment is needed, then treatment is dependent on the cause: Illness  In severe bacterial cases, antibiotic eye drops and eye ointments can be used to clear the infection  Irritant conjunctivitis will clear up as soon as whatever is causing it is removed  Allergic conjunctivitis can usually be treated with anti-allergy medications such as antihistamines (the substance that caused the allergy should be avoided)

 Treatments for conjunctivitis can be purchased OTC, however, almost half of all simple cases of conjunctivitis clear up within 10 days without any treatment  Public Health England (PHE) advises that children with infective conjunctivitis do not need to be excluded from Advice to patients school, nursery or child minders, and it does not state any requirement for treatment with topical antibiotics

 All infectious eye conditions may benefit from bathing the affected eye(s) in boiled, cooled water to remove any crusting and to keep the area clean

 Chloramphenicol 0.5% eye drops (P) (brands include: Golden Eye Antibiotic / Optrex Infected / Brolene) Examples of medicines  Chloramphenicol 1% eye ointment (P) (brands include: Brochlor / Golden Eye Antibiotic / Optrex Bacterial available OTC Conjunctivitis)

 Children under 2 years  Pregnancy OTC restrictions  Breastfeeding  Many eye preparations should not be used by contact lens wearers (check individual packs for details)

‘Red flag’ symptoms Exceptions

COUGHS AND COLDS AND NASAL CONGESTION Most colds start to improve in 7 to 10 days. Most coughs clear up within two to three weeks. Both conditions can Illness cause nasal congestion. Neither condition requires any treatment. Coughs and colds and nasal congestion

Advice to patients These conditions do not require any treatment. However, some OTC medicines help to relieve symptoms

 Paracetamol (P and GSL) (brands include: Anadin Paracetamol 500mg tablets / Mandanol 500mg tablets / Calpol Infant Sugar Free 120mg/5ml suspension / Calpol Six Plus Sugar Free 250mg/5ml suspension / Calpol Six Plus 250mg Fastmelts)  Ibuprofen (P and GSL) (brands include: Nurofen 200mg caplets / Nurofen for Children 100mg/5ml oral suspension / Cuprofen Maximum Strength 400mg tablets)  Pseudoephedrine 60mg tablets (P) (brands include: Sudafed Decongestant) Examples of medicines  Paracetamol 250mg + guaifenesin 100mg + phenylephrine 5mg tablets (GSL) (brands include: Beechams available OTC All-In-One)  Aspirin 600mg + caffeine 50mg (P and GSL) (brands include: Beechams powders)  Paracetamol 500mg + pseudoephedrine 22.5mg + diphenhydramine 12.5mg tablets (P) (brands include: Benylin 4 Flu)  Sodium chloride 0.9% (P and GSL) (brands include: Snufflebabe nasal drops and spray / Sterimar congestion relief spray)  Aromatic inhalations (GSL) (brands include: Olbas oil / Vicks vapour rub)

 Paracetamol - long term conditions requiring regular pain relief, severe renal or severe hepatic impairment, children under 2 months, babies born before 37 weeks and babies weighing less than 4kg  Ibuprofen - long term conditions requiring regular pain relief, asthma, unstable high blood pressure, patients taking anticoagulants, stomach ulcer, perforation or bleeding (active or history of), renal, hepatic or cardiac OTC restrictions impairment, pregnancy, breastfeeding, children under 3 months and not for use in chicken pox

 Pseudoephedrine - children under 12 years, pregnancy, breastfeeding, severe hypertension, severe coronary artery disease, severe renal impairment, phaeochromocytoma, diabetes, hyperthyroidism and closed angle glaucoma

‘Red flag’ symptoms Exceptions

CRADLE CAP (SEBORRHOEIC DERMATITIS – INFANTS) Cradle cap is harmless and doesn’t usually itch or cause discomfort. It occurs during the first 3 months of life Illness and generally resolves spontaneously within 1 year without treatment.

 The scales can be loosened by rubbing oil on the baby’s head at night then shampooing out in the morning Advice to patients  Scales should not be picked off the scalp  The condition is harmless and is not due to infection, allergy or poor hygiene

 Emulsifying shampoo (GSL) (brands include: Dentinox Cradle Cap Treatment Shampoo / Johnson’s Baby oil) Examples of medicines  Coal tar 1% + coconut oil 0.1% + salicylic acid 0.5% shampoo (GSL) (brands include: Capasal Therapeutic available OTC shampoo)

 Oils (GSL) (brands include: John’s Baby oil)

 Cradle cap that has spread to the face OTC restrictions  The skin of the scalp appears broken or inflamed

If causing distress to the infant and not improving Exceptions

CYSTITIS (MILD) Mild cystitis is a common type of urinary tract inflammation, normally caused by an infection; however it is usually more of a nuisance than a cause for serious concern. Mild cases can be defined as those that are Illness responsive to symptomatic treatment but will also clear up on their own. If symptoms don’t improve in 3 days,

despite self-care measures, then the patient should be advised to see their GP.

 Symptomatic treatment using products that reduce the acidity of the urine to reduce symptoms are available, but there is a lack of evidence to suggest they are effective  Start taking the remedy as soon as possible after the onset of symptoms, and complete the course of treatment even if symptoms appear to resolve Advice to patients  Increase fluid intake to help flush out the infection and encourage urination

 Reduce caffeine and alcohol intake  Avoid tight fitting clothes and underwear, as these can encourage bacterial growth  Avoid acidic drinks and spicy foods as these can cause bladder irritation

 Sodium citrate 4g sachets (GSL) (brands include: Cystocalm / Cymalon / CanesOasis) Examples of medicines Potassium citrate 1.5g liquid / effervescent tablets or 3g sachets (GSL) (brands include: Cystopurin / available OTC  Effercitrate)

 Sodium citrate 4g sachet products – men, children under 16 years, diabetes, heart disease, hypertension, OTC restrictions renal disease, pregnancy and breastfeeding  Potassium citrate products - children under 6 years, history of renal disease, pregnancy and breastfeeding

‘Red flag’ symptoms Exceptions

HAEMORRHOIDS  Commonly known as piles, haemorrhoids are varicose veins that occur in or around the rectum  They can be internal or external  There are a number of possible causes including constipation, obesity, pregnancy and childbirth and people Illness who sit or stand all day may be more prone  Symptoms include itching, discomfort and sometimes pain  There may be bleeding when the bowels are open, usually seen as traces of blood on the toilet paper or on the surface of the stools

 In many cases, haemorrhoids don't cause symptoms and some people don't even realise they have them  Haemorrhoids often clear up by themselves after a few days  Making simple dietary changes and not straining on the toilet are often recommended first Advice to patients  Avoiding constipation by increasing fibre and fluid intake can help  There are many treatments (creams, ointments and suppositories) that can reduce itching and discomfort and these are available OTC for purchase

 Zinc oxide (GSL) (brands include: Anusol cream and ointment) Examples of medicines  Zinc oxide + lidocaine (P) (brands include: Germoloids cream, ointment and suppositories) available OTC  Zinc oxide + hydrocortisone (P) (brands include: Anusol Plus HC ointment and suppositories)

 Children under 18 years  Significant amounts of bleeding, or blood that is dark or mixed in with the stools OTC restrictions  Breastfeeding  Hydrocortisone containing products should be used for a maximum of 7 days, and should not be used by pregnant women

‘Red flag’ symptoms Exceptions

INFANT COLIC  Infant colic is described as repeated episodes of excessive crying that cannot be explained in an otherwise healthy, well fed baby Illness  Usually occurring in the late afternoon or evening, the condition is characterised by frantic, high-pitched crying and the baby bringing his or her knees to the chest  Bouts start around 2-4 weeks of age and last for 3-4 months. It is rare in babies older than 6 months

 As colic eventually improves on its own, medical treatment isn’t usually recommended Advice to patients  There are some OTC treatments available that could be tried, however, there is limited evidence for the effectiveness of these treatments

 Simeticone 40mg/ml suspension (GSL) (brands include: Infacol) Examples of medicines  Dimeticone 42mg/5ml drops (GSL) (brands include: Dentinox) available OTC  Sodium hydrogen carbonate 52.5mg/5ml (GSL) (brands include: Woodward’s Gripe Water)

OTC restrictions  Dimeticone 42mg/5ml – fructose, glucose-galactose or sucrose intolerant patients (contains sucrose)

‘Red flag’ symptoms Exceptions

SORE THROAT (ACUTE) A sore throat due to a viral or bacterial cause is a self-limiting condition. Symptoms resolve within 3 days in 40% Illness of people, and within 1 week in 85% of people, irrespective of whether or not the sore throat is due to a streptococcal infection.

There is little evidence to suggest that treatments such as lozenges or throat sprays help to treat the cause of Advice to patients sore throat and patients should be advised to take simple painkillers and implement some self-care measures such as gargling with warm salty water instead

 Benzocaine 0.71% spray (GSL) (brands include: Ultra Chloraseptic) Examples of medicines  Benzydamine hydrochloride 0.15% (P) (brands include: Difflam spray, sore throat rinse) available OTC  Lidocaine lozenges (P) (brands include: Chloralieve / Covonia)

 All preparations – pregnancy and breastfeeding  Benzocaine – Children under 6 years OTC restrictions  Benzydamine hydrochloride – spray: children under 6 years, sore throat rinse: children under 12 years  Lidocaine lozenges – children under 12 years

‘Red flag’ symptoms Exceptions

ACNE (MILD)  Acne, particularly acne vulgaris, is the most frequently encountered skin disorder in teenagers and young adults  It is a disorder of the sebaceous follicles of the skin and is associated with the extra oiliness of the skin caused by hormonal changes at puberty Illness  Increased sebum production and blocked follicles lead to the formation of comedones, then microorganisms

break down the excess sebum into fatty acids, which cause inflammation and irritation  Typically, the face, neck and shoulders are affected  In most cases, acne resolves before the age of 30

 Acne is a common skin condition that affects most people at some point, although acne can't be cured, it can be controlled with treatment  Simple washing with an antibacterial soap and warm (not hot) water twice a day will help manage the condition  Several creams, lotions and gels for treating acne are available at pharmacies. Treatments can take up to Advice to patients three months to work  Apply products to the entire area affected and not just individual spots  Avoid greasy or thick make up, look for products that claim to be anticomedogenic or oil free  Keep all acne preparations away from eyes, mouth and mucous membranes and irritated skin  Benzoyl peroxide has a bleaching effect, which may affect fabrics and hair and may cause skin irritation or peeling, so tolerance should be built up gradually

Examples of medicines  Benzoyl peroxide 5% and 10% (P) (brands include: Acnecide gel) available OTC  Nicotinamide 4% gel (P) (brands include: Freederm / Nicam)

 Children under 12 years  Elderly OTC restrictions  Pregnancy and breastfeeding  Damaged skin

No routine exceptions have been identified Exceptions

ATHLETE’S FOOT / RINGWORM  Athlete's foot is a rash caused by a fungus that usually appears between the toes Illness  Ringworm is a common fungal infection that can cause a red or silvery ring-like rash on the skin. Despite its name, ringworm doesn't have anything to do with worms athlete’s foot / ringworm

 These fungal infections, medically known as "tinea", are not serious and are usually easily treated OTC  They are contagious and easily spread  It is important to practice good foot hygiene Advice to patients  Continue treatment for 2 weeks after the athlete’s foot appears to have cleared to ensure it is cured  Wearing natural fibres, such as cotton socks and leather shoes will allow the feet to breathe and reduce the risk of reinfection  Use antifungal powder in shoes and socks to prevent reinfection

 Miconazole 2% cream and powder (P) (brands include: Daktarin) Examples of medicines  Terbinafine 1% (GSL) (brands include: Lamisil AT 1% cream, spray / Lamisil Once solution) available OTC  Clotrimazole 1% (P) (brands include: Canesten cream / Canesten Dermatological spray / Canesten Dual Action cream)

 All preparations – diabetes, pregnancy and breastfeeding OTC restrictions  Miconazole – cream: extra monitoring for patients on anticoagulants  Terbinafine – cream and spray: children under 16 years, solution: children under 18 years

 Lymphoedema Exceptions  History of lower limb cellulitis

BURNS AND SCALDS (MINOR) Illness Burns and scalds are damage to the skin caused by heat. Both are treated in the same way.

 Depending on how serious a burn is, it is possible to treat burns at home  Antiseptic creams and treatments for burns should be included in any products kept in a medicine cabinet at home  Cool the burn with cool or lukewarm running water for 20 minutes (do not use ice, iced water, or any creams Advice to patients or greasy substances like butter)

 Remove any clothing or jewellery that is near the burnt area of skin, including babies' nappies, but do not move anything that is stuck to the skin  Cover the burn by placing a layer of cling film over it

 Antiseptics (GSL) (brands include: Germolene wound care cream / Savlon antiseptic cream / Betadine dry powder spray / Sudocrem antiseptic healing cream) Examples of medicines  Cooling gels (GSL) (brands include: Acriflex skin cooling gel) available OTC  Paracetamol and ibuprofen can be used to treat any pain (see coughs and colds and nasal congestion for more information)

Betadine dry powder spray – pregnancy, breastfeeding, children under 2 years, avoid regular use in patients OTC restrictions taking lithium or patients with thyroid disorder

More serious burns always require professional medical attention. Burns requiring hospital A&E treatment include but are not limited to:  all chemical and electrical burns Exceptions  large or deep burns  burns that cause white or charred skin  burns on the face, hands, arms, feet, legs or genitals that cause blisters

CONSTIPATION (INFREQUENT) Illness Constipation is common and it affects people of all ages. It can usually be treated at home with simple changes to diet and lifestyle.

 Pharmacists can help if diet and lifestyle changes are not helping  They can suggest an OTC laxative. Most laxatives work within 3 days (they should only be used for a short time only)  Drink plenty of fluids and avoid alcohol  Increase the fibre in diet  Add some wheat bran, oats or linseed to diet  Advise patients not to delay the urge to go to the toilet  Increase exercise / activity (a daily walk or run can help go more regularly)

Advice to patients For babies and toddlers:  For bottle-fed babies offer extra drinks of water between feeds (do not add more water to formula feeds)  Breastfed babies rarely get constipated (they do not need anything but breast milk for the first 6 months)  Gently moving babies legs in a bicycling motion or carefully massaging their tummy can help to stimulate their bowels  Give older children plenty of fluids and encourage them to eat fruit (the best fruits for constipation include apples, grapes, pears and strawberries)  Some children feel anxious or stressed about using the toilet, this can cause them to hold in their poo and lead to constipation. This usually happens during potty training or if their usual toilet routine has changed e.g. after moving house or starting nursery, therefore give children plenty of time to use the toilet while they are still learning

 Senna (stimulant laxative) (GSL) (brands include: Senokot 7.5mg tablets / Senokot Max Strength 15mg tablets / Senokot 7.5mg/5ml syrup) Examples of  Bisacodyl (stimulant laxative) (P and GSL) (brands include: Dulcolax 5mg tablets / Dulcolax 10mg suppositories / Entrolax 5mg medicines available tablets) OTC  Docusate sodium 100mg capsules (stool softener and weak stimulant) (P and GSL) (brands include: DulcoEase)  Ispaghula husk 3.5g sachets (bulk forming) (P) (brands include: Fybogel Hi-Fibre)  Lactulose 10g/15ml oral solution (osmotic laxative) (P)  Glycerin suppositories (lubricant and rectal stimulant) (P and GSL)

 Senna – intestinal obstruction, severe dehydration, children under 12 years, pregnancy and breastfeeding  Bisacodyl – intestinal obstruction, severe dehydration, pregnancy and breastfeeding, children under 10 years OTC restrictions  Docusate sodium – intestinal obstruction  Ispaghula husk – intestinal obstruction, faecal impaction, children under 6 years  Lactulose – intestinal obstruction

Exceptions Laxatives are not recommended for children unless they are prescribed by a GP

DANDRUFF Illness Dandruff is a common skin condition. It can be defined as mild scaling of the scalp without itching.

 Dandruff isn't contagious or harmful and can be easily treated with OTC anti-fungal shampoos Advice to patients  Products containing coal tar can stain baths and fabrics  Patients with dandruff should avoid overusing hairdryers

 Ketoconazole 2% shampoo (P) (brands include: Nizoral) Examples of medicines  Selenium sulphide 2.5% shampoo (P) (brands include: Selsun) available OTC  Coal tar shampoo (GSL) (brands include: Neutrogena T/Gel / Alphosyl 2-in-1)

 All preparations – pregnant and breastfeeding  Ketoconazole – children under 12 years OTC restrictions  Selenium sulphide – children under 5 years, broken or severely inflamed skin  Coal tar – children under 12 years

No routine exceptions have been identified Exceptions

DIARRHOEA IN ADULTS (ONE-OFF / NON SERIOUS) Acute diarrhoea is usually caused by a bacterial or viral infection and other causes include drugs, anxiety or a Illness food allergy. Diarrhoea in adults

 Diarrhoea normally affects most people from time to time and is usually nothing to worry about  It can take a few days to a week to clear up  Stay at home and get plenty of rest  Drink lots of fluids, such as water or squash (small sips can help if sickness is involved)  Patients should eat again when they feel able to (there is no need avoid any specific foods) Advice to patients  Do not have fizzy drinks (they can make diarrhoea worse)

For babies and toddlers:  Carry on breast or bottle feeding  If they are being sick, try giving small feeds more often than usual  Give babies on formula or solid foods small sips of water between feeds

 Oral rehydration sachets (GSL) (brands include: Dioralyte / Dioralyte Relief) Examples of medicines  Loperamide 2mg (P and GSL) (brands include: Imodium capsules and Instants / Diah-Limit capsules / available OTC DioraleZe capsules)

 Oral rehydration – patients with liver or kidney disease, patients on low potassium/sodium diets, diabetes OTC restrictions  Loperamide – children under 12 years, inflammatory bowel disease, post bowel surgery, post pelvic radiation, colorectal cancer

This recommendation does not apply to children Exceptions

DRY EYES / SORE TIRED EYES Dry eye syndrome, or dry eye disease, is a common condition that occurs when the eyes don’t make enough Illness tears, or the tears evaporate too quickly. Dry eyes / sore tired eyes

 Most cases of sore tired eyes resolve themselves  Mild to moderate cases of dry eye syndrome or sore tired eyes can usually be treated using lubricant eye treatments that consist of a range of drops, gels and ointments that can easily be purchased OTC  Keep eyes clean  Take breaks to rest eyes when using a computer screen Advice to patients  Make sure computer screen is at eye level, to avoid straining eyes  Use a humidifier to stop the air getting dry  Get plenty of sleep to rest eyes  Contact lens wearers can take them out and wear glasses to rest eyes  Medications with anticholinergic side effects, which can exacerbate dry eye syndrome should be reviewed and stopped where appropriate, such as topical and systemic antihistamines

 Hypromellose eye drops (P) (brands include: Artelac 0.32%)  Carbomer eye gel (P) (brands include: GelTears 0.2% / Liquivisc 0.25%) Examples of medicines  Carmellose 0.5% and 1% eye drops (P) (brands include: Carmize / Celluvisc) available OTC  Sodium hyaluronate eye drops (P) (brands include: Clinitas Soothe 0.4% / Hyabak 0.15%)  Lacri-Lube eye ointment (P)

OTC restrictions Some products have restrictions for contact lens wearers (check individual packs for details)

 Severe symptoms where the use of ocular lubricants is essential to preserve sight function  Severe ocular surface disease (OSD) caused by the following conditions: Sjögren’s syndrome, autoimmune Exceptions disease (e.g. Rheumatoid arthritis, ulcerative keratitis), neurotrophic cornea  Previous corneal conditions, recurrent corneal erosions, corneal injury

DRY SKIN (MILD) Illness Dry skin is a condition marked by scaling, itching and cracking.

 Emollients are often used to help manage dry, itchy or scaly skin conditions  Emollients are moisturising treatments applied directly to the skin to soothe and hydrate it, they cover the skin Advice to patients with a protective film to trap in moisture

 Patients with mild dry skin can be successfully managed using OTC products on a long term basis

Examples of medicines  Emollients (GSL and P depending on product and pack size) (brands include: Aveeno / Balneum / Cetraben / available OTC E45 / Oilatum / Zerobase)

 Broken or infected skin OTC restrictions  See individual products for age restrictions

No routine exceptions have been identified Exceptions

EARWAX Earwax is produced inside ears to keep them clean and free of germs. It usually passes out of the ears Illness harmlessly, but sometimes too much can build up and block the ears.

 A build-up of earwax is a common problem that can often be treated using eardrops bought from a pharmacy. These can help soften the earwax so that it falls out naturally Advice to patients Do not use fingers or any objects like cotton buds to remove earwax, as they may result in compaction of the  earwax or piercing of the ear drum

 Olive oil ear drops (GSL) (brands include: Cerumol Extra Virgin) Examples of medicines  Docusate sodium 0.5% ear drops (P) (brands include: Waxsol) available OTC  Urea hydrogen peroxide 5% ear drops (GSL) (brands include: Otex)  Urea hydrogen peroxide 5% + glycerin ear drops (GSL) (brands include: Earex Advance)

 All preparations – perforated ear drum, inflammation of the ear  Acetic acid – children under 12 years  Urea hydrogen peroxide – children under 5 years OTC restrictions  Urea hydrogen peroxide + glycerin– children under 5 years

(N.B. Some ear drops contain arachis oil, a refined version of peanut oil usually considered non-allergenic, check individual packs for details)

No routine exceptions have been identified Exceptions

EXCESSIVE SWEATING (HYPERHIDROSIS)  Excessive sweating (hyperhidrosis) is a common condition in which a person sweats excessively Illness It can affect the whole body or just certain areas 

 First line treatment involves simple lifestyle changes  It can also be treated with OTC high strength antiperspirants  Wear loose-fitting clothes to minimise signs of sweating  Wear socks that absorb moisture and change socks at least twice a day if possible Advice to patients  Wear leather shoes and try to wear different shoes day to day  Do not wear tight clothes or man-made fabrics – for example, nylon  Do not wear enclosed boots or sports shoes that may cause feet to sweat more  Do not do things that might make sweating worse – for example, drinking alcohol or eating spicy food

Examples of medicines  Aluminium chloride 20% solution (P) (brands include: Driclor / Anhydrol Forte) available OTC

 Should only be used on small area of skin OTC restrictions  Should not be used on skin that is broken  Should not be used immediately after washing or shaving

No routine exceptions have been identified Exceptions

HAY FEVER / SEASONAL RHINITIS (MILD TO MODERATE SYMPTOMS)  Hay fever is a common allergic condition that affects up to one in five people Illness  It is usually worse between late March and September, especially when it is warm, humid and windy. This is when the pollen count is at its highest hay fever / seasonal rhinitis

 There is currently no cure for hay fever, but most people with mild to moderate symptoms are able to relieve symptoms with OTC treatments recommended by a pharmacist  More than one product can be used at a time (as long as a doctor or pharmacist has been consulted)  Some antihistamines may cause drowsiness, which may cause problems with driving and the affect is potentiated by alcohol Advice to patients  Avoid going outdoors when the pollen count is very high and during daily pollen peaks (early morning and dusk)  Avoid walking through long grass and lawn mowing  Wash hair after being outside  Avoid stroking animals that may have pollen on their coats  Keep all windows closed, even at night  Wear sunglasses on warm sunny days

 Chlorphenamine (P) (brands include: Piriton Allergy 4mg tablets / Piriton 2mg/5ml syrup) Examples of  Loratadine (P and GSL) (brands include: Clarityn Allergy 10mg tablets / Lorapaed Allergy Relief 5mg/5ml oral solution) medicines available  Acrivastine 8mg capsules (P and GSL) (brands include: Benadryl Allergy Relief) OTC  Cetirizine (P and GSL) (brands include: Piriteze 10mg Allergy tablets / Piriteze Allergy 5ml/5ml syrup)  Beclometasone 0.05% nasal spray (P and GSL) (brands include: Beconase Hayfever)  Sodium cromoglicate 2% eye drops (P and GSL) (brands include Allercrom / Optrex Allergy / Opticrom Hayfever)

 All preparations – pregnancy and breastfeeding  Chlorphenamine – epilepsy, taken monoamine oxidase inhibitors within the last 14 days, raised intra-ocular pressure including glaucoma, prostatic hypertrophy, severe hypertension or cardiovascular disease, bronchitis, bronchiectasis or asthma, hepatic impairment, renal impairment, rare hereditary problems of galactose intolerance, Lapp lactase deficiency or glucose-galactose malabsorption, tablets: children under 6 years, syrup: children under 1 year OTC restrictions  Loratadine - rare hereditary problems of galactose intolerance, the Lapp lactase deficiency or glucose-galactose malabsorption, liver impairment, tablets: children under 6 years, oral solution: children under 2 years  Acrivastine - children under 12 years and adults over 65 years, renal impairment, rare hereditary problems of galactose intolerance, the Lapp lactase deficiency or glucose-galactose malabsorption  Cetirizine – renal impairment, rare hereditary problems of fructose intolerance, tablets and syrup: children under 6 years  Beclometasone – children under 18 years  Sodium cromoglicate – children under 6 years

Exceptions No routine exceptions have been identified

HEAD LICE Head lice are a common problem, particularly in school children aged 4-11. They are largely harmless, but can Illness live in the hair for a long time if not treated and can be irritating and frustrating to deal with.

 They are not associated with dirty hair and are picked up by head-to-head contact  Live head lice can be treated by wet combing - wash hair as usual then use conditioner, do not wash this off, use a normal comb to untangle hair, then a fine-toothed head lice detection comb to remove live head lice (do wet combing on days 1, 5, 9 and 13 to catch any newly hatched head lice and check all household members’ hair is free of lice on day 17)  Chemical treatment is only recommended in exceptional circumstances and in these cases OTC medicines can be purchased from a pharmacy Advice to patients  If appropriate everyone in the household needs to be treated at the same time - even if they don't have symptoms  Prophylactic use of head lice products is not recommended as it may cause resistance and scalp irritation  Lotions, rather than shampoos are recommended because they stay in contact with the hair for longer  Some of the products listed are alcoholic lotions and therefore flammable. Patients should be advised not to use hair dryers on hair wetted with these lotions and instead the lotions should be allowed to dry naturally in a well ventilated area, away from naked flames  Avoid sharing hats, combs, hairbrushes, towels, pillows

 Dimeticone 4% (GSL – spray, P – lotion) (brands include: Hedrin cutaneous lotion / Lyclear treatment spray) Examples of medicines  Malathion 0.5% aqueous liquid (P) (brands include: Derbac-M) available OTC  Permethrin 1% (P) (brands include: Lyclear Crème Rinse)  Head lice comb

OTC restrictions  All preparations – babies under 6 months

 Concurrent scalp conditions such as psoriasis Exceptions  Signs and symptoms indicative of severe infestation (e.g. tiredness)

INDIGESTION AND HEARTBURN Indigestion is a term used to describe a range of symptoms such as discomfort, distension, belching, flatulence, nausea and Illness vomiting, or heartburn. The condition may be due to incomplete digestion or delayed emptying of food from the stomach.

 Most people are able to manage their indigestion by making simple diet and lifestyle changes, or taking medication such as antacids  Most people can ease symptoms by simple changes to diet and lifestyle and avoiding foods that make indigestion worse (e.g. rich spicy or fatty foods, caffeinated drinks) Advice to patients  Maintain a healthy weight as being overweight can cause extra strain on the stomach  Tight clothing may cause discomfort  Eating frequent, smaller meals may be better than fewer larger meals  Stress may be a trigger, so using relaxation methods may help  Propping up the head of the bed may help to prevent acid reflux at night, as well as not going to bed with a full stomach

 Antacids (P and GSL) (brands include: Maalox suspension / Mucogel suspension / Phillips’ Milk of Magnesia liquid / Rennie tablets) Examples of  Alginates (P and GSL) (brands include: Gaviscon Original liquid / Gaviscon Peppermint Flavour tablets / Gaviscon Advance medicines available suspension, tablets / Acidex suspension) OTC  Bismuth compounds (P) (brands include: Pepto-Bismol tablets, suspension)  Ranitidine 75mg tablets (P and GSL) (brands include: Gavilast / Ranicalm)  Esomeprazole 20mg tablets and capsules (P and GSL) (brands include: Nexium Control)

 All preparations – aged over 45 years or under 12 years, symptoms longer than 1 week, symptoms not relieved by OTC products, difficulty swallowing, complaining of breathlessness, chest tightness, coughing, wheezing or pain radiating down the arm or into the back, unexpected weight loss, blood in stools, vomiting  Antacids – products containing magnesium and aluminium should not be used by anyone with hypophosphataemia, kidney failure, see individual products for age restrictions OTC restrictions  Alginates – patients on sodium restricted diets, renal failure, hypercalcaemia, nephrocalcinosis, kidney stones, see individual products for age restrictions  Bismuth compounds – aspirin hypersensitivity, patients taking anticoagulation medication, diabetes, gout, children under 16 years, pregnancy and breastfeeding  Ranitidine – children under 16 years indigestion and heartburn  Esomeprazole and pantoprazole – children under 18 years, pregnancy and breastfeeding, renal or hepatic impairment

Exceptions No routine exceptions have been identified

INSECT BITES AND STINGS Illness Most insect bites and stings are not serious and will get better within a few hours or days.

Advice to patients OTC treatments can help ease symptoms, such as painkillers, creams for itching and antihistamines

 Mepyramine 2% cream (GSL) (brands include: Anthisan)  Hydrocortisone 1% cream (P) (brands include HC45) Examples of medicines  Savlon Bites & Stings Pain Relief gel (GSL) available OTC  Calamine lotion (GSL)

 Oral antihistamines can also be used (see hay fever / seasonal rhinitis for more information)

 All preparations – broken or infected skin  Mepyramine – children under 2 years OTC restrictions Hydrocortisone – children under 10 years, maximum 7 days use   Savlon – children under 12 years

No routine exceptions have been identified Exceptions

IRRITABLE BOWEL SYNDROME (MILD OCCASIONAL SYMPTOMS)  Irritable Bowel Syndrome (IBS) is a common gut disorder, though its cause is unknown  Up to 1 in 5 people in the UK develop IBS at some stage in their life, with women, teenagers and young adults more likely to suffer Illness  There is no test for IBS, so diagnosis is by exclusion and should be confirmed by a doctor  Symptoms can vary between episodes and may affect both the upper and lower gastrointestinal tract, they include one or all of abdominal pain, bloating, diarrhoea, constipation, excessive wind, changed stools and rectal discomfort or urgency  Other symptoms may occur, such as nausea, headache, belching, poor appetite and tiredness

 It is usually a lifelong problem. It can be very frustrating to live with and can have a big impact on everyday life. There is no cure, but diet changes and medicines can often help control the symptoms  Avoid stress – stress is one of the main triggers for IBS episodes  Identify food triggers – wheat, rye, barley, dairy products, caffeine and onions have all been linked to IBS  Increasing fibre or reducing alcohol intake may help  Exercise may be beneficial, especially if symptoms include trapped wind or constipation  Quit smoking Advice to patients  Infections may set off an attack

 Try probiotics for a month to see if they help  Do not delay or skip meals  Do not eat too quickly  Do not eat lots of fatty, spicy or processed food (cook homemade meals using fresh ingredients when possible)  Do not eat more than 3 portions of fresh fruit a day (a portion is 80g)  Do not drink more than 3 cups of tea or coffee a day  Avoid fizzy drinks

Examples of  Hyoscine butylbromide 10mg tablets (brands include: Buscopan Cramps (P) / Buscopan IBS Relief (GSL)) medicines available  Mebeverine 135mg tablets (P) (brands include: Colofac IBS) OTC  Alverine capsules (P) (brands include: Audmonal 60mg / Audmonal Forte 120mg)  Peppermint oil 0.2ml capsules (GSL) (brands include: Colpermin IBS Relief)

 All preparations – undiagnosed or symptoms are experienced for the first time  Hyoscine butylbromide – patients with narrow angle glaucoma, myasthenia gravis, megacolon, pregnancy and OTC restrictions breastfeeding, Buscopan cramps: children under 6 years, Buscopan IBS Relief: children under 12 years  Mebeverine – children under 18 years, pregnancy and breastfeeding  Alverine – children under 12 years, paralytic ileus, intestinal obstruction, pregnancy and breastfeeding  Peppermint oil – children under 15 years, peanut or soya allergy, chronic heartburn, pregnancy and breastfeeding

Exceptions ‘Red flag’ symptoms

IRRITANT DERMATITIS (MILD) Irritant dermatitis is a type of eczema triggered by contact with a particular substance. Once treated most people can expect their Illness symptoms to improve and/or clear up completely if the irritant or allergen can be identified and removed or avoided. It is most commonly caused by irritants such as soaps, washing powders, detergents, solvents or regular contact with water.

 Treatment normally involves avoiding the allergen or irritant and treating symptoms with OTC emollients and topical corticosteroids  The best way to prevent contact dermatitis is to avoid contact with the allergens or irritants that cause symptoms  If contact cannot be avoided, take steps to reduce the risk of the allergens or irritants causing symptoms, including: - Cleaning skin – when contact is made with an allergen or irritant, rinse the affected skin with warm water and an emollient as Advice to patients soon as possible - Using gloves to protect hands – but take them off every now and again, as sweating can make any symptoms worse. It may be useful to wear cotton gloves underneath rubber gloves if rubber is an irritant - Changing products that irritate skin – check the ingredients on make-up or soap to make sure it does not contain any irritants or allergens; in some cases, contact the manufacturer or check online to get this information - Applying emollients frequently and in large amounts – these keep skin hydrated and help protect it from allergens and irritants; emollients can be used as soap substitutes rather than regular bar or liquid soaps, which can dry out skin

 Emollients (GSL and P depending on product and pack size) (brands include: Aveeno / Balneum / Cetraben / E45 / Oilatum / Diprobase)  Crotamiton 10% cream (GSL) (brands include: Eurax) Examples of medicines  Crotamiton 10% + hydrocortisone 0.25% cream (P) (brands include: Eurax Hc) available OTC  Urea 5% + lauromacrogols 3% cream (GSL) (brands include: E45 Itch Relief / Balneum Plus)  Urea 10% + lactic acid 5% cream (P) (brands include: Calmurid)  Hydrocortisone 1% cream (P) (brands include HC45)  Clobetasone butyrate 0.05% cream (P) (brands include: Eumovate Eczema & Dermatitis)

 All preparations - broken or infected skin  Emollients – see individual products for age restrictions OTC restrictions  Crotamiton – children under 3 years  Crotamiton + hydrocortisone – children under 10 years  Hydrocortisone – children under 10 years, maximum 7 days use, not for use on the eyes, face or ano-genital region  Clobetasone – children under 12 years, maximum 7 days use, not for use on the eyes, face or ano-genital region

Exceptions No routine exceptions have been identified

MIGRAINE (INFREQUENT)  A migraine is usually a moderate or severe headache felt as a throbbing pain on one side of the head  Many people also have symptoms such as feeling sick, being sick and increased sensitivity to light or sound  Migraine is a common health condition, affecting around 1 in every 5 women and around 1 in every 15 men Illness  Migraines usually begin in early adulthood  Some people have migraines frequently, up to several times a week. Other people only have a migraine occasionally  It is possible for years to pass between migraine attacks  The exact cause of migraines is unknown, although they are thought to be the result of temporary changes in the chemicals, nerves and blood vessels in the brain

 Mild infrequent migraines can be adequately treated with OTC analgesics  A number of combination medicines for migraine are available that contain both analgesics and anti-sickness medicines  Some people find migraine attacks are associated with certain triggers, which can include: starting their period, stress, tiredness, certain Advice to patients foods or drinks, therefore avoiding this trigger may help reduce the risk of experiencing migraines  Maintain a healthy lifestyle, include regular exercise, good sleep hygiene and balanced meals  Limit intake of caffeine and alcohol  During an attack, many people find that sleeping or lying in a darkened room can also help

 Paracetamol 325mg + isometheptene 65mg capsules (P) (brands include: Midrid)  Paracetamol 500mg + caffeine 65mg tablets (GSL) (brands include Hedex Extra / Solpadeine Headache / Panadol Extra Advance) Paracetamol 500mg + codeine phosphate 8mg tablets (P) (brands include: Migraleve Yellow / Paracodol) Examples of  medicines  Paracetamol 500mg + codeine phosphate 8mg + buclizine 6.25mg tablets (P) (brands include: Migraleve Pink / Migraleve Complete available OTC (contain Migraleve pink and yellow))  Sumatriptan 50mg tablets (P) (brands include: Migraitan)  Prochlorperazine 3mg buccal tablets (P) (brands include: Buccastem M)

 Paracetamol and ibuprofen can also be used (see coughs and colds and nasal congestion for more information)

 Paracetamol + isometheptene – children under 18 years, severe cardiac, hepatic or renal impairment, severe hypertension, glaucoma, porphyria, pregnancy and breastfeeding  Paracetamol + caffeine – children under 12 years, pregnancy and breastfeeding  Paracetamol + codeine phosphate – children under 12 years, severe liver disease, pregnancy and breastfeeding, maximum 3 days use OTC restrictions (due to codeine)  Paracetamol + codeine phosphate + buclizine – as above  Sumatriptan – maximum 2 tablets/24 hours, history of MI, seizures, stroke or TIA, ischaemic heart disease, coronary vasospasm, cardiac arrhythmias, peripheral vascular disease, hepatic and renal impairment, hypertension  Prochlorperazine – under 18 years, impaired liver function, existing blood dycrasias, epilepsy, Parkison’s disease, prostatic hypertrophy or narrow angle glaucoma

Exceptions No routine exceptions have been identified

MINOR CONDITIONS ASSOCIATED WITH PAIN, DISCOMFORT AND/OR FEVER Minor conditions associated with pain, discomfort and/or fever such as headaches, period pain, mild fever and Illness back pain can be treated at home with OTC analgesics and lifestyle changes, such as getting more rest and drinking enough fluids.

 Patients should be encouraged to keep a small supply of OTC analgesics in their medicines cabinets at home so they are able to manage minor conditions at home without the need for a GP appointment Advice to patients  Examples of conditions where patients should be encouraged to self – care include: headache, colds, fever, earache, teething, period pain, cuts, self-limiting musculoskeletal pain, sprains and strains, bruising, toothache, sinusitis/nasal congestion, recovery after a simple medical procedure, aches and pains and sore throat

 Aspirin 300mg tablets (P) (brands include: Disprin)  Naproxen 250mg (P) (brands include: Boots Period Pain Relief)  Ibuprofen gel (P and GSL) (brands include: Ibuleve 5% / Ibuleve Speed Relief 5% / Ibuleve Maximum Strength 10%)  Diclofenac gel (P and GSL) (brands include: Voltarol Back & Muscle Pain Relief 1.16% / Voltarol 12 hour Examples of medicines Joint Pain Relief 2.32%) available OTC  Rubefacients (P and GSL) (brands include: Movelat Relief / Radian-B muscle rub, lotion, pain relief spray / Deep Heat / Deep Freeze)

 Paracetamol and ibuprofen can also be used (see coughs and colds and nasal congestion for more information)  Paracetamol + codeine phosphate can also be used (see migraine for more information)

 Aspirin – children under 16 years, asthma, peptic ulceration, 3rd trimester of pregnancy, breastfeeding, haemophilia, patients on anticoagulant therapy  Naproxen – children under 15 years or adults over 50 years, peptic ulceration, patients on anticoagulant therapy, only licensed OTC for period pains OTC restrictions  Ibuprofen – children under 12 years, asthma, broken or infected skin, pregnancy and breastfeeding  Diclofenac – children under 14 years, asthma, peptic ulcers, maximum 2 joints to be treated OTC, maximum 7 days (without consulting a doctor), broken or infected skin, patients taking oral NSAIDs, pregnancy and breastfeeding  Rubefacients – children under 12 years, broken or infection skin, asthma for products containing salicylate

No routine exceptions have been identified Exceptions

MOUTH ULCERS Mouth ulcers are usually harmless and do not need to be treated because most clear up by themselves within a Illness week or two. Mouth ulcers are common and can usually be managed at home, without seeing a dentist or GP.

 Mouth ulcers need time to heal  OTC treatment can help to reduce swelling and ease any discomfort  Avoiding foods and drinks that irritate mouth ulcers should help speed up the healing process, reduce pain and reduce the chance of it returning Advice to patients  Do not eat very spicy, salty or acidic food  Do not eat rough, crunchy food such as toast or crisps  Do not drink very hot or acidic drinks such as fruit juice  Do not keep wearing dentures if they do not fit properly – see dentist  Do not smoke

 Choline salicylate based gels (GSL) (brands include: Bonjela / Bonjela Cool Mint)  Lidocaine based gels (GSL) (brands include: Anbesol liquid / Anbesol Adult Strength / Iglu / Medijel)  Benzocaine 10% (GSL) (brands include: Orajel mouth gel) Examples of medicines Chlorhexidine 0.2% (GSL) (brands include: Corsodyl mouthwash, spray) available OTC   Hydrocortisone 2.5mg buccal tablets (P) (available generically)

 Benzydamine spray can also be used (see sore throat for more information)

 All preparations – symptoms lasting longer than 3 weeks, recurrent mouth ulcers, ulcers that become more painful and red  Choline salicylate – children under 16 years, active peptic ulceration, hypersensitivity to salicylates, pregnancy and breastfeeding OTC restrictions  Lidocaine – children under 12 years, pregnancy and breastfeeding

 Benzocaine – children under 12 years, pregnancy and breastfeeding  Hydrocortisone – undiagnosed symptoms, children under 12 years, maximum 5 days (without consulting a doctor), other mouth infection present

No routine exceptions have been identified Exceptions

NAPPY RASH Up to a third of babies and toddlers in nappies have nappy rash at any one time. There may be red patches on the baby's bottom, or the whole area may be red. The affected skin may look sore and feel hot to touch, and Illness there may be spots, pimples or blisters. Most babies with mild nappy rash don't feel sore, but if the rash is

severe babies may feel uncomfortable and be distressed.

 Nappy rash can be caused by: - skin being in contact with nappy contents for a long time - the nappy rubbing against the baby’s skin - not cleaning the nappy area or changing the nappy often enough - soap, detergent or bubble bath - alcohol based baby wipes - recent course of antibiotics

Advice to patients  Change wet or dirty nappies as soon as possible  At each nappy change apply a thin layer of a barrier cream to protect the skin  Clean the whole nappy area gently but thoroughly, wiping from front to back  Use water or fragrance free and alcohol free baby wipes  Bath babies daily (but avoid bathing them more than twice a day as that may dry out their skin)  Leave nappies off for as long and as often as possible, to let fresh air get to their skin  Do not use soap, bubble bath or lotions  Do not use talcum powder as it contains ingredients that could irritate babies skin

 Titanium oxide based barrier products (GSL) (brands include: Metanium Nappy Rash ointment) Examples of medicines  Zinc oxide based barrier products (GSL) (brands include: Sudocrem Antiseptic Healing cream) available OTC  Benzalkonium cream (GSL) (brands include: Drapolene)  Clotrimazole 1% cream (P) (brands include: Canesten)

 All preparations – rash that appears infected, other symptoms such as fever OTC restrictions  Clotrimazole – for nappy rash complicated by fungal infection (usually moist red rash in the folds of the skin with white or red pimples)

No routine exceptions have been identified Exceptions

ORAL THRUSH Thrush is an infection caused by a fungus called Candida. Oral thrush is usually harmless. It is common in Illness babies and older people with dentures or those using steroid inhalers.

 Take care of teeth: brush twice a day, clean dentures, and go for regular check-ups (including patients with dentures)  Patients without teeth should brush gums and tongue with a soft toothbrush  Sterilise dummies regularly  Sterilise bottles after each use Advice to patients  Rinse mouth after eating or taking medicine

 Patients with long-term conditions like diabetes should go to regular check-ups  Do not wear dentures at night  Do not keep wearing dentures if they do not fit properly – see dentist  Do not smoke

Examples of medicines  Miconazole 2% oral gel (P) (brands include: Daktarin) available OTC

 Miconazole - children under 4 months, liver dysfunction, pregnancy and breastfeeding, interacting drugs OTC restrictions including warfarin

No routine exceptions have been identified Exceptions

PREVENTION OF DENTAL CARIES (TOOTH DECAY) The dentist may advise on using higher-strength fluoride toothpaste for patients particularly at risk of tooth Illness decay. Higher strength fluoride toothpastes and mouthwashes can be purchased OTC. Prescription only preparations can be prescribed by a dentist. Prevention of dental caries (tooth decay)

 Visit a dentist regularly – a dentist will decide how often patients need to be seen based on the condition of individuals’ mouth, teeth and gums  Cut down on sugary and starchy food and drinks, particularly between meals or within an hour of going to bed – some medicines can also contain sugar, so it is best to look for sugar-free alternatives where possible  Look after teeth and gums – brush teeth properly with a fluoride toothpaste twice a day, and use floss and an interdental brush at least once a day  Patients with a persistently dry mouth should see a dentist or a GP – this may be caused by certain medicines, treatments or medical conditions Advice to patients

For children:  Establishing good eating habits by limiting sugary snacks and drinks can help children avoid tooth decay  Regular visits to the dentist at an early age should also be encouraged  It is important to teach children how to clean their teeth properly and regularly (a dentist can show how to do this)  Younger children should use a children's toothpaste, but make sure to read the label about how to use it  Children should still brush their teeth twice a day, especially before bedtime

 Sodium fluoride 0.05% (225ppm) mouthwash (GSL) (brands include: Colgate Fluorigard Daily Rinse / Endekay Daily Fluoride Mouthrinse) Examples of medicines  Sodium fluoride 0.32% (1450ppm) toothpaste (GSL) (brands include: Colgate Total) available OTC  Sodium fluoride tablets (P) (brands include: Fluor-A-Day 1.1mg chewable tablets / Endekay Fluotabs 3-6 years 1.1mg tablets / Fluor-A-Day 2.2mg chewable tablets / Endekay Fluotabs 6+ years 2.2mg tablets)

OTC restrictions  All preparations – check water fluoridation level and consult pack dosage instruction

No routine exceptions have been identified Exceptions

SCABIES Scabies is caused by a tiny mite that burrows into the skin and feeds on the epidermis. It is spread by close contact such as holding hands and the mites are commonly found in the skin of the hands and wrists. Illness Symptoms occur about 4-8 weeks after infection and although a rash may not be very obvious, the patient will complain of intense itching. Scabies is very common and anyone can get it. It should be treated quickly to stop it spreading. The scabies rash usually spreads across the whole body, apart from the head.

 Scabies is not usually a serious condition, but it does need to be treated  A pharmacist will recommend a cream or lotion that should be applied over the whole body. It is important to read the instructions carefully. The treatment will need to be repeated 1 week later  Everyone in the household needs to be treated at the same time, even if they do not have symptoms  Anyone that has had close physical or sexual contact in the past 8 weeks should also be treated Advice to patients  Wash all bedding and clothing at 500C or higher on the first day of treatment

 Put clothing that cannot be washed in a sealed bag for 3 days until the mites die  Stop babies and children sucking treatment from their hands by putting socks or mittens on them  Do not have sex or close physical contact until the full course of treatment is completed  Do not share bedding, clothing or towels with someone with scabies

Examples of medicines  Malathion 0.5% aqueous liquid (P) (brands include: Derbac-M) available OTC  Permethrin 5% dermal cream (P) (brands include: Lyclear Dermal cream)

 Malathion – babies under 6 months, broken or infected skin OTC restrictions  Permethrin – children under 2 years (can be used in babies over 2 months under the supervision of a doctor), broken or infected skin

No routine exceptions have been identified Exceptions

SUNBURN DUE TO EXCESSIVE SUN EXPOSURE Sunburn is red, hot and sore skin caused by too much sun. It may flake and peel after a few days. This can be Illness treated at home. It usually gets better within 7 days. Sunburn due to excessive sun exposure

 Get out of the sun as soon as possible  Cool skin with a cool shower, bath or damp towel (take care not to let a baby or young child get too cold)  Apply aftersun cream or spray like Aloe Vera  Drink plenty of water to cool down and prevent dehydration  Take analgesics, such as paracetamol or ibuprofen for any pain Advice to patients  Cover sunburnt skin from direct sunlight until skin has fully healed  Do not use petroleum jelly on sunburnt skin  Do not put ice or ice packs on sunburnt skin  Do not pop any blisters  Do not scratch or try to remove peeling skin  Do not wear tight-fitting clothes over sunburnt skin

Examples of medicines  After sun creams, lotions, gels sprays (GSL) available OTC

OTC restrictions  See individual products for age restrictions

No routine exceptions have been identified Exceptions

SUN PROTECTION Most people prevent symptoms of sun damage developing using sun protection. These products can easily be Illness bought in a pharmacy or supermarket.

 Skin should be protected with clothing (hat, t-shirt, sunglasses) and exposure to sun between 11am and 3pm minimised by staying in the shade  Babies and young children should be kept out of direct sunlight  UVB is mainly responsible for sunburn and has strong links to malignant melanoma and basal cell carcinoma  UVA is associated with skin ageing and can also cause skin cancer, check preparations for a UVA seal - a logo with ‘UVA’ inside a circle, which indicates that the product meets the EU standard  When buying sunscreen, the label should have: Advice to patients  a sun protection factor (SPF) of at least 30 to protect against UVB  at least 4-star UVA protection  Approximately 30 mL sunscreen is required to cover the average body of an adult  Sunscreen should be applied 15-30 minutes before sun exposure, reapply every 2 hours and immediately after swimming, perspiring and towel drying or if it has rubbed off  “Once a day” products can be accidentally removed by water, sweating, abrasion and by towel drying, all of which reduce effectiveness, therefore, it is recommended by the British Association of Dermatologists that these products are also re-applied every two hours

Examples of medicines  Sun protection creams, lotions, gels sprays (GSL) available OTC

OTC restrictions  See individual products for age restrictions

ACBS approved indication (protection against ultraviolet radiation in abnormal cutaneous photosensitivity resulting from genetic disorders or photodermatoses). Preparations with SPF less than 30 should not normally Exceptions be prescribed

TEETHING / MILD TOOTHACHE  Teething can be distressing for some babies, but there are ways to make it easier for them. Toothache can come and go or be constant. Eating or drinking can make the pain worse, particularly if the Illness  food or drink is hot or cold. Mild toothache in adults can also be treated with OTC analgesics whilst awaiting a

dental appointment for further investigation. Teething / mild toothache

 Non-medicinal options such as a teething ring or massaging the gum should be the first line measure for relieving infant teething symptoms, and lidocaine-containing products should only be used when simple measures have failed to provide sufficient relief (as per MHRA) Advice to patients  Teething gels often contain a mild local anaesthetic, which helps to numb any pain or discomfort caused by teething and these can be purchased from a pharmacy. If the baby is in pain or has a mild raised temperature (less than 380C) then paracetamol or ibuprofen suspension can be given  Mild toothache in adults can also be treated with OTC analgesics

 Lidocaine based products (P) (brands include: Anbesol Teething gel / Anbesol liquid / Bonjela Junior gel / Calgel Teething gel / Dentinox Teething gel)  Benzocaine 10% (GSL) (brands include: Orajel dental gel)  Benzocaine 20% (P) (brands include: Orajel Extra Strength gel) Examples of medicines available OTC  Paracetamol and ibuprofen can also be used (see coughs and colds and nasal congestion for more information)  Paracetamol + codeine phosphate can also be used for toothache in adults only (see migraine for more information)

 Lidocaine – babies under 5 months OTC restrictions  Benzocaine – children under 12 years, pregnancy and breastfeeding, do not use continuously (consult a dentist)

No routine exceptions have been identified Exceptions

THREADWORMS Threadworms (pinworms) are tiny worms in bowels. They are common in children and spread easily. Threadworms can be treated without seeing a GP. Symptoms include: Illness  extreme itching around the anus or vagina, particularly at night (as the worms come out whilst sleeping)

 irritability and waking up during the night

 Wash hands and scrub under fingernails – particularly before eating, after using the toilet or changing nappies  Encourage children to wash hands regularly  Bathe or shower every morning  Rinse toothbrushes before using them  Keep fingernails short  Wash sleepwear, sheets, towels and soft toys (at normal temperature)  Disinfect kitchen and bathroom surfaces  Vacuum and dust with a damp cloth Advice to patients  Make sure children wear underwear at night – change it in the morning  Do not shake clothing or bedding, to prevent eggs landing on other surfaces  Do not share towels or flannels  Do not bite nails or suck thumbs and fingers  Do not need to stay off school, nursery or work with threadworms  Medicine kills the threadworms, but it does not kill the eggs  Eggs can live for up to 2 weeks outside the body  Treat everyone in the household, even if they do not have symptoms

Examples of medicines  Mebendazole (P) (brands include: Ovex 100mg tablets / Ovex 100mg/5ml suspension) available OTC

 Mebendazole – children under 2 years, pregnancy or breastfeeding, patients with weight loss, bleeding or OTC restrictions diarrhoea, patients taking metronidazole

No routine exceptions have been identified Exceptions

TOPICAL FUNGAL NAIL INFECTIONS Fungal nail infections (onychomycosis) are an infection of the nail by fungi that include dermatophytes, non- Illness dermatophyte moulds and yeasts (mainly Candida species). Fungal nail infections are common. They are not serious but they can take a long time to treat. Topical fungal nail infections

 Treat athlete's foot as soon as possible to avoid it spreading to nails  Keep feet clean and dry  Wear clean socks every day  Wear flip-flops in showers at the gym or pool  Throw out old shoes  Do not wear shoes that make feet hot and sweaty  Do not share towels Advice to patients  Do not wear other people's shoes  Do not share nail clippers or scissors  Patients should be advised to file and swab the nail surface, then apply the lacquer evenly to the entire nail surface, this process should be repeated weekly  Treatment may take up to 6 months for fingernails and up to a year for toenails  Nail polish and false nails should be avoided during treatment  Diabetic patients should see a foot specialist because any foot injury can lead to complications of diabetes

Examples of medicines  Amorolfine 5% nail lacquer (P) (brands include: Curanail / Schollmed Once Weekly Fungal Nail Treatment) available OTC

 Amorolfine - children under 18 years, diabetic patients, peripheral circulatory disorders, nail dystrophy, OTC restrictions pregnancy and breastfeeding, for the treatment of a maximum of 2 nails

No routine exceptions have been identified Exceptions

TRAVEL SICKNESS Illness Travel sickness is feeling sick when travelling by car, boat, plane or train.

 Mild motion sickness can be treated by various self-care measures, more severe motion sickness can be treated with OTC medicines  Sit in the front of a car or in the middle of a boat to minimise motion  Look straight ahead at a fixed point, such as the horizon  Breathe fresh air if possible (e.g. open car window)  Close eyes and breathe slowly while focusing on breathing Advice to patients  Distract children by talking, listening to music or singing songs  Break up long journeys to get some fresh air, drink water or take a walk  Try ginger, either as a tablet, biscuit or tea  Do not read, watch films or use electronic devices  Do not look at moving objects, such as passing cars or rolling waves  Do not eat heavy meals, spicy foods or drink alcohol shortly before or during travel  Do not go on fairground rides if they cause sickness

 Promethazine tablets (P) (brands include: Avomine 25mg tablets / Phenergan 10mg or 25mg tablets / Phenergan 5mg/5ml elixir) Examples of medicines  Cinnarizine 15mg tablets (P) (brands include: Stugeron) available OTC Hyoscine hydrobromide 150mcg tablets (P) (brands include: Joy-Rides / Kwells Kids)   Hyoscine hydrobromide 300mcg tablets (P) (brands include: Kwells)

 Promethazine – patients with CNS depression, maximum 7 days without medical advice, tablets: children under 5 years, elixir: children under 2 years  Cinnarizine – children under 5 years, patients with Parkinson’s disease, porphyria, hepatic or renal OTC restrictions dysfunction, patients avoiding lactose or sucrose derivatives, avoid using with alcohol, CNS depressants or antidepressants  Hyoscine hydrobromide – patients with glaucoma do not leave children unattended after giving this product, 150mcg tablets: children under 4 years, 300mcg: children under 10 years

No routine exceptions have been identified Exceptions

VAGINAL THRUSH Vaginal thrush is a common yeast infection caused by Candida albicans. It is usually harmless, but can be uncomfortable and can keep coming back. It is not classed as a Sexually Transmitted Infection (STI). The most common symptoms are itching and soreness of the vagina, accompanied by redness or swelling and a thick white discharge. Thrush can be caused by: Illness  antibiotics  uncontrolled diabetes  weakened immune system  menopause  pregnancy

 Avoid soaps and shower gels  Dry the affected area properly after washing  Wear cotton underwear Advice to patients  Avoid sex until thrush has cleared up  Use a condom to help stop it spreading  Take showers instead of baths  Do not use douches or deodorants  Avoid tight underwear or tights

 Clotrimazole 2% cream (P) (brands include: Canesten Thrush External cream)  Clotrimazole 10% vaginal cream (P) (brands include: Canesten Thrush Internal cream)  Clotrimazole 500mg pessary (P) (brands include: Canesten Thrush pessary / Canesten Thrush Soft Gel pessary) Examples of  Clotrimazole 10% vaginal cream + clotrimazole 2% cream (P) (brands include: Canesten Thrush Combi Internal & medicines available External creams) OTC  Clotrimazole 500mg pessary + clotrimazole 2% cream (P) (brands include: Canesten Thrush Combi Pessary & External cream / Canesten Thrush Combi Soft Gel pessary & External cream)  Fluconazole 150mg capsule (P) (brands include: Canesten Thrush Oral capsule)  Fluconazole 150mg capsule + clotrimazole 2% cream (P) (brands include: Canesten Thrush Duo Oral Capsule & External cream)

 All preparations – undiagnosed or symptoms are experienced for the first time, more than 2 attacks in 6 months, pregnant and breastfeeding, women aged below 16 years or over 60 years, any bleeding, no improvement in 7 days, OTC restrictions immunocompromised patients (e.g. diabetes, HIV, patients undergoing chemotherapy)  Fluconazole – renal or hepatic impairment, not to be used in patients taking ergot derivatives, not to be used in women of child bearing age without adequate protection

Exceptions No routine exceptions have been identified

WARTS AND VERRUCAE  Warts are caused by a human papilloma virus, which most frequently affects the hands, feet and anogenital region. Warts Illness have a rough surface, irregular shape and clearly defined borders. There may be black spots in the centre which are dead blood vessels. Sideways pressure may be painful. Warts and verrucae  Verrucae, or plantar warts, affect the feet. Plantar warts grow into the sole of the foot and can cause pain on walking.

 Most people will have warts at some point in their life. They are generally harmless and tend to go away on their own eventually  Warts and verrucae can be spread to other people from contaminated surfaces or through close skin contact  Warts and verrucae are more likely to spread if skin is wet or damaged  It can take months for a wart or verruca to appear after contact with the virus  Wash hands after touching a wart or verruca  Patients with verrucae, should change socks daily  Cover warts and verrucae with a plaster when swimming Advice to patients  Take care not to cut a wart when shaving  Do not share towels, flannels, socks or shoes  Do not bite nails or suck fingers with warts on  Patients with verrucae should not walk barefoot in public places  Do not scratch or pick a wart  Several treatments can be purchased from a pharmacy to treat warts and verrucae more quickly if patients require  Hard skin should be removed with a pumice stone or emery board before applying product  Product use should be confined to the wart of verruca as it may damage the surrounding skin  Treatment can be a long process

 Salicylic acid 12% + lactic acid 4% gel (brands include: Bazuka (P) / Bazuka Treatment (GSL) / Salatac gel (P)) Examples of  Salicylic acid 16.7% + lactic acid 16.7% gel (P) (brands include: Salactol Wart Paint) medicines  Salicylic acid 26% gel (brands include: Bazuka Extra Strength (P) / Bazuka Extra Strength Treatment (GSL)) available OTC  Salicylic acid 50% ointment (P) (brands include: Verrugon Complete / Wartex)  Dimethyl ether + propane (GSL) (brands include: Bazuka Sub-Zero)  Dimethyl ether + propane + isobutene (GSL) (brands include: Scholl Freeze Verruca and Wart Remover)

 All preparations – not for use on warts on the face, genitals, hairy warts, birthmarks and moles, patients with diabetes or OTC restrictions circulatory disorders, a large number of warts or verrucae, broken or infected skin, pregnancy and breastfeeding  Salicylic acid 50% - Verrugon: for treatment of verrucae only, Wartex: children under 18 years, for treatment of warts only

Exceptions No routine exceptions have been identified