13.0 Skin

13.2 Emollient and barrier preparations

Patient concordance and compliance with prescribed dermatology treatments is largely dependent on the cosmetic acceptability of the preparations concerned. The dermatology section of the formulary contains a full range of suitable products to meet the needs of the vast majority of patients.

Fragrances are a major cause of skin sensitization, and as a general principle, products containing fragrance should not be prescribed. Patients insisting on using fragranced products should be advised to purchase their own supply.

**NPSA Alert - Fire Hazard with Paraffin Based Skin Products on Dressings and Clothing

http://www.nrls.npsa.nhs.uk/resources/?entryid45=59876

The National Patient Safety Agency (NPSA) is alerting all healthcare staff involved in the prescribing, dispensing or administration of paraffin based skin products of a potential fire hazard. Bandages, dressings and clothing in contact with paraffin based products, for example White Soft Paraffin, White Soft Paraffin plus Liquid Paraffin 50/50, or Emulsifying ointment are easily ignited with a naked flame or cigarette. Following a reported death, the NPSA commissioned the Health and Safety Executive to undertake fire hazard testing with White Soft Paraffin on a variety of bandages, dressings and clothing. The results showed the ability to reproduce the fire hazard in a controlled environment.

The following actions should apply to all patients in all settings being dispensed, or treated with, large quantities (100g or more) of paraffin based products:

Information should be given about the potential fire risks of smoking (or being near to people who are smoking), or exposure to any open flame or other potential cause of ignition during treatment; and about regularly changing clothing or bedding impregnated with paraffin based products (preferably on a daily basis) as the paraffin soaks into the fabrics and can potentially be a fire hazard.
This information should be given on the first occasion that such treatment is prescribed, dispensed or administered by a healthcare professional and a record kept confirming that such advice has been given. A check should be made on subsequent occasions that the advice has been received previously and understood.
Fire safety information should be displayed prominently in every clinical area where patients may be treated with large quantities of paraffin based products.
If, against advice, a hospitalised patient intends to leave the ward to smoke, they should be informed of the risk and advised to wear a thick outer covering that has not been contaminated with paraffin based products.
Relatives or carers should be informed if a patient does not comply with safety advice.
To implement the NPSA alert, patients who require large quantities of emollient (100g or more) should use a water based product (e.g. cream or lotion) rather than a paraffin based one (e.g. ointment) to reduce the fire risk.

13.2.1 Emollients

Emollients are used to hydrate the skin. Their effects are short lived and they should be applied frequently. To be effective, adequate quantities of emollients should be prescribed. As a rough guide, 30g is sufficient for one total body application for an adult. Most adults could be expected to use 500-1000g of emollient each week (applying to whole body daily).

Light emollients

GREEN Zerocream®

GREEN Cetraben® cream (pump pack)

GREEN E45® cream

Medium emollients

GREEN Epimax® Cream

GREEN Zerobase® Cream

GREEN Zerobase® gel

GREEN Aveeno® cream

GREEN Diprobase® cream

GREEN Doublebase® gel

GREEN Oilatum® cream

GREEN Unguentum® M cream

Heavy emollients - effective but not as cosmetically acceptable.

GREEN Zeroderm® ointment

GREEN Hydromol® ointment

GREEN Epaderm® ointment (Consider using Hydromol - same formula, but less expensive)

GREEN Liquid paraffin 50% / white soft paraffin 50%

GREEN Paraffin, white soft

GREEN Paraffin, yellow soft

GREEN Cetraben® ointment

Containing urea

GREEN Eucerin® cream

With antimicrobial

Appropriate for use if there are recurrent problems with infection.

GREEN Dermol® cream

GREEN Dermol 200® shower emollient

GREEN Dermol 500® lotion

Soap substitutes

All emollients, with the exceptions of Doublebase® and liquid paraffin, may be used as soap substitutes. Aqueous cream may be used a soap substitute but is not recommended as an emollient because it may cause stinging in a high proportion of patients.

GREEN Aqueous cream (as a soap substitute only)

13.2.1.1 Emollient bath additives

GREEN Hydromol Emollient® bath additive

GREEN Oilatum Plus® bath additive (contains antimicrobial agent)

13.2.2 Barrier preparations

Click here to access table of preparations and indications:

First line:

GREEN Metanium® ointment

GREEN Sudocrem® cream

GREEN Zinc and castor oil ointment

GREEN Medihoney® Barrier Cream 50g, 20 x 2g sachet

GREEN Sorbaderm® No-sting Barrier Film 28ml spray, 1ml applicator

Second line, following Specialist Advice:

GREEN Proshield® Foam and Spray Cleanser 235ml

GREEN Proshield® Plus Skin Protective 115g

13.3 Topical local anaesthetics and antipuritics

The underlying cause of the pruritus should be treated. Antipruritics are of limited value.

GREEN Crotamiton cream 10%, lotion 10% (Eurax®)

GREEN Menthol 1% in aqueous cream 500gram (Arjun®)

Facilitation of wound care, cleaning and suturing in A&E only

RED Lidocaine 4%, adrenaline 0.1%, tetracaine 0.5% w/v gel (LAT gel®)

(Unlicensed product. Approved for use in A&E Department only)

13.4 Topical corticosteroids

Potency of steroid required will depend on age, site and chronicity. Face, flexures, skin of the young and more acute eczemas require weaker preparations. Palms, soles and heavily lichenified chronic eczemas require more potent preparations. Try to use the weakest preparation which will keep the eczema in check, but if control is lost, use a short, sharp course of a potent preparation.

Creams are best for wet and weepy lesions.

Ointments are best for dry and scaly lesions.

POTENCY – MILD

First line:

GREEN Hydrocortisone cream 0.5%, 1%, 2.5% , ointment 0.5%, 1%, 2.5%

GREEN Hydrocortisone cream 0.25% & crotamiton 10% (Eurax-Hydrocortisone®)

Second line:

GREEN Fluocinolone 0.0025%cream (Synalar 1 in 10 Dilution®)

(for patients intolerant to hydrocortisone)

POTENCY - MILD WITH ANTIMICROBIAL

GREEN Hydrocortisone 1% & miconazole 2% cream, ointment (Daktacort®)

GREEN Hydrocortisone 0.5% & nystatin 100,000 units/g cream (Timodine®)

POTENCY – MODERATE

First line:

GREEN Clobetasone butyrate 0.05% cream, ointment (Eumovate®)

Second line:

GREEN Betamethasone valerate 0.025% cream, ointment (Betnovate RD®)

GREEN Fluocinolone 0.00625% cream, ointment (Synalar 1 in 4 Dilution®)

GREEN Fludroxycortide occlusive tape 4micrograms/cm2 (Haelan®) - (Dermatology initiation only)

POTENCY – MODERATE WITH ANTIMICROBIAL

GREEN Clobetasone butyrate 0.05% & oxytetracycline/®nystatin cream (Trimovate®)

** product currently unavailable from manufacturer (03/15) - see below for alternative**

POTENCY - POTENT

First line:

GREEN Betamethasone valerate 0.1% cream, ointment (Betnovate®)

Second line:

GREEN Fluocinolone 0.025% cream, ointment (Synalar®)

AMBER Mometasone furoate 0.1% cream, ointment, lotion (Elocon®) (Dermatology initiation only)

AMBER Diflucortolone valerate 0.1% cream, oily cream, ointment (Nerisone®)

Scalp preparations
First line:

GREEN Betamethasone valerate scalp application 0.1% (Betacap®)

Second line:

GREEN Fluocinolone 0.025% gel (Synalar®)

GREEN Hydrocortisone butyrate 0.1% water miscible lotion (Locoid Crelo®)

POTENCY – POTENT WITH ANTIMICROBIAL

GREEN Betamethasone dipropionate 0.064% (≡ betamethasone 0.05%), clotrimazole 1%, cream (Lotriderm®)**

GREEN Fluocinolone acetonide 0.025% & Clioquinol 3% cream,ointment (Synalar C®)

GREEN Fluocinolone 0.025% & neomycin 0.5% cream, ointment (Synalar N®) - (For Otitis Externa only)

POTENCY - POTENT WITH SALICYLIC ACID

GREEN Betamethasone valerate 0.05% & salicylic acid 3% ointment (Diprosalic®)

POTENCY - VERY POTENT

Avoid long-term use without dermatologist supervision

GREEN Clobetasol 0.05%

cream, ointment (Dermovate®)

scalp application (Dermovate®)

GREEN Diflucortolone valerate 0.3%

oily cream, ointment (Nerisone Forte®)

AMBER Clobetasol propionate 500micrograms/gram shampoo (Etrivex®)

Clobetasol Propionate shampoo - Scalp Psoriasis

Clobetasol shampoo should be kept in place without covering for 15 minutes before rinsing. The treatment duration should be limited to a maximum of 4 weeks. As soon as clinical results are observed, applications should be spaced out or replaced, if needed, by an alternative treatment. If no improvement is seen within four weeks, reassessment of the diagnosis may be necessary. Repeated courses may be used to control exacerbations provided the patient is under regular medical supervision.

POTENCY – VERY POTENT WITH ANTIMICROBIAL

Avoid long-term use without dermatologist supervision

GREEN Clobetasol 0.05% & neomycin/nystatin cream, ointment

(Dermovate-NN® brand discontinued prescribe as generic)

3.5.1 Preparations for eczema

Oral retinoids for severe hand eczema

Alitretinoin, for the treatment of Chronic Eczema (TAG 177) Alitretinoin is recommended, within its licensed indication, as a treatment option for adults with severe chronic hand eczema that has not responded to potent topical corticosteroids if the persons has

severe disease, as defined by the physician’s global assessment (PGA) and
a dermatology life quality index (DLQI) score of 15 or more.

Oral alitretinoin is licensed for the treatment of severe chronic hand eczema unresponsive to potent topical corticosteroids, in adults. Alitretinoin should only be prescribed by dermatologists, or physicians with experience in the use of systemic retinoids who have full understanding of the risks of systemic retinoid therapy and monitoring requirements. Prescriptions of alitretinoin for women of childbearing potential should be limited to 30 days of treatment and continuation of treatment requires a new prescription. Ideally, pregnancy testing, issuing a prescription and dispensing of alitretinoin should occur on the same day.

Dispensing of alitretinoin should occur within a maximum of 7 days of the prescription. Pregnancy is an absolute contraindication to treatment with alitretinoin. Basilea Pharmaceuticals has put together a Pregnancy Prevention Programme, containing guidance on prescribing alitretinoin to women of childbearing potential and contraceptive precautions required. A treatment course of alitretinoin may be given for 12 to 24 weeks depending on response. Discontinuation of therapy should be considered for patients who still have severe disease after the initial 12 weeks of treatment. In the event of relapse, patients may benefit from further treatment courses of alitretinoin. Patients should still be advised to use daily emollients during therapy and once the eczema has cleared.

RED Altretinoin (Toctino®) capsules 10mg, 30mg

13.5.2 Preparations for psoriasis

Emollients may be sufficient for mild cases. For other cases the topical preparations may have a beneficial effect. Start with low concentrations and build up.

Topical preparations for psoriasis

Vitamin D and analogues

GREEN Calcipotriol 50micrograms/gram (Dovonex®)

cream, ointment, scalp solution

GREEN Calcipotriol 50 micrograms/gram & betamethasone 0.05% (Dovobet®)

ointment, gel

GREEN Tacalcitol 4 micrograms/gram (Curatoderm®) ointment

GREEN Calcipotriol and betamethasone cutaneous foam (Enstilar®)

Coal tar

GREEN Licensed Coal tar products:

lotion 5% (Exorex®) scalp ointment, coal tar 12% & salicylic acid 2%, sulphur 4% (Sebco®) bath emulsion 40% (Psoriderm®)

AMBER Unlicensed Coal tar products - Dermatology initiation only e.g. coal tar in yellow soft paraffin, various strengths

Dithranol

For other dithranol preparations see appendix 3.

GREEN Dithranol (Dithrocream®) cream 0.1%, 0.25%, 0.5%, 1%, 2%

AMBER Dithranol in Lassar's paste (unlicensed product)

(dermatology initiation only) various strengths

Oral retinoids for psoriasis - for severe resistant or complicated psoriasis, prescribed only by or under the supervision of a consultant dermatologist.

RED Acitretin capsules 10mg, 25mg (hospital only)

13.5.3 Drugs affecting the immune response

CSM Advice – Due to the risk of malignancy, Pimecrolimus 1% cream should be used as a second line treatment for

mild or moderate atopic dermatitis where treatment with topical corticosteroids is either inadvisable or not possible.

Tacrolimus ointment will remain a second line treatment for moderate or severe atopic dermatitis in patients who are

not adequately responsive to or are intolerant of topical corticosteroids.

Treatment with pimecrolimus cream and tacrolimus ointment should:

only be initiated by physicians with experience in the diagnosis and treatment of atopic dermatitis
not to be given to patients with congenital or acquired immunodeficiencies, or to patients on therapy causing immunosupprerssion
not to be applied to malignant or to potentially malignant skin lesions.

The frequency of administration of Tacrolimus ointment 0.03% in children should be limited to once daily. The lower strength of tacrolimus ointment (0.03%), should be used in adults wherever possible.

Prescribers should use these products so as to minimise patient exposure and thereby reduce risk. The following are recommended:

> The medicines should be applied thinly and to affected skin surfaces only.

> Treatment should be short term; continuous longterm use should be avoided.

> If no improvement occurs (after 6 weeks for pimecroliums, or 2 weeks for tacrolimus), or if the disease

worsens, the diagnosis of atopic dermatitis should be reevaluated and other therapeutic options

considered. See age restrictions for each product before prescribing.

NICE Guidance: Atopic Eczema in Children

> Only specialists with experience in dermatology should start treatment with tacrolimus or pimecrolimus after

discussing the risks and benefits of all other options.

> If atopic eczema is not controlled by topical corticosteroids* or where there is a risk of serious adverse effects

treatment options include:

> tacrolimus (0.03%) for moderate to severe atopic eczema in children aged two years and over,

> pimecrolimus for moderate atopic eczema on the face and neck in children aged two years and over.
> Consider for facial atopic eczema in children requiring long-term or frequent use of mild topical corticosteroids > Do not use topical tacrolimus or pimecrolimus:

> for mild atopic eczema,

> as first-line treatment for atopic eczema of any severity,
> under bandages or dressings without specialist dermatological advice.

*Unsatisfactory clinical response to adequate use of the maximum strength and potency of topical corticosteroids that is appropriate for the child's age and the area being treated.

Active plaque psoriasis in adults
Ustekinumab is recommended as an option, alone or in combination with methotrexate, for treating active plaque psoriasis in adults as per NICE TA340 (replaces TA313)

RED Ustekinumab
solution for injection 45mg/0.5ml pfs (Stelara®) (CCG Commissioned)

Moderate to severe psoriasis NICE TA180 (updated)
NICE interactive flowchart - Psoriasis
Ustekinumab is recommended as a treatment option for adults with plaque psoriasis as in NICE TA180 updated

RED Ustekinumab
solution for injection 45mg/0.5ml pfs (Stelara®) (CCG Commissioned)

13.6.1 Topical preparations for acne

For mild and moderate acne a topical preparation is recommended.

Benzoyl peroxide & azelaic acid

Patients should be advised that, in some cases, 4-6 weeks of treatment may be required before the full therapeutic effect is observed.

GREEN Benzoyl peroxide (PanOxyl®) cream 5% & gel 10% (if available)

GREEN Duac Once Daily® (Benzyl peroxide 5% & clindamycin 1%) gel

GREEN Azelaic acid (Skinoren®) cream 20%

Topical antibacterials for acne

GREEN Dalacin T® aqueous lotion (clindamycin 1%)

GREEN Zineryt® topical solution (erythromycin 40mg & zinc acetate 12mg/ml)

Topical retinoids and related preparations for acne

GREEN Adapalene (Differin®) cream 0.1%, gel 0.1%

GREEN Isotretinoin (Isotrex®) gel 0.05%

GREEN Adapalene 0.1%/Benzoyl Peroxide 2.5% (Epiduo®Gel)

GREEN Tretinoin and clindamycin (Treclin®) 1%/0.025% gel

Preparations for rosacea

GREEN Metronidazole (Rosex®) cream 0.75%

GREEN Ivermectin (Soolantra®) cream

13.6.2 Oral preparations for acne

Oral antibacterials for acne

For moderate acne oral antibiotics are usually needed and should be prescribed alongside a topical retinoid or benzoyl peroxide. Oral antibiotics should be limited to the shortest possible period.

If the patient responds it may be continued for 4-6 months. (consider reducing the antibiotic dose by half for the latter period ) then stop completely.

First line

GREEN Tetracycline tablets 250mg (dose: 500mg twice daily)

GREEN Oxytetracycline tablets 250mg (dose: 500mg twice daily)

For use in cases where first line drugs are not tolerated or ineffective

GREEN Doxycycline capsules 100mg (dose: 100mg daily)

GREEN Lymecycline capsules 408mg (dose: 408mg daily)

Hormone treatment for acne

Used as an alternative to oral antibiotics for female patients.

Co-cyprindiol (Dianette®) - used primarily as a treatment for moderate acne or other androgenic conditions especially hirsutism (e.g in patients with PCOS) who also need contraception. It should be discontinued three to four months after the androgenic condition has resolved. It may be continued/restarted, after counselling, if the androgenic condition recurs. It should not be used solely for contraception.

Note: CSM advice is venous thromboembolism occurs more frequently in women taking co-cyprindiol than those taking a low-dose combined oral contraceptive. See BNF for full details.

GREEN Co-cyprindiol tablets (cyproterone 2mg & ethinylestradiol 35mcg)

(Prescribe generically, not as Dianette®)

Oral retinoid for acne

For severe acne which has not responded to oral antibiotics, prescribed only by or under the supervision of a consultant dermatologist.

RED Isotretinoin capsules 5mg, 20mg

13.7 Preparations for warts and calluses

All warts are self-limiting and eventually disappear spontaneously. Salicyclic acid preparations are useful but may cause irritation of the treated area.

First line

GREEN Salactol® paint (contains salicylic acid 16.7%, lactic acid 16.7% in colloidon)

Second line

GREEN Salicylic acid 50% ointment (Verrugon®)

GREEN Salicylic acid 26% polyacrylic solution (Occlusal®)

Third line

GREEN Formaldehyde 0.75% gel (Veracur®)

GREEN Glutaraldehyde 10% solution (Glutarol®)

Anogenital warts

Imiquimod cream is also licensed for the treatment of superficial basal cell carcinomas and is also used for actinic keratoses (unlicensed and specialist use only).

GREEN Podophyllotoxin 0.15% cream (Warticon®)

GREEN Imiquimod 5% cream (Aldara®)

13 8.1 Sunscreen preparations

All the sunscreens listed contain UVB and UVA protection. They are drugs when prescribed for skin protection against ultraviolet radiation in abnormal cutaneous photosensitivity. Need to be endorsed 'ACBS' on FP10 prescription.

GREEN Anthelios® melt in cream (UVA + UVB protection UVB-SPF 50+)

GREEN Sunsense® Ultra Lotion (UVA +UVB protection UVB-SPF 50+)

GREEN Uvistat®cream (UVB-SPF 20)

Sunscreen/ camouflagers

A combination product suitable for patients with darker skin tones which is available from Dundee Hospital only.

RED Dundee Cream (UVB-SPF 50)

Photodamage

GREEN Diclofenac sodium 3% gel (Solaraze®) - prescribe by brand

AMBER Fluorouracil 5% cream (Efudix®)

13 8.2 Hirsutism

BLACK Eflornithine (Vaniqa ® 11.5% cream)

13.9 SHAMPOOS AND SOME OTHER PREPARATIONS FOR SCALP AND HAIR CONDITIONS

GREEN AlphosyI 2 in 1® shampoo

GREEN Capasal® shampoo

GREEN Polytar® liquid

GREEN Selsun® shampoo

Other scalp preparations see

13.4 Clobetasol propionate 500micrograms/gram shampoo (Etrivex®)

13.5.2 Calcipotriol/ betamethasone scalp application (Dovobet®)

13.10.1 Antibacterial preparations

13.10.1.1 Antibacterial preparations only used topically

To reduce the development of resistance it is advisable to limit the choice of antibiotic used topically to one not used systemically. Whenever possible, swabs for bacterial examination should be taken before treatment is started. Mupirocin is generally restricted to use in wounds that are MRSA positive.

GREEN Mupirocin 2% (Bactroban®) ointment / nasal ointment

GREEN Silver sulphadiazine 1% (Flamazine®) cream

13.10.1.2.2 Preparations of antibacterials also used systemically

It is generally advised that topical antimicrobials are not used. The exceptions to this are the use of metronidazole topically for acne rosacea, and in the management of malodorous wounds. Topical fusidic acid should be reserved for impetigo where there are very localised lesions only.

In the presence of visible or proven infection, systemic antibiotics are to be used. See antimicrobial guidelines.

GREEN Fusidic acid 2% (Fucidin®) cream, ointment [see recommendations above]

GREEN Metronidazole (Anabact®) 0.75% gel [see recommendations above]

13.10.2 Antifungal preparations

Take scrapings, hair or nail clippings where possible before treatment is started. Local therapy is used when extent of infection is limited. Systemic therapy is required for widespread infections, or if topical treatment fails. If treating pityriasis vesicolor and topical treatment fails, treat systemically with an azole antifungal (section 5.2).

GREEN Clotrimazole cream 1%, dusting powder 1%

GREEN Miconazole cream 2%

GREEN Terbinafine cream 1%

For infected nails

GREEN Amorolfine nail lacquer 5% (Loceryl®)

Other antifungals (for azole antifungals see section 5.2)

GREEN Terbinafine tablets 250mg

13.10.3 Antiviral preparations

Indicated for treatment of labial and genital herpes simplex infections.

GREEN Aciclovir cream 5%

13.10.4 Parasiticidal preparations

Head lice

Only treat those with living, moving lice present. A course of treatment for head lice should be 2 applications of product 7 days apart to kill the lice emerging from any eggs that survive the first application. All affected household members should be treated simultaneously.

Wet Combing

Head lice can be mechanically removed by combing wet hair meticulously with a plastic detection comb for at least 30 minutes 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.

Dimeticone

Hedrin (4% dimeticone) lotion is a non-insecticide preparation that coats head lice and interferes with water balance in lice by preventing the excretion of water. It can be used from age 6 months, and has shown similar efficacy to phenothrin 0.5% liquid (70% vs. 75% cure rate). As with the other insecticide treatments this is a pharmacy only medicine and treatment should follow the same regime as is laid out for those other products i.e. treatment is 2 applications 7 days apart. The contact time for this product is 8 hours or overnight. One 50ml bottle should be sufficient for two applications on short hair.

Refer to guidelines online here

First (or Second) Line

GREEN Dimeticone lotion 4%, aqueous

First (or Second) Line

Use alcohol based preparations where possible. Use aqueous liquid for those with asthma and severe eczema, children under 5 years and pregnant & lactating women.

GREEN Malathion liquid 0.5%, aqueous

GREEN Malathion lotion 0.5%, alcoholic

Crab Lice

Permethrin or malathion are used to eliminate crab lice. An aqueous preparation should be applied, allowed to dry naturally and washed off after 12 hours. A second treatment will be needed after 7 days.

Scabies

Permethrin is effective for scabies.

GREEN Permethrin cream 5%

13.11.1 Alcohols and saline

Suitable for general cleansing of skin and wounds.

See Joint Wound Care Formulary for order of preference - click here to access it.

GREEN Sodium chloride 0.9% solution sachets (Irripod®, Normasol®)

13.11.2 Chlorhexidine salts

Suitable for disinfection of skin.

GREEN Chlorhexidine cleansing solution (Hibiscrub®)

GREEN Chlorhexidines Gluconate Alcoholic & Aqueous Solutions (Hydrex® & Unisept® respectively)

Both products are for skin disinfection by primary care prescribers only (different preparations are routinely used in secondary care). Both are listed on the Nurse Practitioners Formulary.

13.11.4 Iodine

Suitable for disinfection of skin

GREEN Povidone-iodine (Betadine®)

antiseptic paint 10%, antiseptic solution 10%, dry powder spray 2.5%, surgical scrub 7.5%

13.11.5 Phenolics

Used as part of MRSA regimen

GREEN Octenisan® skin cleanser

GREEN Triclosan skin cleanser

13.11.6 Astringents, oxidisers and dyes

Useful for oozing eczematous reactions

GREEN Hydrogen peroxide solution 3% (10 vols.)

GREEN Potassium permanganate 400mg tablets for solution (Permitabs®)

- 1 tablet dissolved in 4 litres in water provides a 0.01% (1 in 10,000) solution

A potent antiperspirant used in the treatment of severe hyperhidrosis

GREEN Aluminium chloride 20% solution (Anhydrol Forte®)

AMBER Glycopyrronium Bromide powder (Robinul®)