Which skin formulation—ointment, cream, or lotion—is appropriate for different types of lesions and body areas?

Topical Vehicle Selection for Different Lesions and Body Areas

Ointments are the preferred first-line vehicle for dry, scaly, or irritated skin conditions due to their superior occlusive properties, even drug distribution, and maximum penetration, while creams are reserved for cosmetically sensitive areas or when patient preference demands a less greasy formulation, and lotions are appropriate only for large surface areas with minimal dryness or hair-bearing regions. 1

Vehicle Selection Algorithm

For Dry, Scaly, or Thick Lesions → Use Ointments

• Ointments provide maximum drug penetration and prevent evaporation of skin moisture through occlusion 1
• Ointments spread evenly across treated areas without dose variation between center and periphery, unlike creams and solutions which concentrate medication centrally 2
• Ointments are superior for psoriasis, eczema, and hyperkeratotic lesions on the trunk, extremities, and areas requiring maximum therapeutic effect 3, 1, 4
• Apply ointments at nighttime when patients tolerate greasier formulations better; use lighter vehicles during daytime if cosmetic concerns exist 3, 1

For Facial and Flexural Areas → Use Creams

• Creams cause less burning and itching in sensitive areas compared to ointments 1
• Creams are appropriate for facial psoriasis, intertriginous areas, and when cosmetic acceptability is paramount 3, 1
• For infants with mild eczema on the face, hydrocortisone 1% ointment remains preferred despite being greasier, due to superior efficacy 5
• Creams evaporate rapidly due to water/alcohol content, resulting in uneven drug distribution with lower doses at periphery—instruct patients to apply to multiple sites and spread quickly 2

For Hair-Bearing Areas → Use Solutions, Foams, or Gels

• Scalp psoriasis requires non-greasy vehicles: solutions, foams, shampoos, sprays, oils, or gels 3
• Solutions provide 60% marked improvement for scalp psoriasis versus 17% with vehicle alone 3
• Patient preference varies widely for scalp formulations—offer multiple options to maximize adherence 3

For Large Surface Areas with Minimal Dryness → Use Lotions

• Lotions are lighter suspensions appropriate for less severe dryness and large body surface areas 1
• Lotions spread easily but provide less occlusion than creams or ointments 3, 6
• Alcohol-containing lotions should be avoided in favor of oil-in-water creams or ointments for xerotic or eczematous skin 3

Body Area-Specific Recommendations

Trunk and Extremities

• First choice: Ointments for active lesions 3, 1
• Alternative: Creams for daytime use if patient refuses ointments 3
• Apply 8 fingertip units (FTU) per application for anterior or posterior trunk, 8 FTU for one entire leg, 4 FTU for one entire arm 3, 7

Face and Neck

• First choice: Creams to minimize burning/irritation 1
• For severe dryness: Low-potency ointments (hydrocortisone 1%) acceptable 5
• Apply 2.5 FTU per application 3, 7

Hands and Feet

• Palms/soles with thick lesions: Ointments with occlusion 3
• Dorsal surfaces: Creams acceptable 3
• Apply 1 FTU per hand (front and back), 1.5 FTU per foot 3, 7

Scalp

• First choice: Solutions or foams 3
• Apply 3 FTU if using cream/ointment formulation 3, 7

Genitalia

• Use low-potency creams or ointments (avoid high-potency steroids) 3
• Apply 0.5 FTU per application 3, 7

Intertriginous Areas (Groin, Axillae)

• Creams preferred over ointments to reduce maceration risk 1
• Consider antifungal creams if maceration present 1

Critical Pitfalls to Avoid

Creams and Solutions Spread Unevenly

• Rapid evaporation of water/alcohol in creams and solutions causes uneven drug distribution with lower doses at periphery 2
• Instruct patients to apply creams/solutions to multiple sites simultaneously and spread quickly before evaporation occurs 2

Ointment Misconceptions

• Despite conventional wisdom, ointments are not necessarily more potent than other vehicles—efficacy depends on formulation and patient adherence 8
• Poor adherence to ointments due to greasiness often causes treatment failure misattributed to "tachyphylaxis" 8
• Discuss vehicle preferences with patients before prescribing—non-adherence to ointments negates their theoretical superiority 8, 6

Infant-Specific Concerns

• Avoid products containing urea, salicylic acid, or silver sulfadiazine in neonates due to significant percutaneous absorption risk 1
• Do not use potent or very potent topical corticosteroids as first-line therapy in infants—hydrocortisone 1% ointment only 5

Vehicle Component Allergies

• Many vehicles contain contact allergens despite being labeled as emollients 1
• Fragrance-free formulations are essential—contact dermatitis occurs in 34.3% of treatment arms versus 22.1% of controls 1
• If lesions do not respond to treatment, investigate vehicle components for incompatibility reactions before changing active medication 4

Practical Implementation

Matching Vehicle to Skin Condition

• Acute, weeping lesions: Hydrophilic aqueous bases (creams, gels) 4
• Dry, hyperkeratotic lesions: Lipophilic fatty systems (ointments) 4
• Seborrheic skin: Hydrophilic vehicles 4
• Sebostatic (dry) skin: Lipophilic vehicles 4

Occlusion Considerations

• Occlusion dramatically increases potency: flurandrenolide 0.1% tape (class 1 potency) exceeds diflorasone diacetate ointment despite being class 5 in cream form 3
• For resistant plaques on elbows/knees, consider occlusion with plastic wrap overnight after ointment application 3

Two-Week Supply Calculations for Maintenance

• Face/neck: 15-30 grams 7
• Both hands: 15-30 grams 7
• Both arms: 30-60 grams 7
• Both legs: 100 grams 7
• Trunk: 100 grams 7