PRESCRIPTION SCAR GEL New Scars Post Surgical Scars/New Scars Keloids and Hypertrophic Scars
FAX TO:______________________________ SCAR AND WOUND CARE PRESCRIPTION SCAR GEL MULTIPURPOSE TOPICAL SCAR GEL Note: This scar gel therapy compounded using PracaSil™-Plus as a base Topical gel for new and older scars with or without pain, inflammation and/or itching New Scars Fluticasone Propionate 1%/Levocetirizine Dihydrochloride 2%/Pentoxifyline USP 0.5% PrilocaineHCI 3%/Gabapentin USP 15% Keloids and Hypertrophic Scars Painful Scars Gabapentin 15%/Lidocaine HCI 3% Prilocaine HCI 3% Topical Gel Stretch Marks Pentoxifylline 1%/Caffeine 1%, Tranilast 1% Topical Gel Tretinoin 0.1% Topical Gel Tamoxifen Citrate 0.1%/Tranilast 1%/Caffeine Citrated 0.1%/Lipoic Acid 0.5% Topical Gel Pentoxifylline 0.3%/Caffeine 1% EGCg 1% Topical Gel Gabapentin 15%/Lidocaine HCI 3% Prilocaine HCI 3% Topical Gel Betamethasone Valerate 0.1%/Tranilast 1% Pentoxifylline 0.5% Topical Gel Collagenase 350 U/Gm/Hyaluronidase 250 U/gm Compound Topical Gel Betamethasone Valerate 0.1%/Tranilast 1% Topical Gel Scar Prevention EGCg 1%/Dimethyl Sulfone 2%/Tranilast 1% Ascorbic Acid 2% Topical Gel EGCg 1%/Dimethyl Sulfone 5% Ascorbic Acid 2%/Caffeine 1% Topical Gel Acne Scars Tretinoin 0.1% Topical Gel Check Quantity: 120 gm 240 gm 480 gm Check SIG: Apply 1-2 pumps (1-2gm) TOPICALLY to wound/scar FREQUENCY: Post Surgical Scars/New Scars BID Apply 2-4 pumps (2-4gm) TOPICALLY to wound/scar Other _________________________________________ (1 GRAM PER PUMP) PRESCRIPTION WOUND CARE TOPICAL WOUND CARE TREATMENT Venous Ulcers, Pressure Ulcers, Diabetic Ulcers, etc Prescriber please NOTE: Due to risk of renal toxicity, do NOT prescribe polyethylene glycol (PEG) containing compounds for treatment of wounds covering more then 20% of body. DO NOT PRESCRIBE FORMULATIONS CONTAINING MISOPROSTOL TO A PREGNANT AND/ OR BREASTFEEDING FEMALE. Use caution in women of childbearing age. Formulations are topical compounds applied directly to wound and/or dressing. Mupirocin 5%/Itraconazole 5%/Fluticasone Propionate 1%/Urea 40% Spira-Wash™ Gel Phenytoin 5%/Misoprostol 0.0024%/Nifedipine 2% Spira-Wash™ Gel Misoprostol 0.0024%/Metronidazole 2%/Lidocaine HCI 2% Spira-Wash™ Gel Levofloxacin 2%/Mupirocin 4%/Itraconazole 1% Spira-Wash™ Gel Vancomycin 5%/Mupirocin 5% Spira-Wash™ Gel Check to Add to Formulation: Antibiotics/Antifungal Pain/Inflammation Metronidazole 2% Mupirocin 5% Clindamycin HCI USP 1% Polymixin B 2000 Units/gm Ketoprofen 2% Prilocaine HCI 2% Vancomycin 5% Itraconazole 1% Levofloxacin 2% Amikacin 0.3% Other ______________ 120 gm 240 gm 480 gm Check Quantity: Check SIG: Apply 1-2 pumps (1-2gm) TOPICALLY to wound/scar FREQUENCY: BID Apply 2-4 pumps (2-4gm) TOPICALLY to wound/scar Other _________________________________________ (1 GRAM PER PUMP) 1 Physician Signature ID # 2 3 4 5 Other_____________ Date 1200
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