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