The Rest of the Cabinet

TL;DR. Sleep aids, eye and ear drops, skin treatments, motion sickness remedies, mouth and throat products, and the topical preparations that make up most of what people actually buy. Two themes run through it. First, most over-the-counter sleep aids are sedating antihistamines whose effect wears off within days while their impairment does not, and CBT-I outperforms all of them. Second, topical routes are systematically under-used: a topical NSAID, a topical steroid, or an eye drop delivers the drug where it is needed with a fraction of the systemic exposure.

1. Sleep aids

Melatonin is widely misunderstood. It is not a sedative. It is a timing signal: your pineal gland releases it as darkness falls, telling the body clock that night has begun (Chapter 19).

Consequently:

• It works best for circadian problems: jet lag, shift work, delayed sleep phase syndrome.
• It works poorly as a general sleeping tablet. Meta-analyses find it reduces time to fall asleep by roughly 7 to 12 minutes, which is real and small.
• Timing matters more than dose. For jet lag travelling east, take it in the early evening at the destination; for delayed sleep phase, a small dose several hours before the target bedtime.
• Lower doses often work better than higher ones. Physiological doses (0.3 to 1 mg) can be more effective than the 5 to 10 mg commonly sold, because high doses spill over into the following day.
• Regulation varies drastically. In the UK and most of Europe it is prescription-only; in the US it is a dietary supplement, and independent testing has repeatedly found actual content ranging from a fraction to several times the labelled dose, with some products containing serotonin.
• Paediatric melatonin poisonings rose sharply in the US in the 2010s and 2020s, largely from gummies, which look like sweets.

CBT-I (cognitive behavioural therapy for insomnia) is first-line in every major guideline, outperforms medication in the long term, and consists of concrete techniques: stimulus control (bed for sleep only), sleep restriction (counterintuitively, spending less time in bed to consolidate sleep), and cognitive work on sleep-related anxiety. Digital versions work and are widely available.

The behavioural basics that actually matter: consistent wake time (more important than bedtime), morning daylight exposure, no caffeine after early afternoon (Chapter 88), alcohol wrecks sleep architecture even when it speeds sleep onset (Chapter 61), a cool dark room, and getting out of bed if awake for more than about 20 minutes.

2. Eyes

Dry eye: artificial tears. Preservative-free single-use vials if using them more than four times a day, because benzalkonium chloride, the usual preservative, is itself irritating with frequent use. Thicker gels and ointments at night.

Allergic conjunctivitis: antihistamine or mast-cell stabiliser drops (sodium cromoglicate, olopatadine) work better locally than oral antihistamines.

Infective conjunctivitis: mostly viral and self-limiting. Chloramphenicol drops are widely sold and used, and the evidence that they speed recovery in ordinary bacterial conjunctivitis is modest.

How to use eye drops properly, which almost nobody is taught:

1. Wash hands. Tilt head back.
2. Pull the lower lid down to form a pocket.
3. One drop only. The eye holds about 7 microlitres; a drop is 25 to 50. The rest runs down your face or your throat.
4. Close your eye gently and press the inner corner (punctal occlusion) for 1 to 2 minutes. This stops the drop draining into the nose and being absorbed systemically, which both improves the local effect and reduces systemic side effects. This matters most for glaucoma drops containing beta blockers, which can cause bradycardia and bronchospasm systemically.
5. Wait 5 minutes between different drops, or the second washes out the first.
6. Do not touch the dropper to the eye. Discard 28 days after opening.

Red flags requiring urgent assessment, not drops: significant eye pain, sudden vision loss or change, halos around lights with a red painful eye (acute glaucoma), photophobia, a foreign body sensation that will not clear, chemical splash (irrigate immediately and copiously first), and any eye problem in a contact lens wearer.

Contact lens wearers: never use tap water on lenses or cases. Acanthamoeba keratitis is a rare, devastating, sight-threatening corneal infection strongly associated with tap water exposure and swimming or showering in lenses.

3. Ears

Earwax is normal, protective, and self-clearing. The ear canal migrates outward, carrying wax with it.

Do not use cotton buds in the ear canal. They push wax deeper, compact it against the eardrum, and cause a substantial share of impactions, plus perforations and canal trauma. "Do not put anything smaller than your elbow in your ear" is genuinely good advice.

For impacted wax: olive oil or sodium bicarbonate drops for a few days to soften it, then irrigation or microsuction by a professional. Ear candling does not work, has been shown not to create suction, and causes burns and canal obstruction from wax deposits.

Ear infections: outer ear infection (otitis externa, "swimmer's ear") is treated with antibiotic or steroid drops. Middle ear infection (otitis media) is behind an intact eardrum, so drops cannot reach it; most cases in children resolve without antibiotics, and watchful waiting for 48 to 72 hours is standard in many guidelines.

Drops must not be used if the eardrum is perforated unless specifically prescribed, because some are ototoxic.

4. Skin

Emollients need using in far larger quantities than most people use. For widespread eczema, 250 to 500 g a week is a normal prescription. Applied in the direction of hair growth, not rubbed in vigorously.

Emollient fire risk is a genuine and underpublicised hazard. Paraffin-based emollients (and, per current UK guidance, emollients generally) soak into fabric and dressings, and that fabric becomes highly flammable. There have been deaths. Do not smoke, use open flames, or sit close to heaters while wearing emollient-soaked clothing or bedding, and wash fabrics at high temperature, accepting that residue may persist.

Isotretinoin (for severe acne) deserves specific mention: highly effective, and absolutely contraindicated in pregnancy because it is a potent teratogen, requiring strict pregnancy prevention programmes with mandatory contraception and testing. It also causes dryness of skin, lips, and eyes, and carries a contested association with mood changes that warrants monitoring.

Sunscreen is covered in Chapter 94.

5. Mouth and throat

Sore throat: most are viral. Anaesthetic lozenges (benzocaine, lidocaine), NSAIDs, and paracetamol help symptoms. Medicated lozenges are not better than sucking a plain sweet plus a systemic analgesic in most trials. Antiseptic gargles have weak evidence.

Mouth ulcers: most heal in 7 to 14 days. Topical anaesthetics and protective pastes help. An ulcer lasting more than three weeks needs assessment, because oral cancer can present this way.

Oral thrush: miconazole gel or nystatin suspension. In adults, consider inhaled steroid technique (Chapter 78), diabetes, or immunosuppression.

Chlorhexidine mouthwash is effective for gingivitis and short-term use; it stains teeth brown with prolonged use and, as Chapter 38 notes, antiseptic mouthwash abolishes the blood-pressure-lowering effect of dietary nitrate.

Fluoride is the active ingredient in toothpaste that prevents decay. Spit, do not rinse after brushing: rinsing washes away the fluoride that was about to work. This single change is one of the cheapest dental interventions there is, and almost nobody does it.

Teething gels containing benzocaine are not recommended for infants because of a rare risk of methaemoglobinaemia; sugar-free teething rings and paracetamol are preferred.

6. Motion sickness and vertigo

All work far better taken before travel than after symptoms start, because once vomiting has begun, oral absorption stops.

Practical measures: sit where motion is least (over the wing, mid-ship, front seat), look at the horizon, get fresh air, avoid reading, and avoid large or fatty meals beforehand.

7. Smoking cessation

Worth including because it is the highest-value pharmacological intervention in this book.

Nicotine itself is not what causes smoking-related cancer and lung disease; combustion products are. That distinction is the entire basis of harm reduction, and it is discussed properly in Chapter 89.

8. Practical rules for the cupboard

• Use topical routes where you can. Topical NSAIDs, steroids, antifungals, and eye drops all deliver drug locally with a fraction of the systemic exposure.
• One eye drop, then press the inner corner for a minute.
• Nothing smaller than your elbow in your ear.
• Spit, do not rinse, after brushing.
• Sedating antihistamines are a poor long-term sleep solution: tolerance in days, impairment that persists, anticholinergic burden.
• Melatonin is a clock signal, not a sedative, and lower doses are often better.
• Motion sickness drugs must go in before you travel.
• Emollient-soaked fabric is a fire hazard.
• Any mouth ulcer over three weeks, any change in vision, any eye pain: get it looked at.

9. The bottom line

• Over-the-counter sleep aids are mostly sedating antihistamines: tolerance develops within days, impairment does not, and CBT-I beats all of them long term.
• Melatonin is a timing signal that works for jet lag and circadian disorders and works poorly as a general sleeping tablet. Doses on the shelf are usually higher than needed, and US products are unregulated in content.
• One eye drop at a time, close the eye, and press the inner corner for a minute. Never use tap water on contact lenses.
• Earwax clears itself. Cotton buds cause the impactions they are used to treat, and ear candling does not work.
• Emollients should be used in far greater quantity than most people use, and emollient-soaked fabric is a serious fire risk.
• Spit and do not rinse after brushing. Motion sickness treatment must precede the journey.
• Smoking cessation with combination NRT or varenicline plus behavioural support is the single highest-value drug intervention in this book.

Sources and notes

Doses, cautions, and interactions follow the British National Formulary and the electronic Medicines Compendium; US figures follow FDA labelling. Sedating antihistamines as sleep aids, their rapid tolerance, and next-day impairment follow Cochrane and sleep medicine reviews. Melatonin's role as a circadian signal rather than a hypnotic, and its modest effect on sleep onset latency, follow Ferracioli-Oda et al., PLoS ONE, 2013, and Auld et al.'s reviews; jet lag evidence follows Herxheimer and Petrie's Cochrane review. US melatonin product content variability follows Erland and Saxena, Journal of Clinical Sleep Medicine, 2017; paediatric melatonin ingestions follow CDC MMWR reporting, 2022. CBT-I as first-line follows NICE, AASM, and European insomnia guidelines. Eye drop technique, punctal occlusion, and 28-day discard follow ophthalmology guidance. Acanthamoeba keratitis and tap water follows Public Health England and contact lens safety literature. Earwax management and the ineffectiveness and hazards of ear candling follow Seely, Quigley, and Langman, Laryngoscope, 1996, and FDA warnings. Emollient quantities and the emollient fire risk follow NICE guidance and the MHRA's 2018 and 2020 drug safety updates. Isotretinoin pregnancy prevention follows the MHRA programme. Fluoride toothpaste spit-don't-rinse advice follows the Delivering Better Oral Health toolkit and Cochrane reviews. Hyoscine patches and motion sickness timing follow product information. Smoking cessation efficacy comparisons follow the Cochrane reviews by Hartmann-Boyce and colleagues, including the 2024 e-cigarette review finding high-certainty evidence.

Open questions. Melatonin dosing is poorly standardised and most products sold exceed physiological doses without evidence that more is better. Whether long-term use of any sleep medication is net beneficial has not been established.

👉 Next: supplements and herbal remedies.