Pictorials may be used to augment textual instructions in the depiction of safety and warning information on medicines. The objective of this study was to design, develop and evaluate a simple and culturally appropriate pictogram sequence for using nystatin suspension, and to assess its understandability in low-literate Xhosa participants. A new pharmaceutical pictogram sequence was designed through focus group discussions and evaluated in a 2-phase process. The results of Phase 1 (30 participants) identified various problems associated with the new pictogram sequence. It was modified accordingly and re-evaluated in Phase 2 with 20 participants. All participants belonged to the Xhosa group, had between 0 and 7 years of formal schooling and had English as their second language. Acceptance of the new pictogram sequence was based on international standards (ANSI and ISO criterion) for evaluating the comprehensibility of pictograms. In Phase 1, the new pictogram sequence was correctly interpreted by 66.7% of the participants and this complied with the ISO criterion of 67% correct. In Phase 2, 95% of the participants were able to correctly interpret the new pictogram sequence. This result complied with the ANSI criterion of 85% correct, therefore, this new pictogram sequence was considered to be acceptable. This study has illustrated the success of using a consultative approach in the design of new pictograms.