My doctor bag shrinketh

One of my favorite treatments for thick plaque scalp psoriasis or seborrheic dermatitis is a combination of clobetasol gel, tar gel and salicylic acid gel. I recommend that the patient massage the gel into the thickened scalp scale and sleep overnight, then shampoo in the morning. This was one of my recommendations for a patient last week; however, the prescription was never successfully compounded. Why? Because the pharmacist informed me that tar gel is no longer available, and neither is clobetasol gel.

How could this be? I have been using both of these medications for at least 15 years! These are two valuable dermatologic pharmaceuticals. There must be some mistake.

Well, how about another substitution. Perhaps we could substitute fluocinonide gel and add some 2 percent LCD to the salicylic acid gel. It wouldn't be quite as effective or as elegant, but it might fit the bill in a patient with darkly colored hair not susceptible to the staining effects of the LCD.

The revised prescription was called into the pharmacy. Again, it could not be filled. Why? Because the pharmacy had decided that compounded products are not FDA-approved and as such cannot be filled.

One last phone call to a locally owned pharmacy resulted in some remaining tar gel that could be combined with the fluocinonide gel and salicylic acid gel to make the prescription. Problem solved - but not really.

Losing ground

What is the problem? My doctor bag shrinketh! In dermatology, we are losing products more quickly than we are gaining products.

When I left residency some 20 years ago, I could choose from a wide variety of novel branded topical corticosteroids in a variety of vehicles to suit the needs of many dermatologic conditions. I could write a prescription and be sure that my propylene glycol-allergic patient would receive a branded cream that caused no difficulty. As a matter of fact, I could go to my sample closet and quickly determine which of the many products exactly fit the bill.

Now, my sample closet has one shelf with a few topical corticosteroid samples and six shelves filled with over-the-counter hand creams, body lotions, facial moisturizers, bar soaps and facial liquid cleansers. Most of the new pharmaceuticals introduced into dermatology during the past year represented new combinations of old molecules, new formulations of existing molecules, reintroduced grandfathered molecules or generic equivalents.

I can understand that new combinations of existing molecules can be challenging to formulate and require FDA approval. The approval process is expensive and lengthy, since the combination must be proven better than either of the individual molecules separately. This means that a four-arm study must be conducted, which is an expensive analytical nightmare. Nevertheless, I yearn for something new and revolutionary, some new molecule that will re-excite my interest in topical medications.

A topical drug that would make me feel as if I had a special therapeutic bullet to improve the life of my patients suffering from skin disease. Something that would fill by shrinking doctor bag!