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    Clinical pearls in pediatric dermatology


    Dr. Siegfried: We always ask our patients to bring in their tubes and have actually found about a 30% error in pharmacy dispensing, compared to what we have prescribed, either in the quantity, vehicle or the product concentration.  The labels on the tubes sometimes don’t represent what’s in the tube that the label had been attached to.

    Dr. Cordoro: That’s something I haven’t even considered as a possibility. Yet another challenge.

    Dr. Siegfried: The effort required to monitor the actual medication and quantities used can be a nightmare. I would say 70% of people probably don’t use adequate amounts and maybe 20% use too much. I rarely give refills. I prefer that the patient call their pharmacist to fax the refill request, so we know when they get their refills. Monitoring adherence is an important but difficult problem. There’s no right answer.

    Check out part two of this three part series: Pediatric psoriasis, eczema:Triggers and therapies

    Dr. Cordoro: I think one of the challenges also is the psychological warfare that we play when a patient gets a prescription. For example, if we write “450 gram tub” for very widespread, severe disease, and the pharmacy supplies only a 60 gram tube, psychologically, a parent becomes concerned about how much to use given the limited quantity supplied.  At the pharmacy, patients are often given advice, for example, told not to use the prescription for more than two weeks; parents are told that they shouldn’t be using the prescription on their 5-year-old child, etc., but they wait for three months to come back to tell you that.

    Earlier in my career I became frustrated, even angry, when I would hear this, and I would call pharmacies and rant and rave. I think a lot of these really complex inflammatory disease patients aren’t really getting the time that they need from the doctor in that regard. We need to really educate them that we are skin experts who are prescribing the medication this way for a reason, because once they leave your clinic, they are open to the world, and I think that’s when modifications happen. It’s a fascinating and frustrating problem.

    READ: Nailing the diagnosis

    Dr. Siegfried: We have a number of problems with very limited formularies. Do you face that challenge?

    Dr. Cordoro: Absolutely, all the time. I will say this: I feel very fortunate that one of the lessons I learned very early in my residency at the University of Virginia was to be cost-conscious. I, to this day, rarely will write for branded medication if there is a suitable generic alternative. And I think this actually plays into my favorite part of dermatology: The art of mastering the treatment of skin diseases and the ability to find alternate regimens and generic regimens that work, as well as compounding.

    If we can get a pharmacist to make a cream for diaper dermatitis with inexpensive ingredients by mixing a little hydrocortisone, a little Nystatin, and a little zinc oxide, you can save the patient anywhere from $10-$25 which is the price of the commercially available brand. Compounding is becoming a lost art really.

    Check out part two of this three part series: Pediatric psoriasis, eczema:Triggers and therapies

    I think one of the other tricks to dealing with these formulary restrictions is to ask patients to compound simple things by themselves. I will often have a patient add a tube of a topical steroid into plain white petrolatum, or another emollient, to create something that will last them a bit longer, give them a little anti-inflammatory action while repairing the barrier. I think “skin devices”, while well-intentioned, are not affordable for most of my patients and they won’t be covered.

    Formulary problems are also difficult with systemic medications. If there is a systemic medication to be prescribed and I don’t believe there is an adequate substitute, I will call the carrier personally to provide the medical rationale and seek approval for its use.

    My UCSF staff are incredibly gifted in getting these prior authorizations for necessary medications. Sadly this has become just a routine practice for so many prescriptions. Even now, generics require prior authorization for medications that we used to just prescribe liberally.

    NEXT: Getting kids access to medication is increasing

    Elaine Siegfried, M.D.
    Elaine Siegfried, M.D., is professor of pediatrics and dermatology, Saint Louis University Health Sciences Center, St. Louis, Mo. She ...


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