Dermatological Preparations for the Tropics
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Dermatological Preparations for the Tropics A formulary of dermatological preparations and background information on therapeutic choices, production and dispensing Peter Bakker Herman Woerdenbag Vincent Gooskens Ben Naafs Rachel van der Kaaij Nicolien Wieringa Dermatological Preparations for the Tropics A formulary of dermatological preparations and background information on therapeutic choices, production and dispensing Peter Bakker Herman Woerdenbag Vincent Gooskens Ben Naafs Rachel van der Kaaij Nicolien Wieringa Colofon Dermatological Preparations for the Tropics, A formulary of dermatological preparations and background information on therapeutic choices, production and dispensing 2nd revised edition Authors: Peter Bakker Herman Woerdenbag Vincent Gooskens Ben Naafs Rachel van der Kaaij Nicolien Wieringa Publisher: © 2012 Beta Science Shop, University of Groningen, The Netherlands Design & lay-out: Histografica, Soest, The Netherlands ISBN: 978-90-367-5698-3 Any part of this book may be reproduced, used, translated or adapted to meet local needs, without permission from the authors or publisher, provided this is done for non-profit purposes and with acknowledgement. The authors/publisher would appreciate receiving a copy of the materials in which parts of the book are used. To the reader of this book Any part of this book may be reproduced, used, translated or adapted to meet local needs, without permission from the authors or publisher, provided it is for non-profit purposes and includes acknowledgement of the source. The authors/publisher would appreciate receiving a copy of the materials in which parts of the book are used. Some of the names used in this formulary are registered trademarks in a number of countries. They are not characterised as such. Using such names does not imply our preference for a specific brand product. Medicine and pharmacy are fast changing scientific fields. We have taken great care to ensure that perspectives, opinions and practical information in this book are up to date. We have also taken great care to provide correct information. However, the authors and publisher cannot be held responsible for any error in this book nor for the consequences of such errors. We would appreciate to receive any ideas, comments and additions. Books and separate CDs can be ordered from the publisher. This book and its supplements are also available in digital format via www.rug.nl/wewi/dermatology or directly at http://irs.ub.rug.nl/dbi/4fed64994b40a The publisher: Beta Science Shop, University of Groningen PO Box 221, 9700 AE Groningen, the Netherlands [email protected] http://www.rug.nl/wewi/ Scan this code to go to the electronic version of this book. Preface Skin diseases may often be forgotten by policy makers, but not by patients. Many adults and children suffer from common disorders such as pyoderma, scabies, acne, dermatophytosis, skin warts and pediculosis capitis leading to much discomfort, medical expenses and loss of schooldays. In industrialized countries effective and convenient treatments are easily available, and are usually reimbursed by health insurance. In low- and middle income countries (LMICs) and especially for the poorer segments of the population, the situation is different. Many patients first try their luck with the local store or the traditional healer, and only visit a clinic or hospital when the disease has progressed to an advanced stage. And when the diagnosis is finally made the patient, or the parent, often receives a written prescription to buy the treatment in a private pharmacy. In LMICs up to three quarters of medical expenses are paid out of pocket. Poor households in LMICs spent up to 9.5% of their household expenditure on medicines, compared to 3.5% by the poor in high-income countries. Surveys from over fifty LMICs have shown that, on average, more than half of essential medicines are out of stock in public sector facilities, forcing patients to the private sector where brand preferences lead to prices which are 3-5 times higher than those of simple generic products. This picture is especially relevant for dermatological diseases, for which many facilities cannot afford to supply all patients with ready-made dermatological ointments and creams. This book is the very welcome second revised edition of a publication that has stood the test of time. It brings the cost-effective treatment of common skin diseases within reach of all general physicians, clinical officers and nurses in rural clinics and district hospitals. The book also offers very practical guidance to pharmacists and pharmacy technicians in larger hospitals to prepare simple dermatological formulations at very low cost. From an industrial development point of view, domestic production of skin preparations is a good start for building self-reliance in medicine manufacturing. Small-scale production of skin preparations does not require much capital investment, and the products can be adapted to local preferences and labeling. This business case is much easier to make than for manufacture of tablets and injections which require much more capital investment and technical sophistication, and which face immense global competition from large-scale production from countries like India and China. The approach of this book is also very much in line with WHO’s concept of essential medicines: a limited range of carefully selected essential medicines leads to better treatment and lower costs. The book is especially recommended for use by publicly funded or faith-based not-for-profit health care services – in other words, in situations where the health care provider wants to make an honest effort to supply the patients with cheap and cost-effective treatment. Hans V. Hogerzeil, MD, PhD, DSc, FRCP Edin Professor of Global Health, University of Groningen, the Netherlands Former Director of Essential Medicines and Pharmaceutical Policies, WHO, Geneva Preface to the 2nd edition This formulary is a publication of the Science Shop (Wetenschapswinkel) at the University of Groningen in the Netherlands. The local production of medicines in tropical developing countries and regions is one of its fields of interest. Skin diseases are common reasons for seeking medical advice all over the world, and even more so in developing countries (1,2). Up to 20% of people asking for treatment in primary care do so because of skin diseases. Although skin diseases are generally not life threatening, they may cause much discomfort and often have serious social implications. For example, scabies is a common skin disease. At any given time the worldwide burden of disease is about 300 million people (3). Most of these people live in developing regions and countries around the world. The highly negative influence of the disease on their quality-of-life forces even very poor patients to spend their money in search for an effective treatment they will most likely not find (4). During the three years (1977-1980) that one of the authors of this book, Vincent Gooskens, worked as a dermatologist for the Malaŵian government, he experienced the differences between working in a skin clinic in a developed Western country and in a tropical developing country. Nearly all common skin diseases that are present in the Netherlands were just as common in Malaŵi, but a number of skin diseases, including scabies, pyoderma and fungal skin infections, were far more prevalent in Malaŵi. Together with his Malaŵian counterpart, L. Chalira, Gooskens experienced that 90% of their outpatients were effectively treated with cheap and simple medication. The vast majority of patients with a common skin disease in Sub-Saharan African countries, such as Malaŵi, who ask for medical advise, will never see a doctor. Most likely they are treated by a traditional healer or a health worker with little training, in a primary health centre or an outpatient department of a hospital. The health worker can be a medical assistant, nurse or clinical officer, with access to almost none, or very few medications. In order to improve the care of patients with common skin diseases, it is necessary to train the health workers who will actually see and treat these patients, and to provide them with effective medications that are as cheap as possible in order to be affordable. In Malaŵi a simple booklet with essential knowledge about common skin diseases and their treatment with cheap and effective medications was used (5) and the Ministry of Health in Malaŵi decided to have these medications produced locally and distributed all over the country. Gooskens left Malaŵi and his Malaŵian counterpart, an inspired teacher who continued to train medical assistants and clinical officers for many years. Despite his efforts, Chalira could not prevent the production and distribution of skin medications to gradually decline again. Although their efforts did not last, comparable constructive efforts were described more recently by Mahé in Mali (2) and is hopefully followed by many more. A useful pocketbook on the diagnosis and treatment of common skin diseases in Africa has become available free of cost from TALC UK (6). The choice of medication should always be based on scientific grounds. Throughout the years little scientific work has been done to compare the effectiveness of cheap medications, that are produced locally, with the vast and ever growing number of more expensive medications produced by pharmaceutical industries. In this book we collected the available scientific data to make an optimal choice of effective and cheap medications for common skin diseases that can be produced locally and made available in primary health centres and hospitals in developing countries and regions. Since no new books on this subject have been published after the first edition in 1990, we decided to update the book for a second edition. Although this book contains a lot of interesting information for all dermatologists and pharmacists, it is especially meant for those who want to improve the dermatological care in developing countries and regions.