CHAPTER 11 USE OF DERMATOLOGICALS Malaysian Statistics on Medicines 2006

Edited by: Rohna R1, Asmah J2, Roshidah B3

1. Selayang Hospital, 2. Kuala Lumpur Hospital, 3. Melaka Hospital

The topical dermatological medicaments included in this study were antifungals, anti-psoriatics, antibiotics, antivirals, corticosteroids, anti-acne agents, hair growth stimulants, depigmenting agents, calcineurin inhibitors and metronidazole. Topical dermatological medicament is the major therapeutic modality used in treating patients with skin disorders. Utilisation is measured as total dose of topical medicament in g/ml/1000 population/day.

There is a disparity in the utilisation of dermatological medicaments by public and private health care providers with the latter having access to a larger variety of topical medicaments (Table A). Prescribing only medicaments that are available in the Ministry of Health (MOH) drug formulary by healthcare providers in the public sector is one possible explanation for the disparity. The list of medicaments (Table A) that were utilised only by private healthcare providers was not available in the MOH drug formulary. In the public sector, prescribing of certain dermatological medicaments (e.g. topical anti-acne agents) is only by trained dermatologists and they are few in number. In private sector, the non-dermatologists have access to clindamycin and various other topical anti-acne agents such as adapalene and azelaic acid.

The lower usage of the newer but expensive medicaments (e.g. tacrolimus, pimecrolimus, imiquimod and metronidazole) in government healthcare facilities was because of the availability of their cheap and effective equivalents in the MOH drug formulary. In special cases of drug resistance or contraindication, prescribing of dermatological medicaments not in the MOH formulary is permissible after seeking approval from the Director General of Health, Malaysia.

In government healthcare facilities, procurement of dermatological medicaments for acute (acute cutaneous infections) and chronic skin diseases (eczema and psoriasis) took preference over hair growth stimulants (minoxidil, finasteride) and depigmentation agents8-10(hydroquinone) which are perceived as more for cosmetic benefits.

Medications (acitretin and methoxalen) that require vigilant long term monitoring was utilised less in the private sector because patients requiring these agents were often referred to government hospitals for management.

There was a high usage of the moderately potent and very potent topical steroids1-7 by private health care providers. The appropriateness of these prescriptions and monitoring of their side effects1-7 need further study. Similarly the usage of topical antibiotics was more in the private sector as compared to public sector. Here again, the appropriateness of topical antibiotic prescriptions and the drug resistance pattern need further study. Healthcare providers need to be aware of untoward events1-11 that can occur with inappropriate drug usage.

43 CHAPTER 11 Malaysian Statistics on Medicines 2006 USE OF DERMATOLOGICALS

Table A: Utilisation of Medicament by Health Care Providers 2006 Increased medicament usage Increased medicament usage Medicament used in Private in Public Health Facilities in Private Health Facilities Health Facilities only

Topical Anti-fungal medicaments Ketoconazole Isoconazole, Econazole, Nystatin, Miconazole Terbinafine, Fluconazole

Anti-psoriatic therapy Calcipotriol combination therapy Acitretin, Methoxalen

Antibiotic & Antiseptics Tetracycline, Fusidic acid, Neomycin, Silver sulfadiazine Gentamicin, Mupirocin Antiviral Topical aciclovir Tromantadine, Imiquimod Corticosteroids Clobetasone, Triamcinolone Ac lometasone, Dexamethasone Hydrocortisone Betametasone, Mometasone Fl uo ci no lone acetonide, Hydrocortisone aceponate, Fluticasone clobetasol Combination Topical steroid and Bethamethasone AB combination Prednisolone plus AB, Antibiotic (AB)/antifungal Bethamethasone plus other Triamcinolone/dexamethasone plus AB, Hydrocortisone plus AB combination Fluocinolone acetonide/clobetasol plus AB, Hydrocortisone plus other combination

Anti-acne Adapalene, clindamycin, Topi ca l is ot retinoin Azelaic acid Topical erythromycin and erythromycin combination Hair growth stimulants Finasteride Topical minoxidil Depigmenting agent Hydroquinone Calcineurin inhibitors Tacrolimus and pimecrolimus Acne rosacea therapy Topical metronidazole

Table 11.1: Use of Dermatological by Drug Class and Agents, in total dosage/1000 population/day 2006

ATC Drug Class and Agents Unit 2006 D01A A Antibiotics D01A A01 Nystatin g/ml/cc Public 0.1064 Private 0.0089 Total 0.1153 D01A C Imidazole and triazole derivatives D01A C01 Clotrimazole g/ml/cc Public 0.1469 Private 0.3403 Total 0.4872 D01A C02 Miconazole g/ml/cc Public 1.3178 Private 0.6315 Total 1.9493 D01A C03 Econazole g/ml/cc Public - Private 0.0434 Total 0.0434 D01A C05 Isoconazole g/ml/cc Public - Private 0.0003 Total 0.0003 D01A C07 Tioconazole g/ml/cc Public 0.0007 Private 0.0059 Total 0.0066 D01A C08 Ketoconazole g/ml/cc Public 0.0608 Private 0.3199 Total 0.3808

44 CHAPTER 11 USE OF DERMATOLOGICALS Malaysian Statistics on Medicines 2006

ATC Drug Class and Agents Unit 2006 D01A C15 Fluconazole g/ml/cc Public - Private 0.0002 Total 0.0002 D01A C20 Combinations g/ml/cc Public 0.0051 Private 1.7155 Total 1.7207 D01A C52 Miconazole, combinations g/ml/cc Public - Private 0.0229 Total 0.0229 D01A E Other antifungals for topical use D01A E13 Selenium sulfide g/ml/cc Public 0.032 Private 0.0388 Total 0.0707 D01A E15 Terbinafine g/ml/cc Public - Private 0.0277 Total 0.0277 D01A E16 Amorolfine g/ml/cc Public 0.0001 Private <0.0001 Total 0.0002

Table 11.2: Use of Dermatological by Drug Class and Agents, in DDD/1000 population/day 2006 ATC Drug Class and Agents 2006 D01B A Antifungals for systemic use D01B A01 Griseofulvin Public 0.1525 Private 0.231 Total 0.3835 D01B A02 Terbinafine Public 0.0048 Private 0.0081 Total 0.0128

Table 11.3: Use of Dermatological by Drug Class and Agents, in total dosage/1000 population/day ATC Drug Class and Agents Unit 2006 D05A D Psoralens for topical use D05A D02 Methoxsalen g/ml/cc Public 0.0003 Private 0.0001 Total 0.0004 D05A X Other antipsoriatics for topical use D05A X02 Calcipotriol g/ml/cc Public 0.0465 Private 0.0124 Total 0.0589 D05A X52 Calcipotriol, combinations g/ml/cc Public - Private 0.0064 Total 0.0064

45 CHAPTER 11 Malaysian Statistics on Medicines 2006 USE OF DERMATOLOGICALS

Table 11.4: Use of Dermatological by Drug Class and Agents, in DDD/1000 population/day 2006 ATC Drug Class and Agents 2006 D05B A Psoralens for systemic use D05B A02 Methoxsalen Public 0.0012 Private 0.0007 Total 0.002 D05B B Retinoids for treatment of psoriasis D05B B01 Etretinate Public - Private - Total - D05B B02 Acitretin Public 0.006 Private 0.0004 Total 0.0064

Table 11.5: Use of Dermatological by Drug Class and Agents, in total dosage/1000 population/day 2006 ATC Drug Class and Agents Unit 2006 D06A A Tetracycline and derivatives D06A A04 Tetracy cline g/ml/cc Public - Private 0.0041 Total 0.0041 D06A X Other antibiotics for topical use D06A X01 Fusidic acid g/ml/cc Public 0.0303 Private 0.2682 Total 0.2985 D06A X04 Neomycin g/ml/cc Public 0.8132 Private 0.2511 Total 1.0644 D06A X07 Gentamicin g/ml/cc Public 0.0116 Private 0.2203 Total 0.2319 D06A X09 Mupirocin g/ml/cc Public 0.0255 Private 0.0896 Total 0.1151

Table 11.6: Use of Dermatological by Drug Class and Agents, in total dosage/1000 population/day 2006 ATC Drug Class and Agents Unit 2006 D06B A Sulfonamides D06B A01 Silver sulfadiazine g/ml/cc Public 0.1782 Private 0.0919 Total 0.2701 D06B B Antivirals D06B B02 Tromantadine g/ml/cc Public - Private 0.0054 Total 0.0054 D06B A Sulfonamides D06B B03 Aciclovir g/ml/cc Public 0.002 Private 0.0588 Total 0.0608

46 CHAPTER 11 USE OF DERMATOLOGICALS Malaysian Statistics on Medicines 2006

ATC Drug Class and Agents Unit 2006 D06B B10Imiquimod g/ml/cc Public - Private 0.0003 Total 0.0003 D06B X Other chemotherapeutics D06B X01 Metronidazole g/ml/cc Public - Private 0.0113 Total 0.0113

Table 11.7: Use of Dermatological by Drug Class and Agents, in total dosage/1000 population/day 2006 ATC Drug Class and Agents Unit 2006 D07A A Corticosteroids, weak (group I) D07A A02 Hydrocortisone g/ml/cc Public 1.0887 Private 0.6583 Total 1.747 D07A B Corticosteroids, moderately potent (group II) D07A B01 Clobetasone g/ml/cc Public 0.0491 Private 0.0622 Total 0.1113 D07A B03 Flumetasone g/ml/cc Public 0.0002 Private - Total 0.0002 D07A B09 Triamcinolone g/ml/cc Public 0.0013 Private 0.085 Total 0.0863 D07A B10 Alclometasone g/ml/cc Public - Private 0.0001 Total 0.0001 D07A B19 Dexamethasone g/ml/cc Public - Private 0.0005 Total 0.0005 D07A C Corticosteroids, potent (group III) D07A C01 Betamethasone g/ml/cc Public 0.8813 Private 1.3885 Total 2.2698 D07A C04 Fluocinolone acetonide g/ml/cc Public - Private 0.0276 Total 0.0276 D07A C Corticosteroids, potent (group III) D07A C13 Mometasone g/ml/cc Public 0.0168 Private 0.0951 Total 0.1119 D07A C16 Hydrocortisone aceponate g/ml/cc Public 0.0005 Private 0.0083 Total 0.0088

47 CHAPTER 11 Malaysian Statistics on Medicines 2006 USE OF DERMATOLOGICALS

ATC Drug Class and Agents Unit 2006 D07A C17 Fluticasone g/ml/cc Public - Private 0.0182 Total 0.0182 D07A D Corticosteroids, very potent (group IV) D07A D01 Clobetasol g/ml/cc Public 0.0583 Private 0.5533 Total 0.6116

Table 11.8: Use of Dermatological by Drug Class and Agents, in total dosage/1000 population/day 2006 ATC Drug Class and Agents Unit 2006 D07C A Corticosteroids, weak, combinations with antibiotics D07C A01 Hydrocortisone and antibiotics g/ml/cc Public 0.0573 Private 0.0407 Total 0.0981 D07C A03 Prednisolone and antibiotics g/ml/cc Public - Private 0.0006 Total 0.0006 D07C B Corticosteroids, moderately potent, combinations with antibiotics D07C B01 Triamcinolone and antibiotics g/ml/cc Public - Private 0.049 Total 0.049 D07C B04 Dexamethasone and antibiotics g/ml/cc Public - Private 0.0015 Total 0.0015 D07C C Corticosteroids, potent, combinations with antibiotics D07C C01 Betamethasone and antibiotics g/ml/cc Public 0.0198 Private 0.6038 Total 0.6235 D07C C02 Fluocinolone acetonide and antibiotics g/ml/cc Public - Private 0.0016 Total 0.0016 D07C D01 Clobetasol and antibiotics g/ml/cc Public - Private 0.0013 Total 0.0013

Table 11.9: Use of Dermatological by Drug Class and Agents, in total dosage/1000 population/day 2006 ATC Drug Class and Agents Unit 2006 D07X A Corticosteroids, weak, other combinations D07X A01 Hydrocortisone g/ml/cc Public - Private 0.0313 Total 0.0313 D07X C Corticosteroids, potent, other combinations D07X C01 Betamethasone g/ml/cc Public 0.004 Private 0.1847 Total 0.1887

48 CHAPTER 11 USE OF DERMATOLOGICALS Malaysian Statistics on Medicines 2006

Table 11.11: Use of Dermatological by Drug Class and Agents, in total dosage/1000 population/day 2006 ATC Drug Class and Agents Unit 2006 D10A D Retinoids for topical use in acne D10A D01 Tretinoin g/ml/cc Public 0.0358 Private 0.035 Total 0.0708 D10A D03 Adapalene g/ml/cc Public 0.0002 Private 0.0357 Total 0.0359 D10A D04 Isotretinoin g/ml/cc Public - Private 0.0031 Total 0.00 31 D10A E01 Benzoyl peroxide g/ml/cc Public - Private 0.0002 Total 0.0002 D10A F Antiinfectives for treatment of acne D10A F01 Clindamycin g/ml/cc Public 0.0002 Private 0.0894 Total 0.0896 D10A F Antiinfectives for treatment of acne D10A F02 Erythromycin g/ml/cc Public - Private 0.0384 Total 0.0384 D10A F52 Erythromycin, combinations g/ml/cc Public - Private 0.0029 Total 0.0029 D10A X Other anti-acne preparations for topical use D10A X03 Azelaic acid g/ml/cc Public 0.0007 Private 0.012 Total 0.0128

Table 11.12: Use of Dermatological by Drug Class and Agents, in DDD/1000 population/day 2006 ATC Drug Class and Agents 2006 D10B A Retinoids for treatment of acne D10B A0 1 Isotretinoin Public 0.01 Private 0.0073 Total 0.0173

Table 11.13: Use of Dermatological by Drug Class and Agents, in total dosage/1000population/day 2006 ATC Drug Class and Agents Unit 2006 D11A C Medicated shampoos D11A C03 Selenium compounds g/ml/cc Public 0.0604 Private 0.1091 Total 0.1695 D11A X Other dermatologicals D11A X01 Minoxidil g/ml/cc Public - Private 0.0231 Total 0.0231 D11A X10 Finasteride mg Public 0.0012 Private 0.0989 Total 0.1001

49 CHAPTER 11 Malaysian Statistics on Medicines 2006 USE OF DERMATOLOGICALS

ATC Drug Class and Agents Unit 2006 D11A X11 Hydroquinone g/ml/cc Public <0.0001 Private 0.0119 Total 0.012 D11A X14 Tacrolimus g/ml/cc Public 0.0005 Private 0.0098 Total 0.0103 D11A X Other dermatologicals D11A X15 Pimecrolimus g/ml/cc Public <0.0001 Private 0.0019 Total 0.002 References: 1. Rajesh B et al. Factors affecting prescription of ultra-high potency topical corticosteroids in skin disease: an analysis of US national practice data Journal of Drugs of Dermatology, Nov.-Dec. 2005. 2. MA Al-Dhalimi and, N. Aljawahiry. Misuse of topical corticosteroids: a clinical study in an Iraqi hospital Eastern Mediterranean Health Journal Volume 12 No 6 November 2006 Griffiths WAD, Wilkinson JD. Topical therapy. In: Champion RH et al. Textbook of dermatology, vol. 4. 6th ed. Oxford, Blackwell Science, 1998:3547-52. 3. Sulzberger MB, Witten VH. The effect of topically applied compound F in selected dermatoses. Journal of investigative dermatology, 1952, 19(2):101-2. 4. Lagos B, Maibach H. Frequency of application of topical corticosteroids: an overview. British journal of dermatology, 1998, 139(5):763-6. 5. Brodkin RH, Janniger CK. The artful use of topical steroids. Cutis, 1998, 61(3):125-6. 6. Keane FM et al. Unregulated use of clobetasol propionate. British journal of dermatology, 2001, 144(5):1095-6. 7. Fleischer AB Jr, Ford PG. How to prevent side-effects of topical corticosteroids. Skin and aging, 1998, February: 54-65. 8. Mahe A et al. Skin diseases associated with the cosmetic use of bleaching products in women from Dakar, Senegal. British journal of dermatology, 2003, 148(3):493-500. Arnold J, Anthonioz P, Marchand JP. Depigmenting action of corticosteroids. Dermatologica, 1975, 151(5):274-80. 9. Del Giudice P, Pinier Y. The widespread use of skin lightening creams in Senegal: a persistent health problem in West Africa. International journal of dermatology, 2002, 41(2):69-72. 10. Hammarstrom et al. Pharmaceutical care for patients with skin diseases: a campaign year at Swedish pharmacies. Journal of Clinical Pharmacy and Therapeutics, 1995, 20(6):327-334.

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