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“Over the Internet” sale of prescription‐level topical corticosteroids and dilemma of dermatologists

A young woman recently turned up in our outpatient department with complaint of red face. Examination revealed atrophic skin, acne, hypertrichosis, and numerous telangiectasias on the right side of her face, where she had been applying a “cream” for the previous 1 year to cure a trivial scar. Notably, she had procured the combination cream containing tretinoin, mometasone furoate (a potent topical corticosteroid), and hydroquinone from a prime online shopping website, which claimed it to be an herbal/organic product that could be sold without a valid prescription (Figs. 1 and 2). To our surprise, an online search revealed an unannounced and unforeseen plethora of such formulations. Despite a recently reiterated ban on over-the-counter (OTC) sale of topical corticosteroids in India, a majority of combination formulations (steroid/antifungal/antibacterial combinations and fairness creams containing corticosteroid/hydroquinone/tretinoin combinations) were easily available online, both on the affluent commercial marketing websites and the dedicated e-pharmacies, without the need for a prescription. It was disheartening to see these formulations being promoted miscellaneously as treatments for “acne”/“fungal infections”/“skin infections” or “general purpose” creams (Figs. 3 and 4) and being dispensed without the hassle of a valid medical prescription, just like a bunch of groceries (Fig. 5). In addition to the scant and inaccurate information available online, the drugs were marketed with lucrative offers and significant discounts. Added adjectives/superlatives of “100% natural/ pure herbal/organic/safe” were distasteful. The distressing part about this trend is that these websites might represent the first source of information for many patients who surf and self-medicate. Many of these sites additionally provided medication listing (the costumers who bought this also bought these) and doctor listing (advertisement for teleconsultation in the absence of a valid prescription). Cases of corticosteroid abuse are routinely encountered during dermatology practice in India, where patients end up using topical corticosteroids/combinations as a panacea for every dermatological complaint. An ingrained cultural obsession for a fairer skin coupled with blatantly outrageous endorsement of expensive fairness creams by the celebrities feeds the insecurities of people. In addition, the perceived notion of a general similarity among various dermatoses to an untrained eye makes the laymen (friends, saloons, multimedia), nondermatologist-medical professionals, general practitioners, and pharmacists to think that virtually all dermatoses are trivial, self-treatable “allergies” easily amenable to creams/corticosteroids. The same thought process leads to prescription sharing and needs to be changed for good. Sadly, very few outside the specialty of dermatology are versed with the significant cutaneous and systemic adverse effects these corticosteroid-containing topical medications can cause. Despite being designated as “prescription only medications”, the pursuit for such products is colossal, and Indian markets are flooded with OTC topical steroid-containing products, and an unregulated, uninhibited online availability of these formulations is going to make things further worse. The lineup does not stop here, and medications such as systemic retinoids, immunosuppressants, biologics, botulinum toxin,