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Issue 1 (2002)

Economic effectiveness in topical Therapy
Drug Price not the decisive Factor

Today economic effectiveness is just as important as in other areas of medicine. Decisive factors for the attainment of a favorable cost-benefit relationship are besides the price also the effective strength, the application frequency and the quantity of consumption as well as the compliance connected with the product used. The president of the Gesellschaft für Dermopharmazie, Dr. Joachim Kresken, Viersen, emphasized this context which is significant both for the prescribing physician as well as for the self-paying pharmacy customer in a lecture at the 74th Annual Meeting of the North German Dermatological Society in September of last year in Kiel.

Prerequisite for an economically topical therapy is a secured therapeutical and pharmaceutical quality of the topical preparation used, Kresken explained. Prescriptions of drugs for external application the quality of which is not secured could be interpreted as uneconomical treatment measures and cause the respective cost unit to recourse claims. In the prescription area solely the prescribing physician is responsible for the securing of the therapeutical quality in the sense of an evidence-based medicine. The pharmaceutical quality, however, has to be ensured by the pharmaceutical producer or in case of prescription drugs by the producing pharmacy.

A prescription the quality of which cannot be ensured because of chemical or galenic incompatibilities according to recognized rules may on no account be dispensed to patients by the pharmacy. An exclusion of liability in the sense that the physician accepts the responsibility and liability for such a prescription after having been informed about the difficulties is legally not permissible [1]. In order to avoid production problems in the pharmacy, Kresken recommends to the dermatologists to preferably prescribe Extemporaneous Preparations referring to standard regulations for example from the Neue Rezeptur-Formularium (NRF) (New Prescription Formulatory).

Extemporaneous Preparations not
always a better Value

Extemporaneous preparations only have a price advantage towards active substance-identical ready-to-use drugs if larger quantities of the product for example for extensive treatment of an atopical eczema are required. Smaller prescription bases however, are generally more cost-intensive than comparable specialities due to the systematics of the taxation. Thus, for instance the prices for 20 grams of a Clotrimazole cream prepared on prescription are between 4,55 and 6,75 Euro according to the base and package used whereas corresponding ready-to-use drugs only cost 2,49 to 5,15 Euro.

The price of a topical preparation is however by far not the only factor on which the economic effectiveness in topical therapy depends. An important role equally plays effective strength as well as the necessary application duration and the consumption quantity connected with the respective preparation. The latter for example effectively influences the treatment costs of a tinea pedis interdigitalis.

Cost Savings by low Application Frequency

Antimycotics on the basis of azole derivatives as Bifonazole or Clotrimazole have to be applied for a duration of three respectively four weeks for the development of their full clinical effectiveness. Therefore, the treatment has to be continued after the ease of the subjective symptoms at least for two additional weeks, which is unfavorable with respect to the compliance. In contrast to this, Terbinafine-containing topical preparations only have to be applied for a duration of seven days with Tinea pedis interdigitalis in order to attain an at least equivalent therapy result as after a four-week application of Clotrimazole [2, 3] in accordance with present study results.

Therefore, a more economical tinea pedis treatment can be performed with a Terbinafine-containing preparation for topical application than with all other topical antimycotics due to the low product consumption connected with the short application duration. In case of a small area infestation, only a 15-gram pack of the Terbinafine cream available on the market at a price of 7,64 Euro is required. If azole-containing creams are used instead, a product consumption of up to 25 Euro comes about according to the preparation used (table).

Moreover, it is pharma-economically significant that the topical Terbinafine is effective in vivo fungicidal and therefore only has a relatively low danger of recidivation [3].

Table: Drug costs for the Treatment of a Tinea pedis interdigitalis when applying different topical Antimycotics (selection)

Active substance and

size and Prices¹

Consumption quantity²
Active Substance: Terbinafin
Lamisil® Cream
15 g: 7,64 €
Once daily
10,5 g
7,64 €
30 g: 12,75 €
During one week
(1 × 15 g)
Active substance: Bifonazole        
Canesten® Extra Cream
20 g : 7,60 €
Once daily
31,5 g
15,20 €
50 g: 16,75 €
For three weeks
(2 × 20 g)
Bifomyk® Cream
15 g: 4,51 €
Once daily
31,5 g
9,64 €
35 g: 9,64 €
For three weeks
(1 × 35 g)
Active substance: Clotrimazole
Canesten® Cream
20 g: 5,15 €
Twice daily
84,0 g
24,98 €
50 g: 12,49 €
For four weeks
(2 × 50 g)
Fungizid-ratiopharm® Cream
20 g: 3,25 €
Twice daily
84,0 g
14,10 €
50 g: 7.05 €
For four weeks
(2 × 50 g)
Cloderm® Cream 1%
20 g: 2,55 €
Twice daily
84,0 g
9,70 €
50 g: 4,85 €
For four weeks
(2 × 50 g)
¹ Status: 1 April 2002
² Required total quantity at an average consumption of 1,5 g per application
³ For use of most economical pack size (without consideration of possible saving effects by denomination of various pack sizes)

Also the form of Administration is important

The form of administration and the special type of application also have an influence on the economical aspect and the patient acceptance. Thus, two topical acne therapeutics with similar composition but different preparation form (solution respectively gel) have been tested in an experimental study at the dermatological clinic Lübeck [4] on their consumption quantity and their user feeling. The tests revealed a clear distinction in favor of the solution. For an application at the same surface four times less of the solution has been used than of the gel. Furthermore, the direct application of the solution from an applicator bottle has been judged better by the testees than the required mode of application of the gel with the fingers. These findings allow a promising outlook for the clinical application in terms of cost advantage and a higher patient acceptance for the solution. (jk)


[1] Mönch V: Haftung bei Rezepturen. Krankenhauspharmazie 9 (1988) 272
[2] Evans EGV, Dodman B, Williamson DM, Brown GJ, Bowen RG: Comparison of terbinafine and clotrimazole in treating tinea pedis. Br. Med. J. 307 (1993) 645-647
[3] Bergstresser PR, Elewski B, Hanifin J, Lesher J, Savin R, Shupack J, Stiller M, Tschen E, Zaias N, Birnbaum JE: Topical terbinafine and clotrimazole in interdigital tinea pedis: A multicenter comparison of cure and relapse rates with 1- and 4-week treatment regimens. J. Am. Acad. Dermatol. 28 (1993) 648-651
[4] Welzel J: Formulierungen im Vergleich - Mengenverbrauch und Patientenzufriedenheit in der topischen Aknetherapie. Derm. (2001) 204-206


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