The internet is probably one of the most significant advances in recent years which has transcended into all areas of our lives. In the UK, 9 out of 10 households have access to the internet with 89% of UK adults using it at least weekly (1). In healthcare, the internet has made a significant impact with more information and services available to consumers than ever before. The rise of the term “just google it” exemplifies this culture change.
The internet can offer information on virtually any health issue and with advances in technology we see online consultations and even surgery performed across the internet (2). The benefits and downsides of the digital age are well known and continue to be discovered and reported all the time.
Just recently, I was browsing on E-bay and found for sale, a prescription only medicine (POM). A tube of the very potent steroid cream Dermovate® (clobetasol 17-propionate) which was being offered for sale at £10 (see below). The item was just listed as “Derm cream” which was deliberately ambigious enough to evade E-Bay’s automatic checks, as their rules state they do not allow the sale of POM’s anywhere on their site. The item description itself was vague about the product and what it contained only suggesting the user should “Check online for uses”.
Topical steroids are useful and effective drugs for the management of a range of dermatological conditions when they are used appropriately. Known side effects include:
Skin atrophy
Telangiectasia
Striae (stretch marks)
Purpura and bruising
Skin infections and infestations (aggravation of and masking of)
Hyperpigmentation
Hypopigmentation
Rebound Phenomenon (exacerbation of the original skin disease caused by rapid withdrawal of steroid treatment)
The most common podiatric example of steroid mis-use is the application of a steroid cream on a fungal skin infection. Labelled as tinea incognito (3), the steroid suppresses the normal immune response and masks the typical features of tinea pedis. The lesion morphology alters as the margins become less raised or distinct, there is a reduction in scale and skin redness lessens. Moreover, the lesion becomes more extensive and may exhibit unusual features such as pustulation. A similar effect maybe observed if a potent steroid is used in combination with an antifungal, the action of the potent steroid overrides any benefit provided by the antifungal agent and tinea incognito may prevail.
The selling of Prescription Only Medicines on e-bay has been highlighted in the press (4). Sellers (and often patients) have been caught auctioning off unwanted or unused prescription drugs for a quick and, often substantial profit. Looking at this seller’s details this was not a one-off sale of unused skin cream, but a lot had been sold from this particular source. As part of the overall patient assessment it is important to be aware of what medications a patient may be using (prescribed or unprescribed) and where appropriate, advise the patient accordingly.
The problem goes much wider than just auction sites. The rise of illicit online pharmacies has been well documented and reviewed along with its potential effects (5). Unregulated internet pharmacy products are frequently offered without a prescription. Consequently, this may lead to the patient making a potentially incorrect self-diagnosis, risk a drug interaction, side-effect or adverse event which without professional supervision could lead to more significant medical problems.
In the UK, all pharmacies including those providing internet services, must be registered with the General Pharmaceutical Council (GPhC) and meet the standards for registered pharmacies. Like the HCPC, the GPhC has an online service is available which anyone can check to see if a pharmacy is registered: click here. In addition, any company in the UK selling medicines to the public via a website also needs to be registered with the Medicines and Healthcare products Regulatory Agency (MHRA) and to be on the MHRA’s list of UK registered online retail sellers - click here. Of course, this does not stop patients locating sellers and pharmacies outside the UK, but patients should be advised to always use legitimate sources with a prescription to ensure they are receiving a genuine medicine for a condition that has first been properly diagnosed by a healthcare professional.
References
1. Office for National Statistics. Statistical bulletin: Internet access – households and individuals, Great Britain: 2018 2018 [updated August 2018]. Available from: https://www.ons.gov.uk/peoplepopulationandcommunity/householdcharacteristics/homeinternetandsocialmediausage/bulletins/internetaccesshouseholdsandindividuals/2018.
2. Evelth R. The surgeon who operates from 400 km away: BBC News Online; 2014 [24th October 2018]. Available from: http://www.bbc.com/future/story/20140516-i-operate-on-people-400km-away.
3. Arenas R, Moreno-Coutiño G, Vera L, Welsh O. Tinea incognito. Clin Dermatol. 2010;28(2):137-9.
4. Borland S. Patients selling prescription drugs on eBay: Warning black market medication is costing the NHS thousands The Mail Online; 2017. Available from: https://www.dailymail.co.uk/news/article-4126374/Patients-selling-prescription-drugs-eBay.html.
5. Mackey TK, Nayyar G. Digital danger: a review of the global public health, patient safety and cybersecurity threats posed by illicit online pharmacies. Br Med Bull. 2016;118(1):110-26.