672 JOURNAL OF THE SOCIETY OF COSMETIC CHEMISTS chosen. These were mainly special shampoos used particularly in eczematous patients, and they were, very largely, cetrimide shampoos. MR. P. Mox•¾: Would you suggest that the results shown in your Tables would be applicable to most other institutions dealing with these problems in the United Kingdom? TI• L•CTUR•R: I can not really comment. I had access only to the records of the Royal Free Hospital, but my experience in discussing problems with dermatologists would lead me to believe that it is a general trend, which may be more pronounced in some cases than in others. MR. N.J. VAN ABex: Is there any evidence to indicate how far the patient has benefited by the changing pattern of dermatological prescribing since 19517 Pre- sumably, data on the resolution of skin diseases in out-patients is difficult to obtain, but can this be derived from numbers of working days lost? TI• L•CTUR•R: My examination of the records did not extend that far. As I went through the records I obtained the impression that they were outpatients, the majority of whom did not come back. Whether this was because they were cured or because they decided to find some other treatment I would not like to say. DR. C. F. H. V•cI(•Rs: If I may, I •vould like to comment on this from the clinical angle because the question has been raised whether your figures represent the whole of this country. I think I can speak quite definitely for at least two, and probably three or four, northern centres and I •vould think that there would be several striking differences. The first of these would be in eczema where crude coal tar is still used to a very much greater extent than Table II would suggest, though I would entirely agree that topical corticosteroids have revolutionised this disease. Their long term management is still helped tremendously by the use of crude coal tar. With regard to psoriasis, I think if you took figures from the four Northern centres with outpatient psoriasis treatment units, you would find a completely different set of results. Tar and dithranol would top the bill by a very long way, with corticosteroids probably used only in perhaps 10% of these patients. I •vonder if I could also comment on the very real question--has the change in therapy in any •vay influenced the wellbeing of our patients? I am sure that the most important thing that has happened here has been the fact that patients with previously incapacitating diseases, sometimes requiring admission to hospital, are no longer admitted to hospital, but remain at work. This is reflected in the decrease in the number of beds in many dermatological units over the last few years. MR. M. J. BussE: It seems that between 1951 and 1957 (Table IV) there was a craze for mercury salts and this has dropped to nil by 1967. I wonder whether you could elaborate and tell us the background for this. In page 671, you refer to the inactivation of chlorocresol in a cream in the presence of cetomacrogol. I would like to say that there is unpublished laboratory evidence available showing that 0.1% chlorocresol in a cream base containing cetomacrogol is quite effective both antifungally and antibacterially, against heavy inoculate.

THE CHANGING PATTERN OF TOPICAL DERMATOLOGIGAL THERAPY 673 T•u LECTURER: One of the difficulties of these figures is that there has been a change in the staff over the same period, and therefore the use of mercury salts could well reflect a change in staff as well as a change in the attitude to the treatment. With regard to the preservation of cream containing chlorocresol in the presence ooe cetomacrogol emulsifying wax, I based this comment on a paper that appeared about a year ago in The Lancet in which there had been an outbreak of pseudomonas infection following the use of a proprietary steroid cream that had been diluted with cetomacrogol cream. The information that I had was that the activity of chlorocresol is considerably reduced in the presence of cetomacrogol and in these circumstances a pseudomonas infection was able to proliferate in the cream. Whether this was due to the fact that the cream that was used for dilution was already heavily contaminated with pseudomonas I really do not know. I think that there is little doubt that if you get a heavy inoculum then 0.1% of chlorocresol in the presence o • cetomacrogol will not inhibit a growth of pseudomonas. I made this comment (and I have made it elsewhere) largely to try to discourage dermatologists from requesting that these proprietary products should be diluted. I think that it is highly desirable that the pharmaceutical industry should get together with the dermatologists in order to determine what concentrations of steroids are really wanted so that they can be produced as proprietary preparations. I consider it an undesirable situation when hospital and retail pharmacists are called upon to dilute proprietary products when they do not have the full knowledge of the formulation which the manufacturer has used. DR. C. W. MARSD•: I would like to congratulate you on a very fascinating paper, and at the same time to disagree completely with Dr. Vickers. I think that this paper proves the point that this is what dermatologists do, not what dermatologists think they do. I notice in Table Ioe that you show an increase in the use of topical corticosteroids of over 50% and an increase in the use of antibacterials and antibiotics of only 9%. I think it is true that the combination of corticosteroids, antibacterials and anti- biotics has increased at the same rate. Can you explain this difference in the figures? T• L•CTU•R: I based this survey on the examination of 50 prescriptions selected at random from the records. In my own hospital there are many fewer pre- scriptions for antibiotic corticosteroid combinations in the treatment of eczema, than there are for simple corticosteroid preparations. Du. H. BAKER: I think you flatter clinical dermatologists in suggesting that the changes described reflect a rationalisation and greater understanding of the mode of action of various topical medicaments. As one or two previous speakers have just commented, fashion, teaching and dissatisfaction with previous methods of therapy have partly led to these changes, and partly they involve a desire on the part of dermatologists to jump at any new chance of improving his therapeutic armamen- tarturn. A second point concerns the current use of topical steroids: this very much reflects fashion, I would suspect in ten years' time the figures will be much lower and I xvould support Dr. Vickers' comments, particularly on the use of topical steroids in treatment of psoriasis. In the hands of a physician familiar with its use the old fashioned dithranol (not the newer variant) is undoubtedly the most valuable topical