Under My Skin

The $400 generic


Oren is 11. I often see him around the neighborhood.

The other day I gave his father a lift. “Oren had a rash on his face,” said Ben, slipping into the passenger seat. “The pediatrician said she thought it was eczema, but she gave him an acne medicine.”

I raised my eyebrows, but said nothing.

Dr. Alan Rockoff

Dr. Alan Rockoff

“She warned me that the cream was going to be expensive,” Ben said, “and it was, but she says she gets good results with it. And it did help. The rash went away in 2 days.”

“How much did it cost?” I asked.


“$400!” I couldn’t quite stifle my shock. “What was in the cream?” I asked.

“Here it is,” he said. “I took a picture of the tube on my phone.”

He showed me a snapshot of a tube of clindamycin/benzoyl peroxide.

Although I try not to meddle in the medical issues of friends, I decided to make a small exception in this case. “Next time someone prescribes an expensive skin cream,” I said, “let me know. Maybe I can help you find a more affordable alternative.”

What skin problem did Oren have? I have no idea. I see his face enough to know that he has no acne at all. Nor would acne go away in 2 days.

On the other hand, if he did have a flare of eczema – I’ve never noticed that on him either – acne medicine would aggravate it, if anything.

Besides those questions, I have another one: Regardless of what she thought the diagnosis was, why on earth did Oren’s pediatrician feel compelled to prescribe a $400 generic? I say “compelled” because she told Ben straight out that the cream was going to cost a lot. But she just had to prescribe it because her experience told her it worked.

What experience did she have, exactly? What else had she tried that didn’t work? And what did she mean by “work”?

Ben’s and Oren’s experience is just a small, unnoticed incident of no general interest. It will spur no magazine exposés, incite no lawsuits, launch no professional or political inquiries.

• Oren’s pediatrician will go on prescribing a hideously priced cream intended to treat who-knows-what. Nobody will suggest to her that she might at least consider doing otherwise.

• Pharmacy benefit managers will not crack down on either pediatrician or cream. They have bigger fish to fry, like biologics that cost $50K per year.

• Health care administrators will take no notice. They will instead think up more creative and onerous disincentives to restrain providers from prescribing anything expensive. Whether they will also figure out how to keep monopolistic generic drug manufacturers from jacking up prices into the stratosphere is something else.

• Medical educators will strengthen their focus on sophisticated science (Genomics! Precision Medicine!), while doing a wholly inadequate job of passing on simple lessons that might help primary clinicians do a better job of managing everyday skin problems. Just yesterday, my colleague and I saw two patients who had been taking doxycycline for years with no clinical benefit, three kids with eczema who had used a succession of antifungal creams for over 4 months, one woman who had been dousing herself repeatedly with permethrin – to no avail – because her mites lived exclusively in her brain and those of her prescribers, and a partridge with alopecia in a pear tree. (OK, not the last one). All that in just 1 day!

• Simple common sense will stay elusive. Most rashes are really not rocket science.

I apologize, dear colleagues, for being so cranky. Much jollier to be upbeat and amusing. It’s just that, after 40 years in the business, observing the same skull-exploding clinical behaviors gets a little old, along with the observer.

Oren and Ben are fine, though. Oren’s face is as clear as ever. (It’s genetic – his mom has great skin). Even Ben isn’t disturbed. First of all, the rash went away. Second, he has an annual $2,000 drug cost deductible, “so I’d have to spend it anyway.”

“Look, Ben,” I told him, “if you need help exhausting your deductible, I’ll be happy to send you a couple of bills. No problem.”

He smiled. I guess he doesn’t really need my help on that.

Dr. Rockoff practices dermatology in Brookline, Mass, and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His new book “Act Like a Doctor, Think Like a Patient” is now available at amazon.com and barnesandnoble.com. This is his second book. Write to him at [email protected].

Next Article: