Dermatological diseases constitute a significant global health burden, affecting approximately one-third of the population at any given time and ranking as the fourth leading cause of disability worldwide ^[1]. Recent estimates from the Global Burden of Disease Study indicate that dermatological conditions resulted in over 41 million disability-adjusted life years (DALYs) globally, with prevalence rates varying dramatically between regions ^[1]. In developed nations such as the United Kingdom and United States, approximately 20-33% of the population experiences skin conditions requiring medical attention, while in developing countries, this figure can exceed 45%, largely due to environmental factors, limited access to healthcare, and socioeconomic disparities ^[1]. The economic impact is substantial, with dermatological care accounting for billions of dollars in healthcare expenditures annually, compounded by indirect costs including work absenteeism and reduced quality of life ^[3,4].

The Indian subcontinent presents unique challenges in dermatological care, with prevalence rates of skin diseases reaching 45.3% in certain regions ^[5]. The tropical climate, characterized by high humidity and temperature throughout the year, creates ideal conditions for microbial proliferation, particularly fungal and bacterial pathogens ^[6]. Additional factors including population density, inadequate sanitation infrastructure, limited access to clean water, and diverse cultural practices significantly influence disease patterns and severity ^[7,8]. The burden is particularly pronounced in coastal regions of South India, where the combination of warm, humid conditions and socioeconomic factors contributes to a high incidence of both inflammatory and infective dermatological conditions ^[9]. Recent epidemiological studies from tertiary care centers across India have documented that inflammatory conditions, particularly various forms of eczema, account for 30-40% of dermatological consultations, while infective conditions comprise another 25-35%, with considerable regional variation ^[10-13].

Current management of dermatological conditions relies heavily on a stepped therapeutic approach, with topical preparations forming the cornerstone of treatment and systemic therapy reserved for severe, resistant, or extensive disease. The World Health Organization’s Model List of Essential Medicines includes several dermatological preparations, emphasizing the importance of ensuring their rational use. However, appropriate selection of therapeutic agents requires careful consideration of multiple factors including disease severity, extent of involvement, patient compliance, cost-effectiveness, and local antimicrobial resistance patterns. In resource-limited settings, the challenge is compounded by the need to balance optimal therapeutic outcomes with economic constraints while simultaneously implementing antimicrobial stewardship principles to prevent the development of drug resistance. The judicious use of topical corticosteroids, appropriate selection of antimicrobial agents, and restriction of systemic medications to genuinely indicated cases represent fundamental principles of rational prescribing in dermatology.

Despite the substantial burden of skin diseases in developing countries, comprehensive data on real-world prescription patterns remains limited, particularly from tertiary care settings that manage more complex and severe cases ^[14,15]. Previous studies have highlighted considerable variation in prescribing practices across different regions and healthcare settings, with concerns about potential overuse of topical corticosteroids, inappropriate antibiotic selection, and inadequate adherence to evidence-based guidelines ^[2]. Understanding current prescription patterns is essential for developing institutional protocols, implementing targeted antimicrobial stewardship programs, optimizing therapeutic outcomes, and ensuring cost-effective care delivery. Therefore, this study aimed to systematically analyze prescription patterns for inflammatory and infective skin diseases in a tertiary care hospital in South India, evaluate the rational use of medications against current treatment guidelines, and identify areas for potential improvement in dermatological prescribing practices. The findings would provide valuable baseline data for quality improvement initiatives and contribute to the broader understanding of real-world dermatological therapeutics in resource-limited settings.

This was a retrospective cross-sectional study conducted over a 12-month period in the Department of Dermatology, Venereology and Leprosy at Justice K S Hegde Charitable Hospital, Deralakatte, Mangalore, Karnataka, India. This tertiary care teaching hospital, affiliated with a medical college, serves as a major referral center for the coastal region of South Karnataka, with a catchment population of approximately 1.5 million. The dermatology department provides comprehensive outpatient services with an average daily attendance of 80-100 patients, managing a diverse spectrum of dermatological conditions ranging from common inflammatory disorders to complex infectious diseases. The hospital maintains electronic medical records integrated with a manual prescription documentation system, ensuring comprehensive capture of patient and prescription data. All patients aged above 10 years who presented to the dermatology outpatient department with diagnoses of inflammatory or infective skin diseases during the study period were eligible for inclusion. Inflammatory conditions included various forms of eczema (endogenous and exogenous), psoriasis, and other papulosquamous disorders, while infective conditions encompassed bacterial, fungal, viral, and parasitic infections of the skin. Consecutive sampling was employed to include all eligible patients attending during the study period, ensuring representative capture of prescription patterns. Patients with vitiligo, pigmentary disorders without associated inflammation or infection, and pregnant women were excluded from the study due to distinct therapeutic considerations and potential confounding of prescription patterns. No sample size calculation was performed a priori, as the study aimed to include all eligible patients presenting during the defined study period. Data were collected from outpatient medical records using a specially designed, structured proforma. The data collection instrument captured demographic information including age and gender; clinical information comprising primary dermatological diagnosis; and complete prescription details including generic and brand names of medications, dosage, route of administration, frequency, and duration of therapy where documented. Disease diagnoses were recorded as documented by the treating dermatologist, based on clinical examination and supported by relevant laboratory investigations where performed. Dermatological conditions were classified according to standard dermatology textbooks [16]. Two investigators independently reviewed the medical records and prescription data to ensure accuracy and completeness. Discrepancies were resolved through consensus discussion with a senior dermatologist. Quality control measures included random verification of 10% of the data entries against original records. Data were compiled and organized systematically by disease category to facilitate analysis of disease-specific prescription patterns. Medications were classified into therapeutic categories including topical corticosteroids, topical antimicrobials (antibacterial, antifungal), systemic antibiotics, systemic antifungals, antihistamines, and other adjunct medications. Inflammatory skin diseases were defined as non-infectious dermatological conditions characterized by erythema, scaling, pruritus, and histological evidence of inflammatory infiltrate, including various forms of eczema, psoriasis, and other papulosquamous disorders [16]. Infective skin diseases comprised conditions caused by pathogenic microorganisms including bacteria (pyodermas, folliculitis), fungi (dermatophytosis, candidiasis, pityriasis versicolor), viruses (herpes simplex, varicella zoster), and parasites (scabies). Prescription pattern was defined as the documented combination of medications prescribed for each dermatological condition, including both topical and systemic agents along with adjunct therapies. Rational drug use was evaluated based on World Health Organization criteria, considering appropriateness of drug selection, correct dosing, adequate duration, and alignment with established treatment guidelines [17]. Data were entered into Microsoft Excel 2010 and analyzed using Statistical Package for Social Sciences (SPSS) version 20.0 (IBM Corporation, Armonk, NY, USA). Descriptive statistics were employed to characterize the study population, with categorical variables expressed as frequencies and percentages, and continuous variables as means with standard deviations or medians with ranges as appropriate. The distribution of dermatological conditions, prescription patterns, and drug utilization were analyzed across demographic subgroups including age categories and gender. Chi-square test was used to compare categorical variables between groups, with statistical significance defined as P<0.05. For presentation purposes, drugs were ranked by frequency of prescription within each disease category, and the most commonly prescribed medications were identified for detailed analysis. The study protocol was reviewed and approved by the Institutional Ethics Committee of Justice K S Hegde Charitable Hospital prior to data collection. As this was a retrospective study involving review of existing medical records without patient contact or intervention, a waiver of individual informed consent was granted by the ethics committee. Patient confidentiality was strictly maintained throughout the study by de-identifying all data prior to analysis, with no personally identifiable information included in the dataset. Data access was restricted to the research team members, and all data were stored securely in password-protected electronic files.

Demographic Characteristics

A total of 747 patients with inflammatory and infective skin diseases were included in this study over the 12-month period (Table 1). The demographic distribution revealed a male preponderance with 430 (57.5%) male patients and 317 (42.5%) female patients. Age distribution analysis demonstrated that the majority of patients belonged to younger age groups, with the 15-24 years age group constituting the largest proportion at 266 patients (36%), followed by the 25-34 years group with 165 patients (22%). The pediatric population (≤14 years) comprised 146 patients (19%). Progressive decline was observed in older age groups: 35-44 years (104 patients, 14%), 45-54 years (34 patients, 5%), 55-64 years (23 patients, 3%), and ≥65 years (9 patients, 1%). This age distribution pattern reflects the typical demographic presentation of dermatological conditions in tropical settings, where younger individuals demonstrate higher healthcare-seeking behavior for skin conditions.

Table 1: Demographic Characteristics of Study Population (n=747)

Disease Pattern

Among the 747 patients studied, inflammatory conditions constituted 226 cases (30.3%), while infective conditions accounted for 358 cases (47.9%) (Table 2, Figure 1). The most prevalent condition was exogenous eczema, affecting 138 patients (18.5%), with a relatively balanced gender distribution (male 78, female 60). Dermatophyte infections ranked second with 132 cases (17.7%), demonstrating significant male preponderance (male 94, female 38). Bacterial infections were diagnosed in 114 patients (15.3%), with comparable distribution between genders (male 67, female 47). Acne vulgaris affected 97 patients (13%), showing female predominance (male 43, female 54). Endogenous eczema was observed in 88 patients (11.8%), with higher prevalence in females (male 42, female 46). Pityriasis versicolor affected 78 patients (10.4%), scabies 34 patients (4.6%), and pityriasis rosea 30 patients (4%). Less common conditions included papulosquamous disorders (13 patients, 1.7%), herpes infections (13 patients, 1.7%), and chronic paronychia (10 patients, 1.3%). Gender-specific analysis revealed statistically significant male predominance in dermatophyte infections, while acne vulgaris and endogenous eczema showed female predominance.

Table 2: Distribution of Dermatological Conditions (n=747)

Figure 1: Distribution of Dermatological Conditions by Gender

Distribution of Dermatological Conditions

Legend: Bar chart showing the distribution of the 11 dermatological conditions across 747 patients. Exogenous eczema was the most prevalent condition (18.5%), followed by dermatophyte infections (17.7%) and bacterial infections (15.3%). Blue bars represent male patients, orange bars represent female patients. Dermatophyte infections and scabies showed male predominance, while acne vulgaris, endogenous eczema, and chronic paronychia showed female predominance.

Prescription Pattern

Overall prescription pattern

Prescription pattern analysis revealed a rational, stepwise therapeutic approach with predominant use of topical preparations as first-line therapy. Across all conditions studied, topical corticosteroids represented the most frequently prescribed drug class, with mometasone furoate being the preferred agent, accounting for 39% of topical corticosteroid prescriptions in eczematous conditions. Combination therapy was commonly employed, particularly in inflammatory conditions where 67% of exogenous eczema patients received both topical agents and systemic adjuncts. Antimicrobial therapy demonstrated judicious prescribing patterns, with topical preparations preferred over systemic agents. Among topical antimicrobials, mupirocin (2%) was most commonly prescribed for bacterial infections (65% of cases), miconazole (2%) for dermatophyte infections (39% of cases), and various azole antifungals for fungal conditions. Systemic antimicrobial therapy was reserved for extensive or severe infections, with 44% of dermatophyte infections and 41% of bacterial infections requiring systemic therapy. Antihistamines served as frequent adjuncts for symptomatic relief, with chlorpheniramine being the most commonly prescribed (38-45% across different conditions), followed by cetirizine and levocetirizine. The prescription pattern reflected appropriate use of generic medications and evidence-based therapeutic choices aligned with current dermatological guidelines.

Disease-Specific Prescription Patterns

For exogenous eczema (n=138), topical mometasone furoate (0.1%) was prescribed most frequently (54 patients), followed by mometasone furoate combined with fusidic acid (50 patients), and clobetasone propionate combinations (31 patients) (Table 3). Monotherapy with topical agents alone was employed in 33% of cases, while 67% received combination therapy with adjuncts. Chlorpheniramine (4mg) was the most common adjunct (36 patients), followed by cetirizine (20 patients). Systemic corticosteroids were prescribed in select cases requiring intensive therapy (prednisolone 10 patients, methylprednisolone 6 patients).

In dermatophyte infections (n=132), topical therapy comprised miconazole 2% (48 patients), clotrimazole 1% (41 patients), and sertaconazole 2% (20 patients) (Table 3). Systemic antifungal therapy was administered to 58 patients (44%), with fluconazole 150mg being strongly preferred (38 patients, 66% of systemic prescriptions) over terbinafine 250mg (20 patients, 34%). This preference for fluconazole may reflect considerations of cost-effectiveness, broader spectrum coverage, and once-weekly dosing convenience. All patients received antihistamine adjuncts for symptomatic relief, predominantly chlorpheniramine (60 patients).

For bacterial infections (n=114), topical mupirocin 2% (74 patients) and fusidic acid 2% (40 patients) were the mainstay of therapy (Table 3). Systemic antibiotics were prescribed conservatively in only 47 patients (41%), demonstrating appropriate antimicrobial stewardship. Among systemic antibiotics, amoxicillin-clavulanate combination therapy was preferred (32 patients, 52% of systemic prescriptions), with doses of 500mg/125mg (24 patients) or 250mg/125mg (8 patients). Alternative systemic agents included cephalexin 500mg (5 patients), cefadroxil combinations (7 patients), and linezolid 600mg (3 patients) for resistant cases. Analgesic adjuncts, primarily paracetamol 500mg (30 patients) and ibuprofen 400mg (17 patients), were employed for symptomatic relief in 47 patients presenting with pain or fever.

Table 3: Disease-Specific Drug Utilization for Top Three Conditions

Note: Percentages for drug categories calculated from total patients in each condition; percentages for systemic medications and adjuncts calculated from patients receiving those categories.

Acne vulgaris (n=97) was predominantly managed with topical therapy alone in 61% of cases. The fixed-dose combination of clindamycin 1% and tretinoin 0.025% was most frequently prescribed (40 patients, 41%), followed by retinoic acid 0.05% (20 patients) and benzoyl peroxide preparations (18 patients). Systemic therapy was reserved for moderate to severe cases (38 patients, 39%), with doxycycline 100mg being the preferred agent (27 patients, 71% of systemic prescriptions), followed by azithromycin 500mg (9 patients) and isotretinoin 20mg (2 patients) for severe nodulocystic acne.

Indicators of rational drug use

The prescription patterns demonstrated several indicators of rational drug use aligned with evidence-based guidelines and antimicrobial stewardship principles. The average number of drugs per prescription ranged from 1-3, reflecting appropriate polypharmacy that balanced therapeutic efficacy with patient compliance. Generic prescribing was practiced extensively, with essential medicines from the WHO Model List forming the core of therapeutic choices. Topical therapy was appropriately emphasized as first-line treatment across conditions, with 33-70% of patients managed with topical preparations alone, thereby minimizing systemic exposure and adverse effects. Systemic antimicrobial use was judicious and targeted, with only 41% of bacterial infections requiring systemic antibiotics compared to higher rates reported in other studies, indicating good antimicrobial stewardship. The preference for narrow-spectrum agents (mupirocin, fusidic acid for bacterial infections) over broad-spectrum antibiotics for localized infections further supports rational prescribing. Combination therapy with topical antimicrobials plus corticosteroids was appropriately employed in inflammatory conditions with secondary infection, while avoiding indiscriminate use. The step-care approach was evident, with escalation to systemic therapy reserved for extensive disease (44% of dermatophyte infections), treatment failures, or specific indications such as onychomycosis requiring systemic antifungals. Patient-centered prescribing was reflected in the consideration of dosing convenience (fluconazole once-weekly regimen) and cost-effectiveness (generic formulations), factors critical for treatment adherence in resource-limited settings.

This comprehensive analysis of 747 patients provides valuable insights into real-world prescription practices for dermatological conditions in a tertiary care setting in coastal South India. Our study revealed that infective skin diseases (64%) predominated over non-infective conditions (36%), with dermatophyte infections (17.7%) and bacterial infections (15.3%) representing the most common infectious entities. Among inflammatory conditions, exogenous eczema was most prevalent (18.5%), followed by endogenous eczema (11.8%). The demographic profile demonstrated a male preponderance (57.5%) with peak presentation in the 15-24 age group (36%), consistent with the active lifestyle and environmental exposure patterns typical of this age cohort. Notably, prescription patterns reflected rational therapeutic approaches, with predominant use of topical therapy as first-line treatment and judicious addition of systemic medications when clinically indicated. The preference for mometasone furoate (39% in eczema) among topical corticosteroids and fluconazole (66% for systemic antifungal therapy) demonstrates cost-conscious, evidence-based prescribing aligned with current treatment guidelines.

Our finding that infectious diseases outnumbered non-infectious conditions contrasts notably with studies from other regions of India. Studies from Kerala [10] and Kolkata [14] reported higher prevalence of non-infectious conditions (57.07% and 54.3% respectively) compared to infectious diseases. This divergence may reflect the unique tropical coastal climate of Mangalore, characterized by high humidity and temperature, which creates ideal conditions for fungal and bacterial proliferation. Similar patterns were documented by Kuruvilla et al [9] in their study from Dakshina Kannada, the same geographical region, lending credence to the climate-geography hypothesis.

The predominance of dermatophyte infections (17.7%) aligns closely with findings from Das KK [12] in Guwahati, who reported fungal infections at 14.24%, and Devi et al [13] in North-Eastern India at 17.19%. However, our rate was lower than the 20.6% reported by Yasmeen [18] in Pakistan, possibly reflecting differences in hygiene practices and healthcare access patterns between the two nations.

Regarding prescription patterns, the preference for fluconazole (66%) over terbinafine in systemic antifungal therapy warrants particular attention. While European and North American guidelines increasingly favor terbinafine for dermatophyte infections due to superior mycological cure rates, our prescribing pattern may be justified by several local factors. Fluconazole offers broader spectrum coverage, requires less frequent dosing (enhancing compliance in resource-limited settings), and is significantly more affordable in the Indian pharmaceutical market. Furthermore, emerging reports from South Indian centers have documented increasing terbinafine resistance in dermatophytes, potentially explaining the clinical preference for fluconazole.

The appropriate use of topical corticosteroids, with mometasone furoate being the most prescribed (39%), reflects evidence-based practice. Mometasone, a medium-to-potent topical corticosteroid, offers an optimal benefit-risk ratio with once-daily application that improves patient adherence. This preference aligns with international eczema management guidelines [19] and conventional western medicine approaches [20].

The judicious use of systemic antibiotics in only 41% of bacterial infection cases represents exemplary antimicrobial stewardship, particularly important given the global antimicrobial resistance crisis. This conservative approach aligns with recent WHO recommendations emphasizing topical therapy for localized skin infections. The preference for amoxicillin-clavulanate (52% of systemic prescriptions) over broader-spectrum agents demonstrates appropriate empirical selection based on expected pathogens in skin and soft tissue infections, consistent with recommendations by V Ki and C Rotstein [21].

For acne vulgaris management, the combination of topical clindamycin and tretinoin (41%) as the most prescribed topical regimen, along with doxycycline (71%) for systemic therapy, demonstrates strict adherence to Indian Acne Alliance guidelines [17]. The limited use of isotretinoin (only 2 patients) reflects appropriate reservation of this potent medication for severe, recalcitrant cases.

Clinical Implications

The prescription patterns observed in this study have several significant clinical and public health implications. First, the predominant use of topical therapy as first-line treatment—evident in 67% of eczema cases and 59% of bacterial infections—represents a clinically sound, stepped-care approach that minimizes systemic drug exposure while maintaining therapeutic efficacy. This approach is particularly relevant in tropical developing countries where medication costs significantly impact treatment adherence and health outcomes.

The economic implications of prescribing practices deserve emphasis. In the Indian healthcare context, where out-of-pocket expenditure accounts for approximately 60% of total health spending, the preference for cost-effective therapeutic agents becomes critical for ensuring treatment completion. Topical therapy in our setting averages INR 150-250 per month, substantially lower than systemic therapy at INR 500-1000 per month. The appropriate use of generic medications and first-line therapeutic agents observed in this study suggests cost-conscious prescribing that may enhance treatment adherence in economically disadvantaged populations.

The appropriate use of combination topical preparations (corticosteroid plus antimicrobial) in specific clinical scenarios—rather than routine use—demonstrates awareness of current guidelines discouraging indiscriminate use of such combinations. This judicious approach addresses legitimate concerns about antimicrobial resistance development and contact sensitization to topical antibiotics, particularly in the context of prolonged use.

The frequent prescription of antihistamines as adjunctive therapy (60-70% in inflammatory conditions) addresses the symptomatic relief crucial for quality of life improvement. While our study documented predominant use of first-generation antihistamines like chlorpheniramine, likely due to cost considerations, there may be opportunities for selective use of second-generation agents in patients requiring daytime alertness, such as students and professionals engaged in skilled work or driving.

The prescription patterns also reflect appropriate risk stratification. The selective use of systemic therapy in 44% of dermatophyte infections and 41% of bacterial infections suggests clinical judgment in identifying cases requiring more aggressive intervention—likely those with extensive involvement, multiple site disease, or failure of topical therapy. This individualized approach, rather than protocol-driven uniformity, represents the art of clinical medicine integrated with evidence-based guidelines.

Antimicrobial Stewardship

The antimicrobial prescribing patterns observed in this study demonstrate commendable stewardship practices, particularly relevant in the current era of escalating antimicrobial resistance. The restriction of systemic antibiotics to 41% of bacterial skin infections represents a conservative, evidence-based approach that prioritizes topical therapy for localized infections. This practice aligns with WHO recommendations and helps preserve systemic antibiotic efficacy for truly severe infections.

The choice of narrow-spectrum agents where appropriate—evidenced by the use of mupirocin (65%) as the topical antibiotic of choice—reflects targeted antimicrobial selection. Mupirocin, with its specific activity against staphylococci and streptococci (the primary pathogens in pyodermas), represents an optimal first-line choice that minimizes disruption of normal skin flora and reduces selection pressure for resistance in other bacterial species.

When systemic antibiotics were deemed necessary, the preference for amoxicillin-clavulanate (52%) over broader-spectrum agents like fluoroquinolones or third-generation cephalosporins demonstrates appropriate empirical selection. This choice provides adequate coverage for beta-lactamase-producing staphylococci while avoiding unnecessary use of antibiotics classified as “watch” or “reserve” categories in the WHO AWaRe classification.

For antifungal therapy, the combination of topical and systemic agents in 44% of dermatophyte infections represents a rational approach to extensive or severe infections, potentially preventing treatment failure and reducing overall disease duration. The minimal use of systemic antifungals for conditions adequately treated with topical therapy alone (54% received topical-only treatment for pityriasis versicolor) further demonstrates appropriate antimicrobial stewardship.

However, opportunities for improvement exist. Documentation of treatment duration, monitoring for therapeutic response, and specific indications for systemic therapy escalation would enhance antimicrobial stewardship. Implementation of institutional antibiograms to guide empirical antibiotic selection and regular prescription audits with feedback to prescribers could further optimize antimicrobial use.

Strengths and Limitations

This study possesses several methodological strengths that enhance the validity and applicability of findings. The substantial sample size of 747 patients provides adequate statistical power for detecting clinically meaningful patterns and associations. The comprehensive 12-month study period captures potential seasonal variations in disease patterns and prescribing practices, important considerations in tropical climates with distinct monsoon seasons. The systematic data collection using a structured proforma ensures consistency and completeness of information on demographics, diagnoses, and detailed drug prescriptions including formulations, doses, and routes of administration. The tertiary care hospital setting provides access to consultant-level dermatologists, ensuring that prescribing practices reflect expert clinical judgment.

However, several limitations merit consideration in interpreting the findings. The retrospective cross-sectional design precludes assessment of treatment outcomes, therapeutic failures, adverse effects, or patient adherence—all critical parameters for comprehensively evaluating prescription appropriateness. The single-center nature of the study, while providing depth, limits generalizability to other healthcare settings, particularly primary care facilities where disease severity profiles and resource availability may differ substantially. The absence of follow-up data prevents evaluation of treatment modifications, persistence of therapy, or long-term outcomes.

The exclusion of patients under 10 years of age eliminates an important demographic, as pediatric dermatology often presents unique disease patterns and requires different therapeutic approaches with distinct safety considerations. The study lacks cost-effectiveness analysis, which would provide valuable insights for resource allocation and formulary decisions in developing country contexts. Patient-reported outcomes, including quality of life assessments and satisfaction with treatment, were not captured, representing missed opportunities for holistic evaluation of care quality.

Additionally, the retrospective design may have introduced information bias, as prescription records may not capture all relevant clinical details that influenced prescribing decisions, such as disease severity, previous treatment failures, or patient-specific factors like occupation or allergies. The absence of standardized disease severity scoring limits ability to assess whether prescribing patterns appropriately matched disease severity.

Future Directions

This study establishes important baseline data on prescription patterns in dermatology, but several avenues for future research emerge from its findings. Prospective observational studies with systematic follow-up would enable assessment of treatment outcomes, adverse effects, and patient adherence, providing more comprehensive evaluation of prescription appropriateness. Such studies should incorporate validated disease severity scoring systems (e.g., SCORAD for eczema, PASI for psoriasis) to enable severity-stratified analysis of prescribing patterns.

Multicenter studies encompassing diverse geographical regions, climate zones, and healthcare settings (tertiary, secondary, and primary care) would enhance generalizability of findings and enable identification of setting-specific prescribing patterns. Comparative studies between public sector and private healthcare facilities could reveal important differences in prescription practices driven by economic incentives and resource availability.

Pharmacoeconomic analyses incorporating cost-effectiveness and cost-utility assessments would provide valuable data for formulary decisions and health policy development. Such studies should consider both direct medical costs and indirect costs including productivity losses and quality-adjusted life years (QALYs). Implementation research evaluating the impact of antimicrobial stewardship interventions, prescription audit-and-feedback programs, and continuing medical education on prescribing practices would guide quality improvement initiatives.

Patient-centered outcomes research incorporating quality of life assessments, treatment satisfaction, and patient preferences would provide holistic evaluation of care quality beyond purely clinical endpoints. Investigation of prescribing practices for emerging therapeutic modalities, including newer biologics and small molecule inhibitors increasingly used in dermatology, would be valuable as these agents become more accessible in developing countries.

Finally, surveillance studies monitoring antimicrobial resistance patterns in common dermatological pathogens would enable evidence-based updating of empirical treatment recommendations and guide antimicrobial stewardship efforts. Linking prescription data with resistance surveillance would enable assessment of the relationship between prescribing patterns and resistance emergence.

This comprehensive analysis of 747 patients with inflammatory and infective skin diseases demonstrates largely rational prescribing practices aligned with current evidence-based guidelines. The appropriate emphasis on topical therapy as first-line treatment, with systemic medications reserved for severe or extensive disease, reflects both clinical wisdom and economic pragmatism in resource-limited settings. The judicious use of systemic antibiotics in only 41% of bacterial infections indicates commendable antimicrobial stewardship, particularly important given rising resistance rates globally. Regular prescription audits and educational interventions focusing on antimicrobial stewardship and cost-effective prescribing may further optimize treatment outcomes. This study provides valuable baseline data for developing institutional protocols and can inform policy decisions for dermatological care in similar resource-limited settings.

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