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Original article
Inaccessible back: frustration and misery of lonely patients
  1. Mousumi Dasgupta Zaman
  1. Correspondence to Dr Mousumi Dasgupta Zaman, James Paget University Hospitals, Lowestoft Road, Great Yarmouth, NR31 6LA, UK; mousumi0001{at}


This article introduces an idea of a new medical device to apply topical treatments in relatively inaccessible places of body, for example, the back. Currently patients with different inflammatory (eg, Eczema, Psoriasis) or dysplastic (eg, Actinic Keratosis, Bowen's disease, Superficial Basal Cell carcinoma) dermatological conditions usually rely on relatives/carers or use mass produced back applicators and compliance varies depending on availability of carer, ranges of joint movements and so on. This new device, which follows the similar technology of inhaler/flex-pen (a hollow tube containing active ingredients with applicator button at proximal end and releasing pore/pores at distal end), will enable patients to become more independent leading to better compliance. Moreover, in some cases of dysplastic lesions, like Superficial Basal Cell Carcinomas, this will reduce the number of unnecessary surgical procedures.

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For any clinician, compliance is a big issue. Most of the time it is the unwillingness of the patient which creates major compliance problem, however, on rarer occasions one would find that patients are not unwilling, rather they are unable to comply.

Dermatological conditions affecting inaccessible areas of back and buttock (even lower limbs for some particular group of patients) is one of those conditions where patient is very willing to apply treatment offered but unfortunately they are either completely unable or are struggling to do so. With increasing number of people living on their own this is becoming almost a daily problem. Although younger people are no exception but generally it is the elderly who suffer the most due to much reduced flexibility of body, poor joint mobility, protruding abdomen and finally social situation, when one spouse is either dead or much too poorly to help.

Initially I used to suggest them to buy mass produced back applicators but I hardly found anybody who is satisfied with that suggestion. Applying thick greasy ointments or runny lotions (or even worse gels), on a hairbrush like structure is not an easy job and when you are adding cleaning of that applicator after use, to the equation, it becomes obvious why patients consider their money have been wasted on that particular product.

I have patients who apply cream/ointment on doorframe and then rub their back against it. Surely in 21st century that is not a very smart way of ensuring patient compliance.

Moreover, when it comes to a solitary malignant lesion (ie, single superficial basal cell carcinoma), patients are of course advised to apply anticancer drugs on affected area only to avoid undue absorption. Try, however, hard you may with mass produced back applicators, it is really impossible to put it on that precise spot. More than once we had to excise a superficial basal cell carcinoma on the back because of this particular application problem. Whereas conditions like superficial basal cell carcinoma and actinic keratosis are perfectly treatable with topical 5% imiqimod or 5% flurouracil, compliance problem is making us perform unnecessary surgical procedures at risk of bleeding, infection and scarring.

Over last few decades medical devices have evolved so dramatically that one wonders why nothing has been done to address this issue. My secret feeling is that because it has never been a life-threatening problem, it has simply been ignored. Also lonely voices are seldom heard.

Yet the solution should not be too difficult. Already we have seen invention of ‘Flexpen’ has made delivery of daily Insulin much easier1 ,2 and hand held inhalers revolutionised management of asthma and chronic obstructive pulmonary disease.3 ,4 We can use the same technology of a tubal structure containing active ingredients to develop a new applicator for topical dermatological preparation (figure 1).

Figure 1

Readily available claw modelled back scratcher which can be modified into topical drug administrator.

It can be designed as a modified hand shaped back scratcher or curved handle back brush with a releasing button on proximal end. Distal end would be expanded or claw like with rough pore/pores releasing medication which can be rubbed on easily by patient himself or herself without depending on a reluctant spouse or carer, if there is one.

Based on the ingredients, it could be mono porous (single opening to squirt ointment on a precise dysplastic spot) or poly porous (3–5 pores to cover patches or plaques in eczema or psoriasis; figures 2 and 3).

Figure 2

Tubal structure with active ingredients and releasing button at proximal end. Distal end can be mono-porous or poly-porous based on requirement.

Figure 3

Alternatively it can be designed as a multi-porous hair brush like structure for bigger plaques/patches.

Since this applicator can also be used in cosmetic sector, I do not see why it should not be cost-effective for a pharmaceutical company to develop a primary prototype.

It probably will not save a life but it would certainly make many lives much easier and comfortable. When a particular itchy spot drives any of us to distraction, imagine the misery of an elderly, lonely person with an inaccessible eczematous/psoriatic patch with constant irritation or a bleeding basal cell carcinoma and you would know why we should really do something about it.


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  • Competing interests None.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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