And if the treatment still does not work

After agreeing on a treatment, a patient may return saying that the treatment does not work. Having explored obvious issues such as whether the ointment ever reached the skin, and whether the "allergic reaction" from topical benzoyl peroxide was in fact a predictable irritant reaction which could be circumvented by less frequent or vigorous application, other treatment options are often explored. If several treatments fail in a particular patient, the patient may belong to a subset with refractory disease, making it even more difficult to generalise from clinical trials of people with more responsive forms of the disease. Dermatologists frequently face the problem of trying several drugs in succession. External trial evidence could be improved by better descriptions of study participants in terms of previous treatments and by means of sequential RCTs that try different treatment approaches following failure of a treatment.

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