Improving Outcomes in Adults with Atopic Dermatitis: Part I – Impact of Nonadherence

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Effective treatments for adults with atopic dermatitis (AD) have been available for decades, and yet clinicians and patients alike struggle with achieving adequate outcomes. Poor adherence is a critical factor limiting patients’ treatment outcomes. Even patients with extensive, lichenified AD plaques who are admitted to the hospital and started on 0.1% triamcinolone topical ointment improve rapidly over just a few days. The success of hospitalization is likely due to strict application of treatment rather than the hospital environment itself.1,2  

Medication nonadherence is pervasive throughout healthcare, with nonadherence rates varying from 15% to 93%.3 The annual cost to the United States healthcare system due to nonadherence is $300 billion, which is comparable to the total gross domestic product of Denmark.4 Adherence to topical medications is dismal, with adherence rates declining to 32% over 8 weeks in atopic dermatitis and 51% in psoriasis.5,6 These rates were measured using electronic monitors in medication containers and were vastly different than patients’ self-reported adherence rates of greater than 90%.6 Even highly effective targeted biologic therapies are often not used optimally. Over half of patients prescribed injectable biologics do not fill their prescriptions within the first month of their appointment, and only about a quarter of those patients fill their prescription within 6 months.4
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If we are dispirited about treatment failure, imagine how disheartened our patients feel. In order to provide the best care for our patients and give them the best chance at successfully managing their AD providers need to utilize specific approaches to improve adherence and outcomes. A pyramid model can be used to describe the various approaches to patient adherence (Figure 1).7 The next 3 parts of this 4 part series will address these levels of the pyramid: (1) Foundation, (2) Basics and (3) Advanced approaches.

Mr Heath is a medical student at Oregon Health and Science University School of Medicine in Portland, OR.

Dr Feldman is with the Center for Dermatology Research and the Departments of Dermatology, Pathology, and Public Health Sciences at Wake Forest University School of Medicine in Winston-Salem, NC.


1. Lewis DJ, Feldman SR. Rapid, successful treatment of atopic dermatitis recalcitrant to topical corticosteroids. Pediatric dermatology. 2018;35(2):278-279.

2. Mudigonda T, Kaufman W, Feldman SR. Horrendous, treatment-resistant pediatric atopic dermatitis solved with a change in vehicle. J Drugs Dermatol. 2016;15(1):114-115.

3. Balkrishnan R. The importance of medication adherence in improving chronic-disease related outcomes: what we know and what we need to further know. Medical Care. 2005;43(6):517-520.

4. Harnett J, Wiederkehr D, Gerber R, Gruben D, Bourret J, Koenig A. Primary nonadherence, associated clinical outcomes, and health care resource use among patients with rheumatoid arthritis prescribed treatment with injectable biologic disease-modifying antirheumatic drugs. J Manag Care Spec Pharm. 2016;22(3):209-218.

5. Krejci-Manwaring J, Tusa MG, Carroll C, et al. Stealth monitoring of adherence to topical medication: adherence is very poor in children with atopic dermatitis. J Am Acad Dermatol. 2007;56(2):211-216.

6. Carroll CL, Feldman SR, Camacho FT, Manuel JC, Balkrishnan R. Adherence to topical therapy decreases during the course of an 8-week psoriasis clinical trial: commonly used methods of measuring adherence to topical therapy overestimate actual use. J Am Acad Dermatol. 2004;51(2):212-216.

7. Lewis JD, Feldman, R Steven. Practical ways to improve patient adherence. Columbia, SC: CreateSpace Independent Publishing Platform; 2017.