Poor adherence to treatment is a major issue in the management of chronic skin diseases, such as psoriasis. The application of psoriasis medicine is often messy, inconvenient, and uncomfortable, noted Steven R. Feldman, MD, PhD, professor of dermatology, pathology, and public health science at Wake Forest University School of Medicine in Winston-Salem, NC.
“Topicals work much better when patients actually use them,” said Dr Feldman, who presented at this year’s Autoimmune Interdisciplinary Summit in New York. He reviewed several factors contributing to treatment nonadherence and spoke on ways to get patients to use their medicine better.
“When a patient fails drug X, it may be because they’re not taking drug X; poor adherence is often underappreciated,” he said. “Physicians are taught in medical school everything you could want to know about making the right diagnosis and prescribing the right treatment. The third leg of a three-legged stool is to get the patient to actually take the treatment. In fact, you don’t even need one of those other legs. As long as you get the right treatment and get them to use it, whether you make the right diagnosis or not actually isn’t all that relevant to how well patients do.”
Phases of Adherence
Patients proceed through a number of adherence phases. “I write or send a prescription electronically to a pharmacy. The patient may fill the prescription or they may not fill the prescription. If they fill it, they may start on treatment. If they start on treatment, they may use it well or they may use it poorly and then they may stop treatment often before they’re supposed to,” Dr Feldman said.
In dermatology, there are 3 common reasons patients may not get better. “The wrong diagnosis and the wrong treatment are usually not two of the three reasons. The number one reason was because patients don’t put the stuff on. Poor compliance. The second most likely reason is that they’re not doing it, and the third most likely reason they’re not doing it. And you could ask them in research studies, ‘Are you taking the medicine the way the doctor says?’ and 40% of them will tell you they’re not doing it.1 And the other 60% may not be telling you the truth,” he said.
In a research study2 from Denmark where there is a national pharmacy, the researchers gave patients prescriptions and then went to their national pharmacy database to see how long it took before the prescription was filled. “For acne and infections prescriptions, 90% of the prescriptions were filled within about 2 weeks, which looks pretty good, except it means 10% of those prescriptions are not filled which is already an error rate that seems unacceptable. For atopic dermatitis, you can see about one-third of the prescriptions were not filled within a month, and it looks like half the psoriasis prescriptions were not filled. I think that is because a lot of us in dermatology were taught to give people with psoriasis greasy ointments that they really don’t want to put on, and if you do that they’re not going to fill the prescription,” he said.
For another research study3 that used bottles and caps with computer chip compliance monitoring, patients’ adherence and reports of their adherence varied (Figure 1). While some patients were very exacting in their taking and reporting of medication use, others were not. For example, 2 participants said they took the medicine and did not. “I call this normal patient behavior,” Dr Feldman said. “These other individuals are in a research study. They’re highly motivated research subjects. They’ve been given the medicine. You don’t have to worry about them not filling it. They’re being told they’re being monitored. They’re filling out a daily diary and they’re bringing the containers back to be weighed, so this adherence is probably a lot better than what you would normally see overall.”
Figure 1. Results of electronic monitoring/self-reported adherence in patients with skin disease.
The initial study4 had 30 individuals studied over 8 weeks (Figure 2). The first day when they received the medicine they use it. “Then over the next few days, the adherence went down rather quickly. Then, it went down a little more slowly after that, but it seems like there’s something going on. The data are a little noisy, but it seems like with regularity every two weeks their use of the medicine improves. What goes on in patients’ lives every two weeks that makes them use their medicine better? It’s the visits to the doctor,” he said, noting that patients often exhibit better adherence when they know a doctor’s appointment is coming up.
Figure 2. Measuring mean daily adherence to topical therapy in patients with psoriasis.
Patients are nonadherent for many different reasons, including poor motivation, lack of trust in the physician, fear of medication, burden of treatment, forgetfulness, laziness, and resignation.5-8 (Figure 3).
Figure 3. Patients are nonadherent for many different reasons.
“I try to use tools that will make individuals use their medicine well, for the most part irrespective of why they’re not using their medicines,” he said.
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Encourage Improved Compliance
Dr Feldman offered some pearls to help patients become more compliance.
- Involve patients in the treatment plan. One vehicle generally works better than all the others: the one that particular patient doesn’t mind using. Ask patients if they have a preference on the medicine’s vehicle (ie, lotion or cream or injection or pill).
- Don’t scare patients with side effects. Most of our treatments are very safe. Avoid presenting risks in a manner that makes patients think that rare risks are common. One pearl when talking about side effects is positive framing when presenting safety data. “If you tell people 1 in 100 will experience a specific side effect, they’re going to think they’re going to be the one. That’s going to scare them. Instead, what I tell them is 99 out of 100 don’t get that side effect,” he said.
- Prescribe fast-acting treatments. “I prescribe medicines that will work fast because often patients give up on treatments quickly. If they don’t see improvement fast, they’ll give up and they won’t use the medicine and they’ll come back after maybe a week saying, they used it and it didn’t work,” Dr Feldman said.
- Most importantly, encourage trust. It is critically important for patients to believe you are focused on them. Enter the room slowly, sit down, listen to the patient, and carefully examine them, he advised. By empathizing with the patient and asking about their previous treatments and frustrations, patients often feel like the physician understands and is listening.
Yet, physicians often say there is not enough time for this approach. Dr Feldman said he, too, would rather make the diagnosis, give them the treatment, and go on to help the next person. “I want to help as many people as I can in the day. But I’ve discovered that in order to help them I need to make sure that they realize how much I care about them. Medicine has become industrialized making things more difficult, but we can succeed by industrializing this sense of caring,” Dr Feldman said.
- Consider the setting. Is the office a warm and inviting place to come? Is it organized? Consider ways to make the office environment more welcoming. For example, hang a sign with a positive message: Our practice continues to grow through referrals from our patients. Thank you for your trust and confidence.
- Simplify the regimen. The more complicated you make the regimen, the worse the adherence is likely to be, he said. Combination products can be helpful.
- Educate and support patients about the power of adherence before you prescribe them medicine. Support can come in a variety of ways including support groups, frequently scheduled office visits, and communication with the patient between visits.
- Scheduling patients for early follow up. “The visit is the single most powerful tool to get somebody to use the medicine,” he said. “In a study that randomized patients to standard-of-care follow up vs standard-of-care plus a 1-week return visit, patients who return at a 1-week follow-up visit use the medicine significantly better than the group that did not get the 1-week follow-up.”9-15
“Focusing on initial adherence is powerful because if you get people in the habit of something and they see that it works, they’ll continue doing it, because it’s their habit,” he said.
Dr Feldman said he started with this idea of close return visits with his scalp psoriasis patients. Scalp psoriasis seems to be one of the most resistant forms of psoriasis to treat. “People don’t do a good job getting medicine on their scalp,” he said. “It is the mother of all compliance problems.”
Dr Feldman noted he would give patients the medicine and tell them to return in 3 days, seeing dramatic improvement. Then, he decided the return visit was not necessary as long as patients checked in with him. He developed a strategy: “I just take my business card, handwrite my cell phone number down on the card, and have them call me in three days,” he said, adding that if he does not answer they usually leave a message saying they are glad the doctor didn’t answer and that the treatment worked. He added: “Handwriting my number (as opposed to having it preprinted) makes them know how much I care about them and therefore, they trust me and use the medicine. It’s very effective.”
In another study16 teenagers with acne were sent an Internet survey (instead of given the cell phone number), to fill out and be entered in a contest for a prize and/or gift cards for reporting their progress to the researchers weekly over the Internet. “This strategy tripled their use of their treatment,” he said.
- Provide written action plan. Patients are frequently overwhelmed during the office visit and a clearly stated written action plan helps them remember step-by-step what they need to do later to remain adherent.
- Side effects are an opportunity. “When I’m taking care of that patient with scalp psoriasis, I often give them clobetasol solution, an alcohol-based solution that stings. I tell the patient, ‘Now, this may sting. That’s a sign that it’s working,’ which is true because it’s a sign they put it on. And if they put it on, it’s working,” he said.
- Address cost. Prescribe low cost medicines when possible. Also offer a range of options, including lower cost generics. Suggest patient assistance programs, such as company-sponsored copay or other assistance programs, or local indigent pharmacy resources.
He noted that in cases of truly resistant patients, consider the possibility they are not using the drugs. “Take it out of their hand. Bring them into your office or hospital and do a treatment there,” he said.
New drug developments are exciting and useful; however, getting patients to take their medications better is low-hanging fruit for improving treatment outcomes, he concluded.
1. Richards HL, Fortune DG, O’Sullivan TM, Main CJ, Griffiths CE. Patients with psoriasis and their compliance with medication. J Am Acad Dermatol. 1999;41(4):581-583.
2. Storm A, Andersen SE, Benfeldt E, Serup J. One in 3 prescriptions are never redeemed: primary nonadherence in an outpatient clinic. J Am Acad Dermatol. 2008;59(1):27-33.
3. Balkrishnan R, Carroll CL, Camacho FT, Feldman SR. Electronic monitoring of medication adherence in skin disease: results of a pilot study. J Am Acad Dermatol. 2003;49(4):651-654.
4. 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.
5. Navarrete-Dechent C, Curi-Tuma M, Nicklas C, Cárdenas C, Pérez-Cotapos ML, Salomone C. Oral and written counseling is a useful instrument to improve short-term adherence to treatment in acne patients: a randomized controlled trial. Dermatol Pract Concept. 2015;5(4):13-16.
6. Butterworth SW. Influencing patient adherence to treatment guidelines. J Manag Care Pharm. 2008;14(6 suppl B):21-24.
7. Finch T, Shim TN, Roberts L, Johnson O. Treatment satisfaction among patients with moderate-to-severe psoriasis. J Clin Aesthet Dermatol. 2015;8(4):26-30.
8. Aslam I, Feldman SR. Practical strategies to improve patient adherence to treatment regimens. South Med J. 2015;108(6):325-331.
9. Sagransky MJ, Yentzer BA, Williams LL, Clark AR, Taylor SL, Feldman SR. A randomized controlled pilot study of the effects of an extra office visit on adherence and outcomes in atopic dermatitis. Arch Dermatol. 2010;146(12):1428-1430.
10. Douglas WS, PoulinY, Decroix J, et al. A new calcipotriol/betamethasone formulation with rapid onset of action was superior to monotherapy with betamethasone dipropionate or calcipotriol in psoriasis vulgaris. Acta Derm Venereol. 2002;82(2):131-135.
11. Papp KA, Papp A, Dahmer B, Clark CS. Single-blind, randomized controlled trial evaluating the treatment of facial seborrheic dermatitis with hydrocortisone 1% ointment compared with tacrolimus 0.1% ointment in adults. J Am Acad Dermatol. 2012;67(1):e11-e15.
12. Guenther L, Van de Kerkhof PC, Snellman E, et al. Efficacy and safety of a new combination of calcipotriol and betamethasone dipropionate (once or twice daily) compared to calcipotriol (twice daily) in the treatment of psoriasis vulgaris: a randomized, double-blind, vehicle-controlled clinical trial. Br J Dermatol. 2002;147(2):316-323.
13. Ortonne JP, Kaufman R, Lecha M, Goodfield M. Efficacy of treatment with calcipotriol/betamethasone dipropionate followed by calcipotriol alone compared with tacalcitol for the treatment of psoriasis vulgaris: a randomised, double-blind trial. Dermatology. 2004;209(4):308-313.
14. Kragballe K, Austad J, Barnes L, et al. Efficacy results of a 52-week, randomised, double-blind, safety study of a calcipotriol/betamethasone dipropionate two-compound product (Daivobet/Dovobet/Taclonex) in the treatment of psoriasis vulgaris. Dermatology. 2006;213(4):319-326.
15. Kaufmann R, Bibby AJ, Bissonnette R, et al. A new calcipotriol/betamethasone dipropionate formulation (Daivobet) is an effective once-daily treatment for psoriasis vulgaris. Dermatology. 2002;205(4):389-393.
16. Yentzer BA, Wood AA, Sagransky MJ, et al. An Internet-based survey and improvement of acne treatment outcomes. Arch Dermatol. 2011;147(10):1223-1224.