Adherence to topical treatment in psoriasis: a systematic literature review

Patient Preferences for Topical Psoriasis Treatments are Diverse and Difficult to Predict

Introduction

Topicals are a mainstay in psoriasis vulgaris treatment and are used concomitantly even in patients receiving systemic therapy. Patient acceptance of topical treatment can impact adherence and, consequently, real-life effectiveness. This study aimed to identify patient preferences for topical treatment attributes and to evaluate patient acceptability of topical treatments.

Methods

This 5-day study evaluated three inactive presentations: fixed combination calcipotriol/betamethasone dipropionate (Cal/BD) ointment vehicle in a tube, Cal/BD gel vehicle in a bottle and Cal/BD gel vehicle in a new Applicator delivery system. Participants with psoriasis on ≥2 locations were recruited, aiming for equal proportions in the categories: male/female; <40/≥40 years old; working/not working. Participants ranked a predefined ‘wish list’ of 13 topical treatment attributes, applied each product and evaluated them in a user survey, indicating how well the products delivered on 16 statements matching the 13 attributes. Afterward, participants indicated preference by psoriasis plaque location.

Results

Patient preferences differed to the extent that the proportion rating an attribute of high importance was similar to the proportion rating the same attribute of low importance. All attributes received similar mean ranking scores. Analysis by demographic characteristics revealed preferences are not associated with gender, age or employment status. Participants did not perceive much difference between the gel and ointment, but expressed preferences for different presentations to treat different plaque locations. The gel Applicator was preferred for 8/14 locations and both gel presentations were strongly preferred for hairy scalp.

Conclusions

Patients with psoriasis have diverse preferences, which cannot be predicted by demographics. Individual patient choice should be considered to increase the acceptability and a range of topical formulations should be available to support treatment adherence and improve clinical outcomes.

Funding

LEO Pharma A/S, Ballerup, Denmark.

The effects of continuous application of sunscreen on photoaged skin in Japanese elderly people - the relationship with the usage

Since photoaging of skin is caused by chronic sun exposure, it is well-recognized that regular sunscreen use can help prevent photoaging of skin in fair-skinned people. Therefore, application of sunscreen is recommended for the prevention of photoaging in many countries. However, the relationship between UV exposure and photoaging has rarely been investigated in clinical studies in Japan. In addition, there have been almost no long-term interventional studies in Japanese people. We have previously conducted a study where Japanese actinic keratosis patients were instructed to continuously apply sunscreen. The results indicated that long-term application of sunscreen is effective in suppressing actinic keratosis progression and generation. In the present study, we investigated the effects of sunscreen on photoaged skin in 14 elderly Japanese people. Skin conditions such as water content, transepidermal water loss, the number of spots, wrinkles, and skin color tone uniformity were measured and compared before and after the study. A statistically significant difference was observed only in skin surface hydration. There were large inter-individual differences in amount of sunscreen used throughout the study. The changes in the number of spots and skin color tone uniformity during the 18 months showed good correlation with amount of sunscreen being used. These results suggest an increase in the number of spots and deterioration in skin color tone uniformity in the 18-month non-sunscreen application period, and that such skin conditions improved with increasing use of sunscreen. In this study, we suggested an inhibitory effect on photoaging symptoms such as spots and skin color tone non-uniformity, by application of the appropriate amount of sunscreen over a long period of time in Japanese people, similar to Caucasians.

Use of clobetasol in lacquer for plaque psoriasis treatment

Clobetasol benefits to control psoriasis lesions are well defined, but there were not studies about its action when used in lacquer vehicle to control skin lesions. A double-blind study was conducted with 40 patients that utilized clobetasol 0.05% in one hemibody and just the vehicle in the other hemibody. Twenty of them used petrolatum as vehicle and the others used lacquer. An assessment was conducted using the clinical index PASI and a quality of life questionnaire (Dermatological Life Quality Index). There was no statistical difference between groups. There was a trend of favorable response particularly in the hemibody treated with clobetasol.

Methodologies for medication adherence evaluation: Focus on psoriasis topical treatment

Adherence to topical treatment has been less studied in comparison with systemic therapeutic regimens and is poorly understood. High-quality research on this area is essential to outline a strategy to increase medication adherence and clinical outcomes. For a more comprehensive understanding of this issue, a systematic review of the methodologies for topical treatment adherence evaluation in psoriasis was undertaken. Twenty one studies were selected from the literature which used six different adherence methodologies. Merely three studies used multiple adherence measurement methods. The most used method was questionnaire (44%) which was also associated with higher variability of the adherence results. One possible explanation is the lack of a validated questionnaire designed specifically for the evaluation of adherence to topical treatment. Only one method (medication weight) takes into consideration the applied dose. However, the estimation of the expected weight is complex, which renders this method, as used presently, less effective. The use of a dosing device could improve its accuracy and be helpful to clearly instruct the patients about the correct dose. As there is no single method that allows an accurate and complete assessment of adherence it is recommended to use a combination of methods, including self-report and medicines' weight measurements.

The potential of polymeric film-forming systems as sustained delivery platforms for topical drugs

INTRODUCTION

Dosing regimens requiring multiple daily applications frequently result in poor patient compliance, especially in the treatment of chronic skin diseases. Consequently, development of sustained delivery systems for topical drugs permitting less frequent dosing is of continuing interest for dermatological therapy.

AREAS COVERED

This potential of polymeric film-forming systems (FFS), created in situ on the skin, as sustained delivery platforms for topical drug delivery is reviewed. Key formulation parameters that determine delivery efficiency are considered focussing on those that permit a drug reservoir to be established in the upper layers of the skin and/or on the skin surface from which release can be sustained over a prolonged period. The advantageous and superior cosmetic attributes of FFS (compared to conventional semi-solid formulations) that offer significantly improved patient compliance are also addressed.

EXPERT OPINION

The promise of polymeric FFS as convenient and aesthetic platforms for sustained topical drug delivery is clear. Manipulation of the formulation allows the delivery profile to be customized and optimized to take advantage of both a rapid, initial input of drug into the skin (likely due to a transient period of supersaturation) and a slower, controlled release over an extended time from the residual film created thereafter.

An Applicator Delivery System for Fixed-Combination Calcipotriene Plus Betamethasone Dipropionate Topical Suspension (Gel): Innovating Psoriasis Vulgaris Treatment Through Patient Collaboration

Treatment non-adherence is a complex problem encountered in all therapy areas, particularly in chronic diseases such as psoriasis vulgaris. To address adherence issues, focus is turning towards developing interventions tailored to individual patient needs. Topical therapies remain the mainstay of psoriasis treatment; however, these are associated with additional challenges where preparations may be perceived as messy, inconvenient and time-consuming. Once-daily fixed-combination calcipotriene 0.005% (Cal) and betamethasone dipropionate 0.064% (BD) topical suspension is a convenient and effective first-line topical psoriasis therapy. To improve the patient experience with this treatment, we undertook a program—in collaboration with patients and healthcare professionals—to develop a topical treatment delivery system that further caters to the unmet needs of psoriasis patients. The finalized Applicator comprises: an easy to operate pump-action lever providing consistently accurate dose delivery (0.05 g of Cal/BD topical suspension/pump); a single-tip nozzle allowing for targeted, precise application to body and scalp psoriasis plaques; two spreading surfaces designed to disperse treatment evenly across both large and small affected skin areas; and a protective cover. Patients listed the following as key Applicator attributes: ease of use, ‘less messy’ treatment, precise application, consistent accurate dosing, ‘no touch’ treatment, reduction of wasted treatment and extended length of reach for awkward areas. Although these attributes were well received by most patients and healthcare professionals, some patients did not perceive them all as improvements over their current treatment; this highlights the need to tailor treatment for each individual patient’s requirements. For patients who prefer using the Applicator, it has the potential to provide greater control over their daily psoriasis management by providing a simple, convenient treatment option, with minimal impact on their lives. The Applicator may represent a more acceptable treatment delivery system for some patients with psoriasis vulgaris and may, therefore, promote long-term treatment adherence.

Funding: LEO Pharma

A Systematic Review of Factors Associated with Non-Adherence to Treatment for Immune-Mediated Inflammatory Diseases

BACKGROUND

Non-adherence impacts negatively on patient health outcomes and has associated economic costs. Understanding drivers of treatment adherence in immune-mediated inflammatory diseases is key for the development of effective strategies to tackle non-adherence.

OBJECTIVE

To identify factors associated with treatment non-adherence across diseases in three clinical areas: rheumatology, gastroenterology, and dermatology.

DESIGN

Systematic review.

DATA SOURCES

Articles published in PubMed, Science Direct, PsychINFO and the Cochrane Library from January 1, 1980 to February 14, 2014.

STUDY SELECTION

Studies were eligible if they included patients with a diagnosis of rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis, inflammatory bowel disease, or psoriasis and included statistics to examine associations of factors with non-adherence.

DATA EXTRACTION

Data were extracted by the first reviewer using a standardized 23-item form and verified by a second/third reviewer. Quality assessment was carried out for each study using a 16-item quality checklist.

RESULTS

73 studies were identified for inclusion in the review. Demographic or clinical factors were not consistently associated with non-adherence. Limited evidence was found for an association between non-adherence and treatment factors such as dosing frequency. Consistent associations with adherence were found for psychosocial factors, with the strongest evidence for the impact of the healthcare professional-patient relationship, perceptions of treatment concerns and depression, lower treatment self-efficacy and necessity beliefs, and practical barriers to treatment.

CONCLUSIONS

While examined in only a minority of studies, the strongest evidence found for non-adherence were psychosocial factors. Interventions designed to address these factors may be most effective in tackling treatment non-adherence.

Real-life effectiveness of once-daily calcipotriol and betamethasone dipropionate gel vs. ointment formulations in psoriasis vulgaris: final analysis of the 52-week PRO-long study

Background

Topical therapies are the mainstay of treatment for psoriasis vulgaris. The fixed combination of calcipotriol (Cal) 50 μg/g plus betamethasone 0.5 mg/g (as dipropionate; BD) is a first‐line topical treatment and available as a gel or ointment. The use of these fixed combination products was compared in PRO‐long, a long‐term noninterventional study, for which interim results (4 and 12 weeks) have previously been reported.

Objective

To describe and compare patients’ perspectives on the fixed combination gel and ointment formulations; to include efficacy, adherence behaviour, treatment satisfaction and health‐related quality of life (HRQoL) aspects during long‐term real‐life psoriasis management.

Methods

PRO‐long was a multicentre, prospective, observational, 52‐week study of patients prescribed fixed combination Cal/BD gel or ointment in clinical practice. For final analysis the following were assessed at weeks 24, 36 and 52: differences in the proportion of patients with ‘mild’/‘very mild’ disease according to patient's global assessment of disease severity, adherence behaviour, treatment satisfaction (nine‐item treatment satisfaction questionnaire for medication) and HRQoL (Skindex‐29).

Results

Patients (n = 328) were prescribed once‐daily Cal/BD gel (n = 152) or ointment (n = 176). At week 52, a higher proportion of patients reported that the severity of their psoriasis was ‘mild’/‘very mild’ vs. baseline (gel: 60.2 vs. 47.1%; ointment: 58.8 vs. 42.4%), with greater treatment satisfaction reported in patients using gel vs. those using ointment. A higher proportion of patients found the gel ‘easy’ to use compared with the ointment (66.7 vs. 45.2%). Daily application of treatment took ≤5 min for 86.1% of patients using gel and 71.0% of patients using ointment.

Conclusion

This real‐life study has demonstrated similar effectiveness between the Cal/BD formulations. However, over a 52‐week treatment period, patients reported greater treatment satisfaction with the gel, which was considered easier to use, faster to apply and overall a more convenient product.

Triamcinolone spray: no-rub application as effective as rub application

BACKGROUND

Adherence to therapy is important to achieve successful treatment outcomes. Although effective, topical treatments in dermatology may result in sticky skin or may be too time-consuming to apply, thereby creating adherence issues. Spray formulations have excellent products aesthetics, but may require a 2-step application process.

AIMS

This study was conducted to determine whether the spray formulation of triamcinolone acetonide (TAC) 0.2% works equally well in a no-rub and rub application process.

METHODS

Fifty patients 18 years of age and older with mild symmetrical arm or leg eczema or atopic dermatitis were enrolled in a 2-week investigator-blinded study. One limb was randomized to be treated with TAC spray and no rubbing, and the other was to be treated with TAC spray and rubbing. Patients applied the spray three times daily for 2 weeks. The use of moisturizers was not permitted.

RESULTS

After 2 weeks, there was a highly clinical and statistical (P < 0.001) improvement in all investigator and patient parameters evaluated with both the no-rub and rub techniques. There was no difference in final assessment scores between the no-rub and rub applications (P > 0.7), and no study product tolerability issues were identified. Transepidermal water loss and corneometry measures revealed no issues in skin barrier impairment even though patients were not permitted to use moisturizers.

CONCLUSION

This study demonstrates the application parity between a no-rub and rub application of TAC spray in the absence of a moisturizer. Both techniques resulted in clinical and significant improvement in eczema and atopic dermatitis and neither resulted in skin barrier issues.

How do disease perception, treatment features, and dermatologist-patient relationship impact on patients assuming topical treatment? An Italian survey

Background

Psoriasis largely affects daily activities and social interactions and has a strong impact on patients’ quality of life. Psoriatic patients have different attitudes toward their condition. Topical medications are essential for the treatment of psoriasis, but the majority of patients do not adhere to these therapies.

Objective

The history of treatment success or failure seems to influence patient attitude toward topical therapy. Therefore, it is important to understand the psychological, experiential, and motivational aspects that could be critical for treatment adherence, and to describe the different attitudes toward topical treatment. Furthermore, the physician–patient relationship and the willingness to trust the dermatologist may have a substantial role in encouraging or discouraging patients’ attitudes toward topical therapy.

Methods

A survey was designed to collect aspects that could be relevant to understanding different patient attitudes toward psoriasis and its treatments. A total of 495 self-administered questionnaires compiled by psoriatic patients were analyzed from 20 Italian specialized hospital centers in order to provide a nationwide picture.

Results

Psoriatic patients have different perceptions and experiences in relation to their condition: half of them consider psoriasis as a disease, while the other half consider psoriasis as a disorder or a nuisance. Topical therapy is the most widely used treatment, even though it is not considered the most effective one and often perceived to be cosmetic. The main findings are: 1) inadequate patient education about this disease, 2) lack of information about topical treatment, and 3) lack of results within the expected time frame. Furthermore, physicians need to build a good relationship with psoriatic patients in order to motivate them, to trust in their care, and to adhere to treatment.

Conclusion

This survey adds new and important details about daily life and well-being and the needs of psoriatic patients, providing suggestions for dermatologists to improve patients management.

Treatment refusal among patients with psoriasis

BACKGROUND

Treatment refusal, which is defined as a patient actively refusing to take treatment despite physician recommendations, has never been evaluated in psoriasis.

OBJECTIVE

To investigate refusal of topical treatments by patients living with psoriasis in France.

METHODS

Using responses to an internet study, participants who refused topical treatment (n = 50) were compared to those who applied topical treatment (n = 205). Participants undergoing phototherapy, biotherapy, and oral treatment were excluded. Spearman rank correlations completed by Fisher's exact tests and Student's t-tests were performed.

RESULTS

Comorbidities, localization of lesions, and symptoms associated with psoriasis were not significant predictors of treatment refusal. Compared to patients who accepted treatment, more patients who refused treatment believed that psoriasis is not manageable (80.0% versus 61.5%; p = 0.01), that psoriasis treatments never work (58.0% versus 27.5%; OR: 2.09 p < 0.0001), and that all creams have the same effects (54.0% versus 31.7%; OR: 1.7, p = 0.003). Among patients who reported seeking medical attention from physicians, more patients in the treatment refusal group reported some level of dissatisfaction with their relationship with their physician than in the treatment acceptance group.

LIMITATIONS

The validity of the self-reported treatment refusal could not be evaluated.

CONCLUSION

Treatment refusal is an important element to be taken into consideration in the management of psoriasis.

A cosmeceutical formulation based on boswellic acids for the treatment of erythematous eczema and psoriasis

Background

Boswellic acids (BAs) show anti-inflammatory properties in a variety of inflammatory diseases, including rheumatoid arthritis, osteoarthritis, and asthma. A topical administration route is currently used to deliver active compounds in psoriatic and eczematous patients. In this double-blind study we compare a novel BA formulation (containing Bosexil^®, INCI [International Nomenclature of Cosmetic Ingredients]: lecithin, Boswellia serrata resin extract) with a placebo formulation. A third arm of the trial received a formulation of Vaccinium myrtillus seed oil, previously demonstrated as an effective local treatment for psoriatic lesions.

Methods

Patients with psoriasis or erythematous eczema were randomly assigned, in a 1:1:1 ratio, to Bosexil^®, V. myrtillus seed oil, or placebo. In order to evaluate the effects of treatment, the changes of scales and erythema from diagnosis to the end of treatment were scored in psoriatic patients, while changes in itch and erythema were analyzed for erythematous eczema patients. Psoriasis Area Severity Index and Eczema Area and Severity Index scores were also calculated.

Results

In patients with psoriasis, scales and erythema improved both with Bosexil^® and the V. myrtillus seed oil treatment in comparison with placebo. In particular, the treatment with Bosexil^® formulation improved scales (70% of cases) and erythema (50% of cases) without any case of worsening. In patients with eczema, the administration of placebo did not result in any improvement in 90% of cases, and in the remaining 10% worsened both itch and erythema. Bosexil^® formulation improved both itch (60% of cases) and erythema (60% of cases) without any case of worsening. V. myrtillus seed oil improved itch and erythema in 66.7% and 77.8% of patients, respectively.

Conclusion

A topical formulation of Bosexil^® may be promising for the treatment of psoriasis and erythematous eczema. Long-term studies are recommended to evaluate the adherence to this topical treatment and its clinical benefits in real life.

Safety and efficacy of calcipotriol plus betamethasone dipropionate gel in the treatment of scalp psoriasis in adolescents 12-17 years of age

Summary

What's already known about this topic?

What does this study add?

Use of solid dispersions to increase stability of dithranol in topical formulations

The present study was planned to improve the stability of dithranol using solid dispersions (SD). Two different SD at a 1:9 ratio of dithranol/excipient were prepared: one of them using glyceryl behenate as excipient and the other using a mixture of argan oil with stearic acid (1:8 ratio) as excipient. Pure dithranol and SD of dithranol were incorporated in an oil-in-water cream and in a hydrophobic ointment in a drug/dermatological base ratio of 1:10. The physical and mechanical properties of semisolid formulations incorporating the pure drug and the developed SD were evaluated through rheological and textural analysis. To evaluate the stability, L*a*b* color space parameters of SD and semisolid formulations, and pH of hydrophilic formulations were determined at defined times, during one month. Each sample was stored at different conditions namely, light exposure (room temperature), high temperature exposition (37 °C) (protected from light) and protected from light (room temperature). Despite higher values of firmness and adhesiveness, hydrophobic ointment exhibited the best rheological features compared to the oil-in-water cream, namely a shear-thinning behavior and high thixotropy. These formulations have also presented more stability, with minor changes in L*a*b* color space parameters. The results of this study indicate that is possible to conclude that the developed SD contributed to the increased stability of dithranol.

Emerging topical treatments for psoriasis

INTRODUCTION

Psoriasis is an immune-mediated chronic inflammatory skin disease which classically presents as erythematous, scaly plaques affecting extensor surfaces of the limbs, scalp and trunk. Approximately 80% of patients have a mild-to-moderate form routinely treated with topical medications, whereas phototherapy, systemic and biological therapies are typically reserved for treatment of moderate-to-severe psoriasis.

AREAS COVERED

The major advances in psoriasis therapy in the past 15 years have been in new immunomodulatory and biological molecules, with a significant unmet need to have new, efficient and safe topical treatment options for the large percentage of patients for whom systemic therapy is not indicated. The available topical therapies (corticosteroids and vitamin D3 analogs) have remained relatively unchanged over the past several decades. This article reviews emerging topical drugs and formulations currently under evaluation in clinical trials.

EXPERT OPINION

The time is right for a revolution in our topical therapy armamentarium. It has lagged significantly behind the systemic biological evolution of new drug development. Our large psoriasis population with mild-to-moderate psoriasis certainly deserves potent but safe and innovative topical agents with a new mode of action as well as with long-lasting clinical efficacy.

Pharmacological effects of vitamin D and its analogs: recent developments

Calcitriol, the hormonally active form of vitamin D, is well known for its diverse pharmacological activities, including modulation of cell growth, neuromuscular and immune function and reduction of inflammation. Calcitriol and its analogs exert potent effects on cellular differentiation and proliferation, regulate apoptosis and produce immunomodulatory effects. The purpose of this review is to provide information on various physiological and pharmacological activities of calcitriol and its newly discovered analogs. Special emphasis is given to skin diseases, cancer, diabetes and multiple sclerosis. A discussion is raised on the mechanisms of action of calcitriol and its analogs in various diseases, as well as on possible methods of delivery and targeting.

Patient-reported outcomes for psoriasis patients with clear versus almost clear skin in the clinical setting

BACKGROUND

There is little evidence to guide the establishment of treatment goals for moderate to severe psoriasis in the clinical setting.

OBJECTIVE

We sought to compare Dermatology Life Quality Index scores and prescription topical medication use between patients with clear versus almost clear skin.

METHODS

This was a multicenter cross-sectional study of 97 patients with clear skin and 441 patients with almost clear skin receiving current systemic therapy or phototherapy for a primary indication of plaque psoriasis evaluated at 1 of 10 US outpatient dermatology sites participating in the Dermatology Clinical Effectiveness Research Network.

RESULTS

In adjusted analyses, patients with clear versus almost clear skin were more likely to report no impact of psoriasis on quality of life (relative risk 1.60; 95% confidence interval 1.37-1.86). Patients with clear versus almost clear skin were also more likely to report no prescription topical medication use in the preceding week (relative risk 2.08; 95% confidence interval 1.73-2.49).

LIMITATIONS

Cross-sectional design prohibits longitudinal assessment of outcomes.

CONCLUSIONS

Clinically important differences in quality of life and prescription topical medication use exist between patients with clear versus almost clear skin. Collectively, our results indicate that achievement of clear skin may be an important clinical distinction among patients with moderate to severe psoriasis.

Self-medication of psoriasis in southwestern China

BACKGROUND

Medication adherence is essential for psoriasis management. Although studies have determined the prevalence and correlative factors of non-adherence, as far as we know, there has been no study specifically addressing them in China.

METHODS

Anonymous 23-item questionnaires were distributed to 324 psoriatic patients from June 2012 to June 2013. χ(2) test, normality test, Student's t test or Mann-Whitney U test, Bonferroni correction and the binary logistic regression model were applied.

RESULTS

Self-medication of psoriasis was high in China (82.4%). Joint involvement, absence of communication with families and short communication duration with doctors were the three top factors affecting adherence. Besides low efficacy (16.0%) and recurrence frustration (27.0%), we found that patients' deception by sham advertisings (24.1%) is an non-negligible issue.

CONCLUSION

Psoriasis self-medication in China was high. Improvement of patients' communication with families and/or doctors were suggested to be crucial to enhance adherence. Meanwhile, extermination of sham advertisings by administrative agencies is of great concern.

Group-based trajectory modeling to assess adherence to biologics among patients with psoriasis

BACKGROUND

Proportion of days covered (PDC), a commonly used adherence metric, does not provide information about the longitudinal course of adherence to treatment over time. Group-based trajectory model (GBTM) is an alternative method that overcomes this limitation.

METHODS

The statistical principles of GBTM and PDC were applied to assess adherence during a 12-month follow-up in psoriasis patients starting treatment with a biologic. The optimal GBTM model was determined on the basis of the balance between each model's Bayesian information criterion and the percentage of patients in the smallest group in each model. Variables potentially predictive of adherence were evaluated.

RESULTS

In all, 3,249 patients were included in the analysis. Four GBTM adherence groups were suggested by the optimal model, and patients were categorized as demonstrating continuously high adherence, high-then-low adherence, moderate-then-low adherence, or consistently moderate adherence during follow-up. For comparison, four PDC groups were constructed: PDC Group 4 (PDC ≥75%), PDC Group 3 (25%≤ PDC <50%), PDC Group 2 (PDC <25%), and PDC Group 1 (50%≤ PDC <75%). Our findings suggest that the majority of patients (97.9%) from PDC Group 2 demonstrated moderate-then-low adherence, whereas 96.4% of patients from PDC Group 4 showed continuously high adherence. The remaining PDC-based categorizations did not capture patients with uniform adherence behavior based on GBTM. In PDC Group 3, 25.3%, 17.2%, and 57.5% of patients exhibited GBTM-defined consistently moderate adherence, moderate-then-low adherence, or high-then-low adherence, respectively. In PDC Group 1, 70.8%, 23.6%, and 5.7% of patients had consistently moderate adherence, high-then-low adherence, and continuously high adherence, respectively. Additional analyses suggested GBTM-based categorization was best predicted by patient age, sex, certain comorbidities, and particular drug use.

CONCLUSION

GBTM is a more appropriate way to model dynamic behaviors and offers researchers an alternative to more traditional drug adherence measurements.

The science of dermocosmetics and its role in dermatology

Our increased knowledge of normal skin physiology has ushered in a subtle revolution in cosmetic science. Originally designed as preparations to enhance personal appearance by direct application on to the skin, cosmetics have now taken on a new role in dermatology, through the support of the management of many skin disorders. This evolving role of cosmetics in skin care is primarily due to scientific and technological advancements that have changed our understanding of normal skin physiology and how cosmetics modify its appearance both physically and biologically. The vast array of techniques currently available to investigate skin responsivity to multiple stimuli has brought about a new era in cosmetic and dermocosmetic development based on a robust understanding of skin physiology and its varied responses to commonly encountered environmental insults. Most cosmetic research is undertaken on reconstructed skin models crucial in dermatological research, given the strict ban imposed by the European Union on animal testing. In addition, the design and conduct of trials evaluating cosmetics now follow rules comparable to those used in the development and evaluation of pharmaceutical products. Cosmetic research should now aim to ensure all trials adhere to strictly reproducible and scientifically sound methodologies. The objective of this review is to provide an overview of the multidisciplinary scientific approach used in formulating dermocosmetics, and to examine the major advances in dermocosmetic development and assessment, the safety and regulatory guidelines governing their production and the exciting future outlook for these dermocosmetic processes following good practice rules.

Using a single product (calcipotriene/betamethasone topical suspension) vs multiple products to manage body and scalp psoriasis: comparisons in resource utilization and costs

OBJECTIVES

To compare resource utilization and costs among patients who used calcipotriene/betamethasone dipropionate topical suspension (Taclonex Scalp Topical Suspension, Leo Pharma A/S) vs those who used multiple body and scalp formulations for psoriasis.

RESEARCH DESIGN AND METHODS

A retrospective study using Truven Health MarketScan Commercial Database from 2006-2011 was performed to identify patients with psoriasis (ICD code 696.1x). Two study cohorts analyzed were cohort A (used body-only formulations for psoriasis and switched on the index date to using calcipotriene/betamethasone dipropionate topical suspension alone) and cohort B (used multiple body and scalp formulations for psoriasis). Patients were required to be continuously enrolled during 180-days pre- and post-index periods. Multiple regression analyses adjusting for baseline demographic and clinical covariates were performed.

MAIN OUTCOMES MEASURES

Number of psoriasis-related outpatient visits, total healthcare costs, psoriasis-related costs, and use of systemic agents during post-index period.

RESULTS

A total of 1923 patients were identified with at least one prescription for calcipotriene/betamethasone dipropionate scalp topical suspension (cohort A = 367, cohort B = 1556). Patients using multiple medications (cohort B) were associated with 48% higher number of outpatient visits as compared with those who used a single formulation (cohort A) after controlling for baseline covariates (p < 0.001). A generalized linear model adjusting for baseline covariates showed significantly higher post-index total and psoriasis-related healthcare costs for cohort B as compared with cohort A (both p < 0.001). Patients in Cohort B also had twice the odds of using systemic agents as compared to patients in Cohort A (p < 0.001).

CONCLUSIONS

Patients with body and scalp psoriasis using a single product had significantly lower overall and psoriasis-related healthcare costs, needed fewer psoriasis-related outpatient visits, and used less systemic agents during the post-index period. A lack of robust clinical measures to define the disease severity may have limited the interpretations from this study.

Bacterial cellulose membranes as drug delivery systems: an in vivo skin compatibility study

Bacterial cellulose (BC) is a highly pure form of cellulose, produced in the form of a swollen membrane by several bacteria that demonstrated to be able to modulate the skin release of model drugs. In the present study, the skin irritation potential of BC was evaluated in human subjects. BC membranes with and without glycerin (acting as plasticizer) were tested. No significant differences were observed for transepidermal water loss (TEWL) measurements in comparison with negative control, 2 and 24 h after patch removal, which is an indicator of an absence of barrier disruption. Similar results were found for erythema. Clinical scores were zero at both times for all volunteers, with the exception of five volunteers that exhibited weak reactions. BC with glycerin provided a skin moisturizing effect statistically higher than the negative control (p=0.044), which was not observed for BC alone. The good skin tolerance found after a single application under occlusion reinforces the putative interest of BC membranes as supports for drug topical delivery. Besides modifying the mechanical properties, the inclusion of glycerin results in a skin moisturizing effect which could be clinically relevant for the treatment for skin diseases characterized by dryness, such as psoriasis and atopic dermatitis.

Adherence to medication in patients with psoriasis: a systematic literature review

Psoriasis is associated with considerable physical and psychological morbidity. Optimal use of psoriasis treatments can limit the physical manifestations of psoriasis and help improve quality of life, but nonadherence is common. Smoking, obesity and excessive alcohol consumption are prevalent in this population. A systematic review of adherence to medication and recommendations for lifestyle change in psoriasis was undertaken, with a critical appraisal of the quality of the selected studies. Electronic searches from inception to March 2012 (PubMed, Web of Science and Embase) were conducted. Twenty-nine studies were included; however, none examined adherence to advice about lifestyle change. Studies using a dichotomous classification of adherence tended to report suboptimal adherence, with 21·6-66·6% of patients classed as adherent. No consistent pattern of results emerged for sociodemographical, disease and lifestyle factors as determinants of adherence. However, some treatment factors were associated with adherence. While mixed findings were reported for quality of life as a determinant of adherence, psychological factors (psychological distress and patient satisfaction with care and therapy) were associated with adherence. Only tentative conclusions can be made for determinants of adherence because the methodological quality of many of the included studies limits conclusions. There is a need for improved quality of research and reporting in this area, and this review provides a platform from which future research within this area should progress, along with suggested research recommendations.

Non-adherence to topical treatments for actinic keratosis

BACKGROUND

There is limited information on the patterns of use, adherence rates, and factors that impact adherence with topical treatments for actinic keratosis (AK).

OBJECTIVES

To establish patterns of use and adherence with topical treatments for AK and to identify treatment-related factors that impact on adherence.

METHODS

A community-based, cross-sectional study was performed using a standardized questionnaire completed online or via telephone interview. Patients were stratified according to the presence of AK lesions on the scalp and/or other extremities; and presence of scarring resulting from treatment.

RESULTS

This study included 305 patients with AK who were currently using a patient-applied topical therapy for AK or had used one within the previous 12 months. In total, 88% (n = 268/305) of patients were either non-adherent, non-persistent or both non-adherent and non-persistent to topical therapy. Duration of treatment was associated with increasing rates of non-adherence (adjusted odds ratio [OR]; for treatment durations greater than 4 weeks, 2.2, P < 0.01): 52% of patients were non-adherent with 3-4 week treatment duration; 69% of patients with 4-8 week treatment duration; and 71% of patients with 6-12 week treatment duration. There were similar increases in non-persistence with increasing treatment duration (adjusted OR; for treatment durations greater than 4 weeks, 2.1, P < 0.05).

CONCLUSION

This study found high rates of non-adherence and non-persistence in patients with AK. Duration of treatment was a significant factor contributing to non-adherence and non-persistence to topical treatments. Patient-applied topical therapies that require less frequent application and have shorter treatment duration may be associated with improved adherence rates.