Characterization of socioeconomic status of Japanese patients with atopic dermatitis showing poor medical adherence and reasons for drug discontinuation

Adult patients with alopecia areata report a significantly better medication adherence compared to those with atopic dermatitis: Results from a large cross-sectional cohort study

Background

Alopecia areata (AA) and atopic dermatitis (AD) are chronic skin diseases where the suboptimal medication adherence (MA) may result in poor clinical outcomes.

Objective

To assess the impact of AA on MA among adults compared to AD.

Methods

Patient reported MA of adults with AA were compared with AD. Patients were identified from the Danish Skin Cohort, a nationwide prospective cohort of dermatological patients in Denmark. We used the Medication Adherence Report Scale- 5, a self-reporting questionnaire, to assess MA. Demographic and disease characteristics were collected. Logistic regression was conducted.

Results

Patients with AA reported higher MA than AD (mean 21.81 vs 18.29). Logistic regression analyses showed AA diagnosis had a statistically significant positive effect on MA (odds ratio = 3.94, 95% CI 2.01-8.89). Men reported significantly higher MA (odds ratio = 1.49, 95% CI 1.14-1.94). Current disease severity did not impact MA.

Limitations

Data were self-reported by patients. Data regarding the specific treatment undergone by patients were not available.

Conclusion

Patients with AA have significantly higher MA compared to patients with AD. The stability of AA patients' symptoms may lead to higher MA due to a desire for disease control. Conversely, the sporadicity of AD symptoms could negatively affect adherence, causing fluctuations in medication use.

Impact of a Digital Atopic Dermatitis Educational Intervention on Hispanic Patients and Family Members

With the increasing incidence of atopic dermatitis (AD) in the U.S., the highest prevalence of AD being found in Hispanic countries, and the rising Hispanic-American population, educational resources on eczema focused on Spanish-speaking populations are needed more than ever. As such, the primary goal of this project was to assess the beneficial impact of an educational intervention conducted through a virtual platform for Hispanic individuals living with atopic dermatitis. Utilizing WhatsApp, the study enrolled 55 participants diagnosed with AD and/or parents of children diagnosed with AD. Participants were enrolled in a seven-day educational module with daily topics on AD health knowledge. A health knowledge survey was administered before the educational program, upon completion of the program, and one month after completion. The program found a 14% increase in AD health knowledge upon completion of the program (p < 0.001). Most importantly, there was no significant difference found between the health knowledge survey submitted at program completion and one month after completion, signaling that health knowledge taught through the course was successfully retained by participants (p = 0.29). Qualitative themes involving atopic disease were additionally explored through group discussions, including mental health and peer stigma. This study is the first of its kind in dermatology utilizing the WhatsApp format. The success of retained health knowledge regarding AD demonstrates that future virtual endeavors can be effective and accessible methods of patient education overall for populations that might not have ease of access to major medical centers.

Medication Adherence of People Living with HIV in Japan-A Cross-Sectional Study

Long-term medical care for people living with HIV (PLHIV) is critical for treatment efficacy, and various studies have examined reasons for antiretroviral therapy (ART) non-adherence. In Japan, doctors assume patients maintain high adherence. However, little is known about real-world treatment adherence. We conducted an anonymous self-administered web-based survey asking about adherence for a total of 1030 Japanese PLHIV who were currently on ART. Adherence was determined using the eight-item Morisky Medication Adherence Scale (MMAS-8), for which scoring ranged from 0 to 8 and scores < 6 points were classified as low adherence. Data were analyzed based on patient-related factors; therapy-related factors; condition-related factors, such as a comorbidity with depression (utilizing the Patient Health Questionnaire 9, PHQ-9); and healthcare/system-related factors. Among 821 PLHIV who responded to the survey, 291 responders (35%) were identified as being in the low adherence group. A statistically significant relationship was found between the number of missed anti-HIV drug doses within the previous 2 weeks and long-term adherence, per the MMAS-8 score (p < 0.001). Risk factors for low adherence included age (younger than 21 years, p = 0.001), moderate to severe depression (p = 0.002, using the PHQ-9), and drug dependence (p = 0.043). Adherence was also influenced by a shared decision-making process, including treatment selection, doctor-patient relations, and treatment satisfaction. Adherence was mainly affected by treatment decision factors. Hence, support of care providers should be considered critical for improving adherence.

Efficacy of Pseudo-Ceramide-Containing Steroid Lamellar Cream in Patients with Mild to Moderate Atopic Dermatitis: A Randomized, Double-Blind Study

Introduction

Atopic dermatitis (AD) is a chronic inflammatory skin disorder involving decreased barrier function of the stratum corneum. This decrease, caused by a reduction in ceramide, the primary component of intercellular lipids in the stratum corneum, leads to a disturbance in the lamellar structure.

Methods

We developed a formulation (test cream) containing a steroid and synthetic pseudo-ceramide (SLE: N-(3-hexadecyloxy-2-hydroxypropyl)-N-2-hydroxyethyl hexadecanamide) that forms a lamellar structure on the skin after its application and drying. The formulation or control cream (a formulation containing a steroid but not pseudo-ceramide that does not form a lamellar structure) was applied twice daily for 2 weeks to the lesional area of 34 participants with mild to moderate AD symptoms.

Results

The test cream showed a periodic structure with an interface space of approximately 8.2 nm in transmission electron microscopy and small- and wide-angle X-ray scattering, similar to the lamellar structure in the human stratum corneum. In the double-blind test, the anti-inflammatory effects of the test cream (n = 17) were comparable to those of the control cream (n = 17). In the test cream group, a significant increase in the stratum corneum moisture content (p < 0.01) and significant decrease in transepidermal water loss (p < 0.05) were observed at weeks 1 and 2 after application compared with those before application. No such change was observed in the control group.

Conclusion

The results indicate that, even with a relatively short application period of 2 weeks, the test cream not only suppressed inflammation of the lesional area, but also improved the inherent barrier function of the stratum corneum, suggesting its potential as a treatment option for patients with AD.

Evaluation of standard treatments for managing adult Japanese patients with inadequately controlled moderate-to-severe atopic dermatitis: Two-year data from the ADDRESS-J disease registry

Atopic dermatitis (AD), a chronic relapsing inflammatory skin disease with a high disease burden, is one of the most common dermatological conditions in Japan. Herein, we report the disease profiles and current AD treatment during 2‐year management of Japanese adults with moderate‐to‐severe AD. ADDRESS‐J was a prospective, longitudinal, observational study that evaluated real‐world effectiveness and safety of current AD treatments of adult patients with moderate‐to‐severe AD (Investigator's Global Assessment score 3 or 4) in Japan. The maximum follow‐up period was 2 years. Among 300 patients enrolled, 288 had ≥1 post‐baseline evaluation and were analyzed (mean age, 35.5 years; 60.1% male). Almost all patients (99.7%) received topical therapy; the most commonly used therapy was topical corticosteroids of the second‐highest potency (86.5%) (e.g., 0.1% mometasone furoate) followed by medium‐potency topical corticosteroids (50.3%) (e.g., 0.05% clobetasol butyrate). At month 12 of the study, 10.4% of patients had Investigator's Global Assessment 0/1, similarly at month 24 (10.8%). A total of 132 patients (45.8%) had ≥1 AD flare‐up during the observation period, with the majority of first flares occurring within the first year of the study. Various physician‐ and patient‐reported outcomes improved considerably during the first 3 months of the study, with only minor changes after this time. In this cohort, 16.7% of patients had skin infections requiring treatment; 7.3% had adverse events (AE) potentially related to treatment; 1.7% had serious AE; and 1.0% had treatment discontinuations due to AE. Limitations include missing data at later timepoints and the inclusion criteria limiting generalizability. In summary, this analysis of the ADDRESS‐J study showed that some patients with moderate or severe AD respond to conventional therapies, while others do not. For those with inadequately controlled moderate‐to‐severe AD, the newly emerged systemic agents, such as biologics, may provide a potential strategy for long‐term disease management.

Targeting therapeutic approaches and highlighting the potential role of nanotechnology in atopic dermatitis

Atopic dermatitis is a chronic as well as widespread skin disease which has significant influence on the life attributes of affected people and their families. Systemic immunosuppressive drugs can be utilised for effective care of disease, although they are often prescribed for rigorous disruption or disease that is complicated to manage. Therefore, topical applications of corticosteroids are considered the primary pharmacologic therapies for atopic dermatitis, and research recommends that these medications might be helpful in preventing disease flare-ups. However, topical medicine administration to deeper layers of skin is challenging because of the skin anatomic barrier that restricts deeper drug permeation, and also due to barrier function abnormalities in atopic dermatitis skin, which might result in systemic drug absorption, provoking systemic consequences. Hence, effective management of atopic dermatitis needs new, effective, safe and targeted treatments. Therefore, nanotechnology-based topical therapeutics have attracted much interest nowadays because of their tendency to increase drug diffusion and bioavailability along with enormous drug targeting potential to affected cells, and, thereby, reducing the adverse effects of medications. In this review, we mention different symptoms of atopic dermatitis, and provide an overview of the different triggering factors causing atopic dermatitis, with emphasis on its epidemiology, pathophysiology, clinical features and diagnostic, and preventive measures. This review discusses existing therapeutics for treating atopic dermatitis, and the newer approaches as well as the current classical pharmacotherapy of atopic dermatitis against new nanoparticle skin delivery systems. This review has also briefly summarised the recent patents and clinical status of therapeutic modalities for atopic dermatitis.

Exacerbating factors and disease burden in patients with atopic dermatitis

The number of patients with atopic dermatitis is on the rise worldwide, and Japan is no exception. According to recent estimates of the percentage of patients with atopic dermatitis in Japan by age, the majority of patients are between 20 and 44 years old. Because the peak age of onset of atopic dermatitis is during infancy, many patients may experience prolonged symptoms from infancy to adulthood. A prolonged clinical course also increases the burden of atopic dermatitis on affected patients. Decreased productivity due to work disruptions, reduced daily activity, higher direct medical costs, fatigue, and daytime sleepiness due to sleep disturbances are typical burdens on patients with atopic dermatitis. In order to reduce these burdens, it is necessary to shorten its clinical course and achieve long-term control without relying on medications, possibly by using avoidance or coping measures of aggravating factors. Typical aggravating factors of atopic dermatitis include irritant dermatitis, food allergy in children, sweating, and psychological stress in adults. Food allergy places a heavy burden on the quality of life of affected patients and their families. The effectiveness of educational interventions for sweating and psychological stress is unclear. We must also evaluate the economic burden and cost-effectiveness of interventions on the patient as aggravating factors to be addressed.

A 52 weeks dupilumab treatment for moderate to severe atopic dermatitis in Korea: long-term efficacy and safety in real world

Previously, we have reported short term effectiveness and safety of dupilumab in Korea. In this study, we are trying to report the long-term effectiveness and safety of dupilumab in Korea. Ninety-nine patients with moderate to severe AD were analyzed. They were evaluated using Eczema Area and Severity Index (EASI), Numerical Rating Scale (NRS), Patient Oriented Eczema Measure (POEM), and Dermatology Quality of Life Index (DLQI) at baseline, week 16, 32 and 52. Efficacy outcomes showed higher improvement at 52 weeks compared with 16 weeks; high percentual reductions in EASI (88.1%), peak pruritus NRS (65.6%), POEM (67.2%), and DLQI (69.0%) compared to baseline. Proportion of patients achieving EASI 75 and 90 were 90.2% and 53.7%. POEM and DLQI had high correlation with clinical measured outcomes. In the analysis for the factors affecting achievement of EASI 90, female gender (OR 2.5), eosinophilia (OR 0.2) and elevated LDH (OR 0.07) were significantly associated. Most frequent adverse events included facial erythema (19.2%) and conjunctivitis (17.2%), which were mild/moderate and resolved during treatment. In conclusion, dupilumab treatment for 52 weeks in Korean patients with moderate-to-severe AD confirmed long term effectiveness and safety.

Burden of illness, medication adherence, and unmet medical needs in Japanese patients with atopic dermatitis: A retrospective analysis of a cross-sectional questionnaire survey

Atopic dermatitis (AD) negatively affects patients' daily lives. Poor medication adherence is a major barrier to treatment success. However, factors causing patients' poor adherence are unclear. This study aimed to identify factors associated with improvement of medication adherence in Japanese patients with AD and to evaluate illness burden and unmet medical needs for AD. We retrospectively analyzed Web-based questionnaire surveys conducted in 2018 in patients with AD aged 15 years and above who had been in- or outpatients within the past year from the survey. Quality of life using the EuroQol 5-Dimension (EQ-5D), and work productivity and activity impairment using Work Productivity and Activity Impairment Questionnaire (WPAI) were compared between patients and matched controls who had not visited a hospital for any disease within the past year. Subpopulation analysis was performed to explore factors affecting medication adherence. Unmet medical needs in AD treatment were identified by the percentage of patients who rated issues on the questionnaire as important but who were unsatisfied with them. In this study, we identified 1739 patients with AD. The scores of EQ-5D and WPAI showed that patients had statistically lower quality of life and higher impairment of work and activities than controls. High medication adherence scores were seen in patients with high health literacy levels and those who were well satisfied with communication with health-care providers, information received from them, or explanations of AD. Current unmet medical needs for AD were medical treatment costs, ease of hospital visits and explanations about disease prognosis. Patients tended to put a higher priority on communication with physicians than on that with nurses and pharmacists. In conclusion, we have identified patients' higher health literacy levels and satisfaction with the communication with their health-care provider as potential factors to improve medication adherence.

The Interplay of Atopic Dermatitis and Sexual Health

Atopic dermatitis (AD), a chronic inflammatory skin condition, negatively affects sexual health in various ways including causing physical discomfort and changes in physical appearance that can lead to low self-confidence. The chronic and debilitating nature of this disease can interfere with the sexual well-being of patients and their partners. This review describes the ways that AD affects sexual health. In addition, we review the impact that partnered relationships and physical intimacy can have on AD and provide practical recommendations for optimizing sexual health in AD patients.

Evaluating the burden of pruritus due to atopic dermatitis in Japan by patient-reported outcomes

AIMS

Although pruritus is a hallmark feature of atopic dermatitis, no study has investigated the associated impact of pruritus, due to atopic dermatitis in Japan. The study aimed to evaluate the real-life burden of atopic dermatitis by pruritus severity in adult Japanese patients. The primary objective was to assess the correlation between pruritus severity and work productivity and activity impairment. A secondary objective was to characterize the impact of pruritus on quality of life and to evaluate the burden of symptoms severity and frequency.

MATERIALS AND METHODS

A cross-sectional internet-based survey was conducted. Eligible patients were currently employed and working adults with atopic dermatitis for at least 6 months. Stratification on pruritus severity assessed by the Worst Pruritus Numerical Rating Scale at the screening was performed to ensure that different severity groups are represented. Correlations were assessed using Spearman's rank-order correlation coefficient. Multivariate regression analyses were performed to assess the impact of pruritus severity on work productivity and quality of life.

RESULTS

The study analyzed 370 patients. Pruritus severity significantly correlated with work impairment (Rho = 0.622, P value (H0: Rho > 0.5) <.001). A greater pruritus severity was associated with greater work productivity and activity impairment and a greater impact on quality of life, sleep, emotional state, and everyday activities. Patients with a greater pruritus severity carried a higher economic burden of treatment and were more often not satisfied with the received therapy.

LIMITATIONS

All data were self-reported by patients via an online survey, which is associated with the risk of misclassification for diagnosis, recall bias, and limited participation of patients.

CONCLUSIONS

The study provides evidence that pruritus is associated with the overall disease burden and impacts many important life aspects of patients with atopic dermatitis in Japan.

Current treatments for atopic dermatitis in Japan

The goal of a treatment regimen for atopic dermatitis is to reach and maintain a state where the patient exhibits mild symptoms or an absence of symptoms, and the patient should not experience disturbance during daily activities. The basis of a treatment regimen for atopic dermatitis is topical therapy, and currently there exist topical corticosteroids, tacrolimus and delgocitinib. Using these, proactive therapy is performed as maintenance therapy after remission induction therapy. However, in cases of moderate to severe atopic dermatitis, topical drugs alone cannot induce remission and systemic therapies such as cyclosporin, ultraviolet therapy, and dupilumab should be used in combination. In particular, dupilumab has many advantages such as high efficacy, relatively few adverse reactions, and ease of use in elderly patients with severe atopic dermatitis. In this review, we present a treatment algorithm for atopic dermatitis that emphasizes the importance of maintaining remission after induction of remission, and summarizes the characteristics of current medication therapy for atopic dermatitis in Japan.

Regulation of Skin Barrier Function via Competition between AHR Axis versus IL-13/IL-4‒JAK‒STAT6/STAT3 Axis: Pathogenic and Therapeutic Implications in Atopic Dermatitis

Atopic dermatitis (AD) is characterized by skin inflammation, barrier dysfunction, and chronic pruritus. As the anti-interleukin-4 (IL-4) receptor α antibody dupilumab improves all three cardinal features of AD, the type 2 cytokines IL-4 and especially IL-13 have been indicated to have pathogenic significance in AD. Accumulating evidence has shown that the skin barrier function is regulated via competition between the aryl hydrocarbon receptor (AHR) axis (up-regulation of barrier) and the IL-13/IL-4‒JAK‒STAT6/STAT3 axis (down-regulation of barrier). This latter axis also induces oxidative stress, which exacerbates inflammation. Conventional and recently developed agents for treating AD such as steroid, calcineurin inhibitors, cyclosporine, dupilumab, and JAK inhibitors inhibit the IL-13/IL-4‒JAK‒STAT6/STAT3 axis, while older remedies such as coal tar and glyteer are antioxidative AHR agonists. In this article, I summarize the pathogenic and therapeutic implications of the IL-13/IL-4‒JAK‒STAT6/STAT3 axis and the AHR axis in AD.

Emerging treatments for atopic dermatitis

Increasing information on the pathophysiology of atopic dermatitis (AD), accumulating data on cellular and molecular pathways in immunological reactions and inflammation, and the expansion of biotechnology and pharmacology have collectively contributed to the development of new pharmacological agents for AD. Novel pharmaceutical agents, including biologics targeting cytokines, which play pathogenetic roles in AD, for example, interleukin (IL)-4, IL-13, IL-31 and IL-22, Janus kinase inhibitors, phosphodiesterase 4 inhibitors and histamine H₄ receptor antagonists, have been approved or are being developed. These agents are expected to be effective in AD patients with skin signs and/or symptoms that are refractory to conventional treatments. The development of novel drugs will accompany the use of predictive biomarkers for each agent in order to optimize treatment in each patient. Convenient tools that support self-decision-making by patients to reflect their preferences, which will increase treatment satisfaction and adherence, are also anticipated.

Individual factors increasing complexity of drug treatment-a narrative review

Purpose

Complexity of drug treatment is known to be a risk factor for administration errors and nonadherence promoting higher healthcare costs, hospital admissions and increased mortality. Number of drugs and dose frequency are parameters often used to assess complexity related to the medication regimen. However, factors resulting from complex processes of care or arising from patient characteristics are only sporadically analyzed. Hence, the objective of this review is to give a comprehensive overview of relevant, patient-centered factors influencing complexity of drug treatment.

Methods

A purposeful literature search was performed in MEDLINE to identify potential complexity factors relating to the prescribed drug (i.e. dosage forms or other product characteristics), the specific medication regimen (i.e. dosage schemes or additional instructions), specific patient characteristics and process characteristics. Factors were included if they were associated to administration errors, nonadherence and related adverse drug events detected in community dwelling adult patients.

Results

Ninety-one influencing factors were identified: fourteen in “dosage forms”, five in “product characteristics”, twelve in “dosage schemes”, nine in “additional instructions”, thirty-one in “patient characteristics” and twenty in “process characteristics”.

Conclusions

Although the findings are limited by the non-systematic search process and the heterogeneous results, the search shows the influence of many factors on the complexity of drug treatment. However, to evaluate their relevance for individual patients, prospective studies are necessary.

Electronic supplementary material

The online version of this article (10.1007/s00228-019-02818-7) contains supplementary material, which is available to authorized users.

Time-Varying Effects of Marital Status on Gastric Cancer: A Population-Based Study

Background

Although prior studies have shown that marital status affects the prognosis of patients with gastric cancer, its time-varying effects are not well understood. We aimed to investigate the changes in marital status’ impact over a 10-year follow-up time among patients with gastric cancer (GC) in the United States.

Materials and Methods

All patients with gastric cancer diagnosed between 2004 and 2008 in the Surveillance, Epidemiology, and End Results (SEER) database were retrieved. Married patients and unmarried patients (single, separated, divorced or widowed) with complete survival time were selected for comparisons. A total of 14,545 patients who had clinical data and follow-up information available were enrolled. We used Kaplan–Meier analyses and time-dependent flexible parametric models to estimate time-varying hazard ratios (HRs).

Results

Unmarried GC patients had worse overall and cancer-specific survival compared with married patients (log-rank test: P < 0.001 and P < 0.001, respectively). The time-varying analysis found that unmarried patients had a significantly higher risk of overall mortality during the 10-year follow-up time, with the lowest adjusted hazard ratio (HR) at 12 months after diagnosis (HR at 12 months, 1.08; 95% CI, 1.03–1.15). For cancer-specific mortality, the time-varying adjusted HR of unmarried patients was significantly higher initially (HR at 12 months, 1.08; 95% CI, 1.02–1.14) but decreased to null after 20 months (HR at 24 months = 1.04; 95% CI = 0.99–1.11).

Conclusion

Unmarried patients had a higher risk of cancer-specific mortality during the 20 months after gastric cancer diagnosis, which may be an appropriate time frame for intervention.

[Clinical Research on the Effects of Differences in Properties of External Preparations for Skin on Application Amount: An Exploratory Investigation of the Relationship between the Base Usability and Application Amount by Questionnaire in Adult Subjects]

Compared to oral medication, the base plays a large role in the external preparation for skin, and dermatologists select the dosage form based on understanding of the effect of the base as well as according to skin symptoms and conditions, application site, age, season, etc. Further, in treatment with external preparations, it is important for patients to understand the application method and continue to apply an adequate amount to achieve the treatment goal. However, there is little evidence regarding the relationship between base properties or usability and the application amount. In this study, we investigated the usability and application amount of three bases with different properties (ointment base, cream base, and lotion base) in 62 adult subjects and exploratively examined the effect of the different base properties on the application amount. The results of this clinical study showed that the usability and preference for the base used for external preparations varies, and poor usability and low preference may lead to a reduction in the application amount. Even with good usability and high preference, there were many cases in which an adequate amount was not applied due to lack of specific instructions on external use. When selecting or changing the base in an external therapy, it is important for not only dermatologists but also pharmacists providing instructions on external use to be aware of the importance of the base and actively instruct patients to apply an adequate amount of the preparation.

Atopic dermatitis disease registry in Japanese adult patients with moderate to severe atopic dermatitis (ADDRESS-J): Baseline characteristics, treatment history and disease burden

Moderate to severe atopic dermatitis (AD) has a high disease burden and a significant effect on quality of life. Observational studies are necessary to determine the patient disease burden and long-term disease control in the Japanese population. ADDRESS-J is a non-interventional, observational registry of adult Japanese patients with moderate to severe AD. Herein, we report baseline data from the ADDRESS-J study describing disease characteristics and current treatment practices. At baseline, 300 adult AD patients with Investigator's Global Assessment (IGA) scores (range, 0-4) of 3 (moderate) or 4 (severe) whose treatments for AD were intensified, were assessed for clinical and patient-reported outcomes and current AD treatments. The registry patients' median age was 34.0 years; 60.7% were male and 71.7% had had AD for more than 20 years. At baseline, 220 study patients had an IGA score of 3 and 80 had an IGA score of 4. The median Eczema Area and Severity Index score was 21.7 (range, 0-72), the median body surface area involvement was 46.25%, and the median pruritus numerical rating scale score was 7.0 (range, 0-10); for each of these measures, higher scores represent greater severity. Most registry patients (86.7%) had recently used topical corticosteroids or topical calcineurin inhibitors as treatment for AD. This registry cohort represents a population of Japanese patients with moderate to severe AD and provides an important resource for characterizing the disease burden and evaluating the safety and effectiveness of various AD treatments.

Treatment Adherence Among Patients with Five Dermatological Diseases and Four Treatment Types - a Cross-Sectional Study

PURPOSE

Treatment non-adherence leads to negative therapeutic outcomes and financial burdens on the healthcare system. This study aims to compare the mean adherence scores among patients with five dermatological diseases and four treatment types and to identify the associated patient-related factors.

PATIENTS AND METHODS

This is a cross-sectional study conducted from January 2019 to August 2019. The questionnaire was distributed among patients attending the outpatient dermatology clinic at King Khalid University Hospital, Riyadh, Saudi Arabia. It included 2330 patients who were over 16 years old and diagnosed with any of the five dermatological diseases (psoriasis, chronic dermatitis, acne vulgaris, hair growth disorders, and vitiligo). The 12-item Medication Adherence Scale was used to quantify the mean adherence score.

RESULTS

Patients with psoriasis or chronic dermatitis were less adherent to treatments than patients with acne vulgaris, hair growth disorder, or vitiligo. Oral treatment and phototherapy had higher mean adherence scores than injection or topical treatment. High adherence was found in female, single patients; those who did not feel stigmatized from using treatment; those who did not have bad experience with the treatment; those who did not suffer from forgetfulness; those who connected receiving treatment with a habit; those who did not lack treatment responsiveness; those who had an excellent relationship with a dermatologist; and patients with a lesion in an exposed area. Stepwise multiple linear regression was also used to identify the independent variables related to adherence score.

CONCLUSION

Psoriasis and chronic dermatitis patients had the lowest mean adherence scores. Patient who were on oral medication had the highest adherence score, while those on topical medication had the lowest score. The thoughtful consideration of factors associated with high adherence is important for optimal therapeutic outcomes.

Strategies for Managing the Costs of Chronic Illness in the Context of Limited Financial Resources: A Qualitative Study in Dominican Persons With Arthritis

OBJECTIVE

Persons who reside in low- and middle-income countries often have insufficient resources to pay for treatments prescribed for their medical conditions. The aim of this study was to determine, using qualitative methods, how patients with arthritis in the Dominican Republic manage the costs associated with chronic illnesses.

METHODS

We conducted individual interviews with 17 Dominican adults with advanced arthritis who were undergoing total knee replacement or total hip replacement at a hospital in Santo Domingo, Dominican Republic. Interviewers followed a moderator's guide with questions pertaining to the financial demands of arthritis treatment and the strategies participants used to pay for treatments. Interviews were audio recorded, transcribed verbatim, and translated into English. We used thematic analysis to identify salient themes.

RESULTS

The thematic analysis suggested that health system factors (such as the extent of reimbursement for medications available in the public health care system) along with personal factors (such as disposable income) shaped individuals' experiences of managing chronic illness. These systemic and personal factors contributed to a sizeable gap between the cost of care and the amount most participants were able to pay. Participants managed this resource gap using a spectrum of strategies ranging from acceptance (or, "making do with less") to resourcefulness (or, "finding more"). Participants were aided by strong community bonds and religiously oriented resilience.

CONCLUSION

This qualitative study illuminates the range of strategies Dominican individuals with limited resources use to obtain health care and manage chronic illness. The findings raise hypotheses that warrant further study and could help guide provider-patient conversations regarding treatment adherence.

Emerging role of interleukin-31 and interleukin-31 receptor in pruritus in atopic dermatitis

Atopic dermatitis (AD) is a chronic or chronically relapsing, eczematous, severely pruritic skin disorder associated with skin barrier dysfunction. The lesional skin of AD exhibits T helper 2 (T_H 2)-deviated immune reactions. Interleukin-31 (IL-31), preferentially produced from T_H 2 cells, is a potent pruritogenic cytokine, and its systemic and local administration induces scratching behavior in rodents, dogs and monkeys. Recent clinical trials have revealed that administration of an anti-IL-31 receptor antibody significantly alleviates pruritus in patients with AD. In this review, we summarize recent topics related to IL-31 and its receptor with special references to atopic itch.

Topical E6005/RVT-501, a novel phosphodiesterase 4 inhibitor, for the treatment of atopic dermatitis

INTRODUCTION

Local adverse effects of steroid use and the burning sensation of calcineurin inhibitors impair patients' adherence to treatment and decrease the treatment response in atopic dermatitis (AD). Steroid phobia appears to be a psychological problem in patients with AD. Topical non-steroidal remedies are in demand. Areas covered: This manuscript reviews the current literature on preclinical and clinical studies regarding topical E6005/RVT-501, a novel phosphodiesterase 4 inhibitor. We also discuss the mechanistic background of E6005/RVT-501 in the treatment of AD. Expert opinion: Topical E6005/RVT-501 improves skin eruption and pruritus of pediatric and adult AD patients without any serious side effects. It is useful for mild to moderate lesions of AD in pediatric and adult patients. Topical E6005/RVT-501 is non-steroidal agent but its potency is equal to that of mild rank topical steroid, therefore, it may fit the demand of patients with steroid phobia. Its steroid-sparing effects may also be investigated in future clinical trials and may minimize the dose and frequency of topical steroids.

Atopic dermatitis: immune deviation, barrier dysfunction, IgE autoreactivity and new therapies

Atopic dermatitis (AD) is a chronic or chronically relapsing, eczematous, severely pruritic skin disorder mostly associated with IgE elevation and skin barrier dysfunction due to decreased filaggrin expression. The lesional skin of AD exhibits Th2- and Th22-deviated immune reactions that are progressive during disease chronicity. Th2 and Th22 cytokines further deteriorate the skin barrier by inhibiting filaggrin expression. Some IgEs are reactive to self-antigens. The IgE autoreactivity may precipitate the chronicity of AD. Upon activation of the ORAI1 calcium channel, atopic epidermis releases large amounts of thymic stromal lymphopoietin (TSLP), which initiates the Th2 and Th22 immune response. Th2-derived interleukin-31 and TSLP induce an itch sensation. Taken together, TSLP/Th2/Th22 pathway is a promising target for developing new therapeutics for AD. Enhancing filaggrin expression using ligands for the aryl hydrocarbon receptor may also be an adjunctive measure to restore the disrupted barrier function specifically for AD.

Poor medication adherence to bisphosphonates and high self-perception of aging in elderly female patients with osteoporosis

Non-adherence to bisphosphonates exposes the elderly female osteoporosis patients to an increased risk of fracture. This was one of the first studies to explore the relationship between medication adherence and self-perception of aging. Feelings of lacking control and expectations for negative events, beliefs of illness's chronic duration nature, and its linkage with aging were associated with of poor medication adherence.

INTRODUCTION

To examine the relationship between medication adherence to bisphosphonates and self-perception of aging in elderly female patients with osteoporosis.

METHODS

This was a cross-sectional survey. A convenience sample of 245 elderly female patients with osteoporosis prescribed regular oral bisphosphonate therapy was recruited from three tertiary hospitals in China. Sociodemographic and osteoporosis-related data, Morisky Medication Adherence Scale-8 (MMAS-8) and Aging Perceptions Questionnaire (APQ) data were collected.

RESULTS

Mean adherence score measured by MMAS-8 was 4.46(SD = 1.91; range, 0.25-7.00). Percentages of good and poor adherence were 28.6 and 71.4 %, which showed a poor medication adherence. Six domains of APQ statistically significantly associated with medication adherence. Interestingly, with control of age, educational status, marital status, and symptoms accompanying osteoporosis as covariates in the multivariate linear regression model, the effects of three domains disappeared. Significantly, worse adherence was observed in those patients who had higher feelings of lack of control, more expectations for negative events, more beliefs of osteoporosis's chronic duration nature and its linkage with aging.

CONCLUSIONS

We conclude that feelings of lacking control, expectations for negative events, beliefs of illness's chronic duration nature, and its linkage with aging were associated with poor medication adherence in elderly female patients with osteoporosis. Concerns about self-perception of aging need to be addressed in order to improve medication adherence.

Assessing Self-reported Medication Adherence in Inflammatory Bowel Disease: A Comparison of Tools

BACKGROUND

Capturing (non)-adherence to medical prescriptions in patients with inflammatory bowel disease (IBD) is challenging. We aimed to compare 3 different tools to measure self-assessed medication adherence of patients with IBD.

METHODS

Adult patients with Crohn's disease and ulcerative colitis were prospectively followed. IBD-specific medication use was collected by 3-monthly questionnaires. At 2.5 years of follow-up, medication adherence was assessed using 3 tools: (1) the 8-item Morisky Medication Adherence Scale (MMAS-8), (2) the single question how well patients take their daily medication using a Visual Analogue Scale (VAS), and (3) the Forget Medicine scale (FM), assessing how often patients forget their medication. Cross-sectional agreement among measures was visualized with scatterplots and quantified with Spearman's rank correlations.

RESULTS

In total, 913 patients with IBD were analyzed, 697 of whom received IBD-specific medication. High adherence on the MMAS-8 was consistent with high scores on the VAS and low scores on the FM. Disagreement between tools increased when patients were less adherent. A correlation of 0.44 was found between the MMAS-8 and VAS; -0.59 between the MMAS-8 and FM, and -0.55 between the VAS and FM (all P < 0.01). The VAS most optimally represented the quantitative variability of adherence, whereas the MMAS-8 and the FM might have resulted in overestimation or underestimation of adherence due to unequal differences in outcome possibilities.

CONCLUSIONS

In patients with IBD, a VAS seems the most appropriate tool for quantifying medication adherence in clinical practice. The MMAS-8 may be used additionally to provide insight in specific reasons for non-adherence.