Can an app supporting psoriasis patients improve adherence to topical treatment? A single-blind randomized controlled trial

Development and real-life use assessment of a self-management smartphone application for patients with inflammatory arthritis. A user-centred step-by-step approach

Background

Mobile health applications (apps) are increasing in interest to enhance patient self-management. Few apps are actually used by patients and have been developed for patients with inflammatory arthritis (IA) treated with disease-modifying anti-rheumatic drugs which use entails risk of adverse effects such as infections.

Objective

To develop Hiboot, a self-management mobile app for patients with IA, by using a user-centred step-by-step approach and assess its real-life use.

Methods

The app development included first a qualitative study with semi-guided audiotaped interviews of 21 patients to identify the impact of IA on daily life and patient treatments practices and an online cross-sectional survey of 344 patients to assess their health apps use in general and potential user needs. A multidisciplinary team developed the first version of the app via five face-to-face meetings. After app launch, a second qualitative study of 21 patients and a users’ test of 13 patients and 3 rheumatologists led to the app’s current version. The number of app installations, current users and comments were collected from the Google Play store and the Apple store.

Results

The qualitative study revealed needs for counselling, patient–health professional partnership, and skills to cope with risk situations; 86.8% participants would be ready to use an app primarily on their rheumatologist’s recommendation. Six functionalities were implemented: a safety checklist before treatment administration, aids in daily life situations based on the French academic recommendations, treatment reminders, global well-being self-assessment, periodic counselling messages, and a diary. The Hiboot app was installed 20,500 times from September 2017 to October 2020, with 4300 regular current users. Scores were 4.4/5 stars at Android and iOS stores.

Conclusion

Hiboot is a free self-management app for patients with IA developed by a step-by-step process including patients and health professionals. Further evaluation of the Hiboot benefit is needed.

Internet-based survey intervention improves adherence to methotrexate among psoriasis patients

BACKGROUND

While it is known that psoriasis patients have poor adherence to both topical and systemic medications, adherence to methotrexate is not well-characterized, and ways to improve methotrexate adherence have not been addressed.

OBJECTIVE

To evaluate whether a digital intervention improved adherence to oral methotrexate as measured by electronic monitoring.

METHODS

Twenty-nine patients were randomized to receive either weekly digital interventions assessing treatment adherence or no intervention for 24 weeks. Patients received medication bottles with electronic monitoring, and returned at weeks 4, 12, and 24 to evaluate disease severity.

RESULTS

The intervention group took methotrexate correctly 77.1% of the weeks observed compared to the control group which averaged 64.5%. More intervention patients took methotrexate as directed compared to the control group (78.3% vs 64.2%, p < 0.0001). Patients were most adherent around follow-up visits, with 100% of digital intervention patients and 80% of control patients taking methotrexate correctly during the week of a follow-up visit (p = 0.02). The digital intervention did not significantly improve disease severity in the intervention group compared to the nonintervention group.

CONCLUSIONS

Low cost, scalable digital interventions may have the potential to increase psoriasis patient adherence to methotrexate, although the mechanism for the improvement is not yet well defined.

Pros and cons of eHealth: A systematic review of the literature and observations in Denmark

Objectives:

The main objectives of this article are to systematically review the recent literature on patient safety in relation to the use of eHealth and to investigate how the Danish authorities supervise private eHealth clinics with regard to patient safety.

Methods:

Original studies reporting the association between patient safety and the use of eHealth as a means of communication between patients and healthcare providers were included. Four literature databases were searched for English-language articles reporting results from cohort studies and clinical trials, published from 2015 until March 2021. Moreover, registered private eHealth clinics in Denmark were evaluated with reference to a recent national audit of patient safety issues in eHealth.

Results:

The literature search retrieved four intervention studies. The studies did not identify any particular patient safety risks associated with the use of eHealth. Many different authorized healthcare providers (preferably, doctors) apply eHealth in various contexts. eHealth is being used as the only form of contact between the healthcare provider and the patient, as a supplement to patient visitations in an outpatient clinic, or as a tool for communicating between two or more healthcare providers. The regulation of eHealth involves patient safety issues but also has interfaces to marketing, IT systems, and infrastructure. Supervision of eHealth includes the organization of clinics, handling patient charts, prescription medicine, patient legal rights, and patient transition. However, there are many interfaces in the division of responsibilities among the various governmental players.

Conclusion:

eHealth is being used increasingly and in many settings, although recently published intervention studies investigating patient safety issues by the use of eHealth are limited. A structured and continuous governmental control and regulation of patient safety in relation to the use of eHealth is warranted.

Use of Mobile Applications in Dermatology

Smartphones and applications related to the same are ubiquitous now. As dermatologists, we have a wide array of smartphone apps at our disposal which we can use to improve our practice in all aspects—clinical, academic, research, and administrative. This article provides an overview of available apps, tips on using apps—both general and specific for dermatology, as well as discusses the scientific validity of some of these apps and the future of smartphone apps in the context of dermatology.

Safety of calcipotriene and betamethasone dipropionate foam for the treatment of psoriasis

Introduction: Psoriasis vulgaris is a chronic inflammatory skin disease characterized by well-demarcated red and scaly plaques. Most patients have mild disease that is usually controlled with topical treatment. Calcipotriene 0.05% and betamethasone dipropionate 0.064% (Cal/BD) in aerosol foam (Enstilar®) is a novel formulation, which has shown promising results in terms of efficacy and safety.Areas covered: This review evaluates the safety profile of Cal/BD aerosol foam and also the key points regarding its efficacy. A literature search was performed in PubMed in November 2019 from the start of records. Additional references were searched and retrieved manually.Expert opnion: Cal/BD aerosol foam has proven its efficacy, safety, and tolerability in several clinical trials and real clinical practice. It has also demonstrated higher efficacy than the ointment and gel formulations of the fixed combination. It has a low incidence of adverse events; nasopharyngitis and site application pain were the most frequently reported. Moreover, it is devoid of changes in calcium homeostasis and hypothalamic-pituitary-adrenal axis. As a result of its unique formulation, it is easily spread, is rapidly absorbed, and has a rapid onset of action. These features upgrade patient's satisfaction and they may increase adherence to topical therapy.

A systematic review of factors influencing treatment adherence in chronic inflammatory skin disease - strategies for optimizing treatment outcome

Adherence describes how a patient follows a medical regime recommended by a healthcare provider. Poor treatment adherence represents a complex and challenging problem of international healthcare systems, as it has a substantial impact on clinical outcomes and patient safety and constitutes an important financial burden. Since it is one of the most common causes of treatment failure, it is extremely important for physicians to reliably distinguish between non-adherence and non-response. This systematic review aims to summarize the current literature on treatment adherence in dermatology, focusing on chronic inflammatory skin diseases such as psoriasis, atopic dermatitis and acne. A systematic literature search was performed using the PubMed Database, including articles from 2008 to 2018. Low treatment adherence is a multidimensional phenomenon defined by the interplay of numerous factors and should under no circumstances be considered as the patient's fault alone. Factors influencing treatment adherence in dermatology include patient characteristics and beliefs, treatment efficacy and duration, administration routes, disease chronicity and the disease itself. Moreover, the quality of the physician-patient relationship including physician-time available for the patient plays an important role. Understanding patients' adherence patterns and the main drivers of non-adherence creates opportunities to improve adherence in the future. Strategies to increase treatment adherence range from reminder programs to simplifying prescriptions or educational interventions. Absolute adherence to treatment may not be realistically achievable, but efforts need to be made to raise awareness in order to maximize adherence as far as possible.

EULAR points to consider for the development, evaluation and implementation of mobile health applications aiding self-management in people living with rheumatic and musculoskeletal diseases

Background

Mobile health applications (apps) are available to enable people with rheumatic and musculoskeletal diseases (RMDs) to better self-manage their health. However, guidance on the development and evaluation of such apps is lacking.

Objectives

The objective of this EULAR task force was to establish points to consider (PtC) for the development, evaluation and implementation of apps for self-management of RMDs.

Methods

A systematic literature review of app content and development strategies was conducted, followed by patient focus group and an online survey. Based on this information and along with task force expert opinion, PtC were formulated in a face-to-face meeting by a multidisciplinary task force panel of experts, including two patient research partners. The level of agreement among the panel in regard to each PtC was established by anonymous online voting.

Results

Three overarching principles and 10 PtC were formulated. Three PtC are related to patient safety, considered as a critical issue by the panel. Three are related to relevance of the content and functionalities. The requirement for transparency around app development and funding sources, along with involvement of relevant health professionals, were also raised. Ease of app access across ages and abilities was highlighted, in addition to considering the cost benefit of apps from the outset. The level of agreement was from 8.8 to 9.9 out of 10.

Conclusion

These EULAR PtC provide guidance on important aspects that should be considered for the development, evaluation and implementation of existing and new apps.

Pharmacokinetics of tazarotene and acitretin in psoriasis

INTRODUCTION

Psoriasis is a prevalent cutaneous condition with severe physical and psychological manifestations. Since the advent of biologics, clinical outcomes in psoriasis have improved. However, retinoids are useful in the correct clinical context. Tazarotene and acitretin are currently the only US Food and Drug Administration approved retinoids for treatment of psoriasis. Both topical tazarotene and oral acitretin act on retinoic acid receptors and retinoid-X-receptors, resulting in altered gene expression of inflammatory cytokines and inhibition of keratinocyte proliferation. Areas covered: This article provides an in-depth pharmacologic and clinical review on the use of tazarotene and acitretin in psoriasis. The PubMed database was searched using combinations of keywords: acitretin, bioavailability, dosing, efficacy, etretinate, interactions, mechanism, pharmacodynamics, pharmacokinetics, pharmacogenetics, psoriasis, safety, tazarotene, tolerability, and toxicity. Expert opinion: Tazarotene and acitretin are effective treatments for psoriasis. Benefits include lack of immunosuppression and success treating inflammatory psoriasis. When combined with other topical and systemic agents, both retinoids improve clinical efficacy while lowering the treatment threshold. However, topical adherence and bothersome side effects can limit retinoid use. Acitretin and tazarotene both improve outcomes through a unique mechanism that especially benefits subsets of patients, despite side effects and limitations.

A smartphone application supporting patients with psoriasis improves adherence to topical treatment: a randomized controlled trial

BACKGROUND

Adherence to topical psoriasis treatments is low, which leads to unsatisfactory treatment results. Smartphone applications (apps) for patient support exist but their potential to improve adherence has not been systematically evaluated.

OBJECTIVES

To evaluate whether a study-specific app improves adherence and reduces psoriasis symptoms compared with standard treatment.

METHODS

We conducted a randomized controlled trial (RCT, clinicaltrials.gov registration: NCT02858713). Patients received once-daily medication [calcipotriol/betamethasone dipropionate (Cal/BD) cutaneous foam] and were randomized to no app (n = 66) or app intervention (n = 68) groups. In total, 122 patients (91%) completed the 22-week follow-up. The primary outcome was adherence, which was defined as medication applied ≥ 80% of days during the treatment period and assessed by a chip integrated into the medication dispenser. Secondary outcomes were psoriasis severity measured by the Lattice System Physician's Global Assessment (LS-PGA) and quality of life, measured using the Dermatology Life Quality Index (DLQI) at all visits.

RESULTS

Intention-to-treat analyses using regression was performed. More patients in the intervention group were adherent to Cal/BD cutaneous foam than those in the nonintervention group at week 4 (65% vs. 38%, P = 0·004). The intervention group showed a greater LS-PGA reduction than the nonintervention group at week 4 (mean 1·86 vs. 1·46, P = 0·047). A similar effect was seen at weeks 8 and 26, although it did not reach statistical significance.

CONCLUSIONS

This RCT demonstrates that the app improved short-term adherence to Cal/BD cutaneous foam treatment and psoriasis severity.