Pharmionics in dermatology: a review of topical medication adherence

Factors Influencing Adherence to Phototherapy in Patients With Psoriasis: A Cross-Sectional Study

AIMS

Assess the level of adherence to phototherapy and determine what factors influence it.

DESIGN

Cross-sectional.

METHODS

This study included a convenience sampling of 72 patients with psoriasis undergoing phototherapy. Data were collected through a self-reported questionnaire with sociodemographic variables, the Goldberg Anxiety and Depression Scale, the Short Form Health Survey and the Dermatology Life Quality Index. Adherence to the treatment and its ending was measured through a session record.

RESULTS

A small percentage of the participants demonstrated adequate adherence, and nearly half of them had low adherence. The factors statistically significant and with a negative impact on adherence were as follows: having a partner, experiencing anxiety or depression or using public transportation to get to the hospital. The probability of not adhering to the treatment increased when: patients found it difficult to attend therapy; perceiving their mental and physical health as being worse; experiencing anxiety or depression; having a diagnosed mental illness; being a man; or having had the sickness for an extended period of time.

CONCLUSION

This study determined the level of adherence to phototherapy and advanced our understanding of this variable. Women exhibited higher levels of adherence compared to men, although they reported worse perceived mental and physical health, and the disease had a higher impact on their life.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

Informing phototherapy nurses on the factors that impact treatment adherence may help to increase the treatment compliance, which may improve psoriasis patients' clinical symptoms.

IMPACT

Increase the body of knowledge about the treatment that phototherapy nurses administer.

REPORTING METHOD

STORBE guidelines.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

How can physicians improve medication adherence and outcomes in dermatological conditions?

INTRODUCTION

Medication non-adherence is a major contributor to suboptimal disease treatment across medical specialties and is a particular hurdle with topicals. While adherence is a patient behavior affected by many socioeconomic and health system factors, physicians can play an important role in encouraging good adherence.

AREAS COVERED

We discuss methods for measuring adherence, including ethics of such research, provide select examples of dermatology-specific adherence studies, and conclude with physician-focused practices to improve patients' adherence. Articles were selected from a PubMed search spanning 2003 to 10 December 2023, using the following terms: 'dermatology,' 'medication,' 'treatment,' 'adherence,' 'compliance,' and 'intervention.'

EXPERT OPINION

Poor adherence to treatment is a major cause of poor treatment outcomes. As the goal of medical care is to achieve successful treatment outcomes, encouraging good adherence may be as much a foundation of care as making the right diagnosis and prescribing the right treatment. Taking a doctor-centric perspective on reasons for non-adherence may be more productive than simply finding fault with the patient. Establishing trust and accountability is a foundation for good adherence; after establishing the provider-patient relationship, physicians can improve adherence by incorporating behavioral and counseling strategies, communicating through technology, and advocating for distribution of validated educational information.

Current Insights on Treatment Adherence in Prevalent Dermatological Conditions and Strategies To Optimize Adherence Rates

Adherence to prescribed medication regimens is crucial for treatment efficacy and patient safety, but it remains a challenge in the medical field, particularly in dermatology, where adherence to prescribed treatments is being intensively evaluated and improved. This narrative review provides a comprehensive overview of adherence behaviors in dermatological diseases, including fungal skin infections, psoriasis, acne, atopic dermatitis, and chronic urticaria, aiming to update scientific information on adherence patterns and management strategies in these highly prevalent conditions. Furthermore, the importance of a holistic approach that integrates patient-centered and physician-centered strategies to optimize treatment outcomes and enhance adherence in dermatological care is highlighted. The role of technological advancements in promoting adherence is also discussed, with an emphasis on the potential for digital solutions to facilitate medication management. Future perspectives underscore the need for targeted interventions to address the multifaceted barriers to adherence, including treatment complexity, healthcare accessibility, and patient-provider communication. By addressing these challenges, healthcare providers can enhance patient satisfaction, improve therapeutic outcomes, and mitigate the adverse consequences of non-adherence in dermatological practice.

Adherence to Psoriasis Therapies

Understanding the underlying causes of nonadherence among patients with psoriasis and adopting strategies to address these issues may allow providers to share responsibility and work alongside patients to overcome these barriers. The review explores patient adherence to different types of psoriasis treatment, suggestions for interventions to overcome barriers, and methods to promote adherence that have been published in the literature.

Relationship between sensorial and physical characteristics of topical creams: A comparative study on effects of excipients

Rising consumer demands for safer, more natural, and sustainable topical products have led to increased interest in finding alternative excipients, while retaining functionality and cosmetic appeal. Particle-stabilized Pickering creams have emerged as possible alternatives to replace traditional surfactant-stabilized creams and are thus one of the focuses in this study. The aim of this paper was to study relationships between sensorial characteristics and physical properties to understand how different excipients affect these aspects, comparing one starch particle-stabilized and three surfactant-stabilized formulations. A human panel was used to evaluate sensorial perception, while physical properties were deduced by rheology and tactile friction, together with in vivo and ex vivo skin hydration measurements. The results show that sensorial attributes related to the application phase can be predicted with rheology, while afterfeel attributes can be predicted with tactile friction studies. Differences in rheological and sensory properties among surfactant-based creams could mainly be attributed to the type of emollients used, presence of thickeners and surfactant composition. Differences between surfactant-based creams and a Pickering cream were more evident in relation to the afterfeel perception. Presence of starch particles in the residual film on skin results in high tactile friction and low perception of residual coating, stickiness, greasiness, and slipperiness in sensorial afterfeel.

Treatment adherence with diclofenac 3% gel among patients with multiple actinic keratoses: an integrated low-intensity intervention program versus standard-of-care

BACKGROUND

Diclofenac 3% gel is a widely used topical treatment with proven efficacy in reducing the burden of Actinic Keratosis (AK), however clinical benefit might not fully translate in clinical practice as non-adherence is substantial for prolonged treatment regimens. We evaluated the efficacy of an integrated low-intensity intervention program versus standard-of-care on treatment adherence among patients with multiple AK receiving diclofenac in hyaluronic acid gel 3%.

METHODS

We designed an open label, randomized, parallel group, interventional, multicenter, longitudinal cohort study including patients with multiple, grade I/II AKs. Visits were scheduled for end of treatment (T4), follow-up 1 (T5) and follow-up 2 (T6) at 90, 180 and 365 days from baseline, respectively. Patients in the intervention group received additional visits at 30 and 60 days from baseline, a brief health education intervention, an enhanced patient-physician communication, a weekly SMS reminder to medication prescriptions.

RESULTS

Patients were equally allocated between intervention (intervention group [IG], N=86) and control group (CG, N=86); at baseline, both groups had similar socio-demographic and clinical characteristics. Change scores from baseline showed a slight increment in quality of life related to AK in both groups (CG: ΔT4 - T1=-0.079; IG: ΔT4 - T1=-0.006; p=0.39) and in quality of physicianpatient interaction reported by IG (ΔT3 - T2=0.18; p<.0001). Adherence rate was not statistically different between IG and CG (28.4% vs 40.7%; p=0.11). Patients reported similar satisfaction for effectiveness, convenience and side effects of treatment. Clinical conditions improved over time and results did not differ between groups; complete clearance rate at 1 year was 18% and 29% for CG and IG, respectively.

CONCLUSIONS

Our findings showed no difference in adherence rate between the two groups, suggesting that enhanced follow-up interventions and health care education may not be sufficient drivers to promote adherence among this clinical population. Further studies are needed to explore barriers to adherence with treatments for AKs.

Topical chemotherapy for penile carcinoma in situ: Contemporary outcomes and reported toxicity

PURPOSE

The toxicity of topical chemotherapeutics has been well-characterized in extra-genital squamous cell carcinoma; however, there is limited data regarding the use of topical agents for penile squamous cell carcinoma in situ (CIS). We aim to describe the clinical outcomes and toxicities associated with the use of topical fluorouracil and imiquimod for penile CIS.

MATERIALS AND METHODS

We performed an observational analysis of penile CIS cases treated with topical chemotherapy from 2009 to 2019 at a tertiary cancer center.

RESULTS

Twenty patients with penile CIS received fluorouracil (n= 17, 85%) or imiquimod (n = 3, 15%). The median age was 66 years. The median follow-up was 18 months. Complete response (CR) was achieved in 65% (n= 13/20), partial response in 25% (n = 5/20), and no response in 10% (n = 2/20). Overall, 50% required additional alternative treatments due to lack of CR or relapse. The median recurrence-free survival was 14 months. Fifty percent of patients reported Common Terminology Criteria for Adverse Events v5.0 grade 1 to 2 acute toxicities, including local skin irritation (40%), pain (35%), dysuria (5%), or nausea (5%). Only 65% completed the full course of treatment. Nonadherence was associated with a diminished CR rate of 28.6%.

CONCLUSIONS

Topical chemotherapy is a reasonable first-line therapy for penile CIS. A substantial proportion of patients experience acute toxicity and are unable to complete the full course of therapy. We recommend that patients with penile CIS be monitored regularly in order to promptly address issues with adherence and toxicity associated with topical treatment.

Effectiveness of a pharmaceutical instruction video for adherence to dermatopathy treatment in patients with cancer receiving the anti-epidermal growth factor receptor antibody

Background

Dermatopathy develops as a side effect in patients receiving anti-epidermal growth factor receptor antibody treatment. Topical moisturizers are used for the prevention and treatment of this dermatopathy. Active participation of patients in their own treatment is important for the appropriate application of topical preparations. We prepared a pharmaceutical instructional video for adhering to the topical application protocol. In this study, we investigated the effectiveness of this pharmaceutical instructional video on treatment adherence.

Methods

Study participants were patients with cancer receiving the anti-epidermal growth factor receptor antibody for the first time. A pharmacist instructed the patients on how to use the pharmaceutical instruction video. Daily topical preparation use following the video demonstration was assessed. The effectiveness of the pharmaceutical instruction video was evaluated by assessing the adherence of patients who did not use the pharmaceutical instruction video for the past 2 periods (26 months; controls 1 and 2). The incidence of side effects was compared between the two control groups and the group of patients who received the pharmaceutical instruction video.

Results

The amount of topical preparation consumed (median, g/day) by patients who received patient compliance instructions using the pharmaceutical instruction video was 9.8 g/day, as compared with control group 1 (4.5 g/day) and control group 2 (5.5 g/day) ( p <  0.001). There was no difference in the incidence of side effects during the three periods.

Conclusion

The use of visual instructional media for patient compliance by pharmacists may be effective in maintaining and improving treatment adherence.

Application errors associated with topical treatment of scabies: an observational study

BACKGROUND

In recent years, there has been a significant increase in scabies infestations throughout German-speaking countries. Given the high frequency of treatment failures, the question arises as to whether topical permethrin treatment is always performed correctly.

PATIENTS AND METHODS

Our department uses a fluorescent test cream to teach patients on how to correctly apply topical permethrin. In the context of a prospective observational study of 21 patients, we systematically assessed and analyzed potential application errors.

RESULTS

None of the participants succeeded in adequately applying the cream to the entire skin as previously instructed. The median number of regions left untreated was six (minimum: 2; maximum: 18), which included a median body surface area of 6 % (minimum: 2 %; maximum: 30 %). With regard to predilection sites of scabies, the ankles were left untreated in 62 % of cases, followed by the interdigital spaces (toes) (33 %) and the sacral region (24 %). All patients considered the pretreatment training to be very useful.

CONCLUSIONS

The present findings clearly demonstrate potential shortcomings when it comes to the application of topical antiscabies treatment. This may provide a (potentially underestimated) explanation for the large number of reports on treatment failures in this regard, which falsely suggest potential treatment resistance.

Mobile e-diary application facilitates the monitoring of patient-reported outcomes and a high treatment adherence for clinical trials in dermatology

BACKGROUND

Assessment of treatment effects in clinical trials requires valid information on treatment adherence, adverse events and symptoms. Paper-based diaries are often inconvenient and have limited reliability, particularly for outpatient trials.

OBJECTIVES

To investigate the utility of an electronic diary (e-diary) application for patients with skin diseases in outpatient clinical trials.

METHODS

An e-diary application was developed and technically validated. Treatment adherence was defined as topical administration by the patient, and patient-reported outcomes, i.e. pain and itch, were evaluated by the e-diary in six clinical trials on newly tested topical drugs. Additionally, the proportion of patients capturing the applied topical drug by camera and filling in the pain and itch scores was defined as e-diary adherence, and patients' perception of usefulness and acceptability of the e-diary were evaluated.

RESULTS

Treatment adherence rates of the included 256 patients were high (median 98%, range 97-99%). E-diary adherence was also high with a median of 93% (range 87-97%) for capturing the applied drug by camera, and 89% (range 87-96%) and 94% (range 87-96%) for entering respectively the itch and pain score. Daily symptom scores provided good insights into the disease burden, and patients rated the e-diary as good to excellent with respect to user acceptability.

CONCLUSIONS

The results suggest that the e-diary is an excellent way to ensure proper treatment administration, indicated by both the high user acceptability scores and high treatment adherence. Moreover, the e-diary may also be valuable for frequent and reliable monitoring of patient-reported outcomes in daily clinical practice.

Adherence to a topical moisturizing preparation for regorafenib-related hand-foot skin reaction

OBJECTIVE

Application of topical moisturizing preparations is important for the prevention and palliation of hand-foot skin reaction induced by multi-kinase inhibitor. Application adherence of topical moisturizing preparations in clinical practice has rarely been reported. This study investigated the factors affecting adherence to the application of topical moisturizing preparations in patients administered regorafenib.

METHODS

The subjects were patients administered regorafenib (n = 118). Consumption of a urea-based moisturizing ointment, hand-foot skin reaction grade (CTC-AE ver 3.0), treatment duration, and dose of regorafenib, factors that might affect the onset of symptoms and adherence, including age, sex, presence of a key person, working status, performance status, past use of capecitabine or epidermal growth factor receptor antibodies, and relative dose intensity were retrospectively investigated. The adherence to the topical moisturizing ointment (<21 g per week) was judged as poor. The data were analyzed by logistic regression analysis.

RESULTS

Working status was associated with poor adherence, showing a positive correlation (odds ratio; 3.024, p = 0.023). In contrast, symptom grade of hand-foot skin reaction and regorafenib relative dose intensity showed negative correlation with poor adherence (odds ratio; 0.971, p = 0.012, and 0.485, p < 0.001, respectively).

CONCLUSIONS

The results suggest that adherence decreases in patients with working. The relative dose intensity of regorafenib decreased when adherence to topical moisturizing ointments decreased. Severe hand-foot skin reaction could be associated with adherence. Patients consciously might not apply the ointment when hand-foot skin reaction did not become severe. It will be problematic for medical personnel to motivate patients for improving adherence to the use of moisturizing ointments.

Adherence to Dihydroartemisinin-Piperaquine Treatment among Patients with Uncomplicated Malaria in Northern Ghana

Treatment adherence has been described as the process whereby patients take medications, follow diet, and effect other lifestyle changes that relate to agreed recommendations from healthcare providers. The determinants of such treatment adherence include patient, the health condition, therapy type, socioeconomic conditions, and the healthcare system. The study examined adherence in malaria patients treated with dihydroartemisinin-piperaquine in routine clinical care in northern Ghana. The study was conducted in Navrongo Health Research Centre in the Kassena-Nankana district of northern Ghana. Patients confirmed with uncomplicated malaria were prescribed dihydroartemisinin-piperaquine in blister packs to be taken daily for three days. Follow-up visits were made on days 3 and 28 after diagnosis to collect data on adherence, drug safety and therapeutic effectiveness. During follow-up visits, in-depth interviews were conducted and the blister packs directly observed for the number of tablets remaining. The in-depth interviews documented day-by-day account of doses taken, number of tablets taken during each dose, time of each dose, reasons for any leftover or missed dose, and whether or not there was vomiting. Treatment adherence was classified as definitely nonadherent, incomplete adherence, and completely adherent. A total of 405 patients were screened; 299 were positive by rapid diagnostic testing and 216 by microscopy. The average age was 12 years and females represented 54.0%. All participants completed day 3 follow-up but 12.7% had leftover pills. Treatment adherence was 50.9% (95% CI 44.1, 57.8), 36.1% (95% CI 29.7, 42.9), and 13.0% (95% CI 8.8, 18.2) for completely adherent, incomplete adherence, and definitely nonadherent, respectively. All completely adherent patients were free of parasitemia on day 28 of follow-up. A total of 49 adverse events related to malaria symptoms were documented. Effort to improve adherence should be individualized as it is dependent on a number of factors such as the patients' temperament, the disease, support at home, and complexity of treatment.

Quality of Life, Behaviour and Attitudes towards Actinic Keratosis in Spain: The PIQA Study

OBJECTIVE

This study was aimed to examine patients' knowledge, behaviours and attitudes regarding actinic keratosis (AK) lesions and the impact of the disease on patients' quality of life (QoL).

METHODS

Observational study of patients with AK lesions in Spain. QoL was evaluated with the validated version of Spanish AKQoL questionnaire. Skin self-examination, sun-exposure, habits and attitudes towards AK's treatment were recorded using different questionnaires. The adherence was assessed by means of the Morisky-Green test. Among other variables, QoL and adherence to treatment were compared by using Pearson's χ² test and one-way ANOVA tests. Inferential analysis regarding such factors and length of treatment were also performed.

RESULTS

A total of 1240 patients (73.6 [10.5] years old) were recruited. Overall, patients that showed higher levels of concern were also showed a higher impairment on QoL. AK had greater effects on women's QoL and those who performed skin self-examination, think that AK is a disease and/or believe that moisturizers can prevent skin aging (P<.05). Adherence and length of treatment were strongly related, since patients with treatments intended for <1week were more likely to show good adherence and complete remission of AK (Odds Ratio [95%CI]: 6.25 [4.55-8.33] and 2.63 [1.96-3.45]), respectively).

CONCLUSIONS

Concerns due to AK are mainly related to sex and to the consideration of AK as a disease. More concerned patients tend to have lower QoL and good adherence to treatment. Short length of treatment was associated with better adherence and complete remission of AK lesions.

Prescription-level factors associated with primary nonadherence to dermatologic medications

PURPOSE

To analyze factors associated with primary nonadherence to dermatologic medications and study whether prescription-level factors are associated with primary nonadherence.

MATERIALS AND METHODS

A retrospective review of medical records of new dermatology patients from January 2011 to December 2013 at a single urban safety-net hospital outpatient dermatology clinic with a closed pharmacy system.

RESULTS

A total of 4307 prescriptions were written for 2490 patients. The overall primary nonadherence rate was 24.7%. The most prescribed medication classes in order of frequency were topical corticosteroids, topical antibiotics, topical retinoids, oral antibiotics, and topical antifungals. After multivariable adjustment for patient, provider, and prescription characteristics, when compared to topical corticosteroids, topical antibiotics, oral antifungals, and oral antivirals were less likely to be filled (RR 0.9 [95% CI, 0.84-0.95]), (RR 0.69 [95% CI, 0.59-0.81]), and (RR 0.65 [95% CI, 0.46-0.93]), respectively. Conversely, topical vitamin D analogs, oral immunomodulators, and oral retinoids were more likely to be filled (RR 1.15 [95% CI, 1.02-1.28]), (RR 1.11 [95% CI, 1.04-1.19]), and (RR 1.15 [95% CI, 1.04-1.27]), respectively.

CONCLUSIONS

Medication class or administration route may be associated with increased risk of nonadherence, and identifying these factors is important in considering ways to reduce primary nonadherence rates in dermatology.

Using Visual Aids to Enhance Physician-Patient Discussions and Increase Health Literacy

Health literacy refers to the comprehension required to make well-informed decisions regarding one's health. It is a critical component in helping patients to understand how to take their medications appropriately. However, many patients do not possess the comprehension necessary for medication adherence. The result of poor literacy is a higher incidence of misunderstanding medication instructions. Visual aids have the ability to transcend language and numeracy barriers and can therefore improve the effectiveness of communication and broaden target audiences. To enhance communication that is language independent, a template was created to provide instructions for proper use and explanation of risks for adverse events. This template is designed to fit on a single double-sided page. This template can be adapted for use in explaining any medication using universal pictograms available from online resources. This would enable any practitioner to design information sheets for their unique use.

Increasing Adherence with Topical Agents for Atopic Dermatitis

Atopic dermatitis (AD) is an intensely pruritic dermatosis that develops most commonly during early infancy and childhood and may follow a chronic, relapsing course into adulthood. As a chronic disease, AD requires treatment over an extended period of time, and is therefore difficult to treat. The main difficulty stems from poor adherence to treatment by patients for reasons such as frustration with medication efficacy, inconvenience, and fear of side effects. Methods that improve adherence include creating therapeutic plans with patient preferences in mind, early follow-up visit, increasing patient education through workshops, and discussing with patients and their caretakers their fears about treatment methods. AD can be exceedingly detrimental to a patient's quality of life. Simple measures to improve adherence may improve patients' treatment outcomes and quality of life.

Treatment Adherence Intervention Studies in Dermatology and Guidance on How to Support Adherence

Adequate adherence to prescribed treatment regimens can help to break the cycle of treatment failure, disease progression and subsequent treatment escalation. Unfortunately, adherence in the treatment of skin disorders such as acne, atopic dermatitis/eczema and psoriasis is often inadequate. A review of the literature identified a number of studies that tested an intervention to improve adherence in dermatology, including the following: electronic messages and/or reminders; more frequent or 'extra' clinic visits; audio-visual and internet-based interventions; and patient support programmes and/or self-management, educational training programmes. While there is no one solution or action for improving adherence, some interventions were more successful than others. We provide practical guidance on how to support adherence based on aspects of the successful interventions identified and on our collective opinion and clinical practice experience. Holding patients accountable, providing a caring and supportive environment, raising awareness of poor adherence and helping patients build a solid medication-taking habit can help to improve adherence so that patients can experience maximal treatment benefits and desired clinical outcomes.

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.

Efficacy of adapalene/benzoyl peroxide combination in moderate inflammatory acne and its impact on patient adherence

BACKGROUND AND OBJECTIVES

Adapalene 0.1 %/benzoyl peroxide (BPO) 2.5 % (Epiduo®) is the first, fixed-dose topical combination gel developed for the once-daily treatment of acne. The objective of this observational study was to assess efficacy and patient adherence under daily clinical practice conditions in a large population of young adults and adolescents (12 to 20 years) with moderate inflammatory acne.

PATIENTS AND METHODS

A total of 2 780 patients receiving adapalene-BPO were evaluated in this multicenter, open-label, prospective non-interventional observational study. Observation time per patient was approximately 12 weeks. Assessment parameters included changes in acne severity, treatment success, safety, and therapeutic adherence.

RESULTS

After 12 weeks, the majority of patients (91.5 %) showed improvement of acne under adapalene-BPO treatment, with an initial therapeutic response noted after a median time of 14 days. Overall, 21.8 % of participants displayed complete resolution of visible acne lesions. Treatment adherence was assessed as good in 63.2 % of patients. The majority of individuals (69.5 %) experienced no or only mild local skin irritations. No serious adverse drug reactions (ADR) were reported during the course of the study.

CONCLUSIONS

Adapalene-BPO is effective and safe in the treatment of moderate inflammatory acne. The fixed-dose combination and easy application simplifies the therapeutic regimen, leading to good treatment adherence in the majority of patients.

Non-adherence and measures to improve adherence in the topical treatment of psoriasis

Psoriasis is a chronic, recurrent immune-mediated skin disease with a 2-3% prevalence in the Western population, which severely affects patients' quality of life and poses a considerable socioeconomic challenge. The majority of individuals have psoriasis in limited areas and topical products are the mainstay of therapy according to existing guidelines. It is known that medication adherence rates are lower for topical treatment than for systemic treatment. Poor medication adherence is a major multidimensional problem for patients with chronic disorders as it is associated with unfavourable treatment outcomes, increased risk for development of concomitant diseases and inefficient use of health resources. Despite four decades of adherence research and the large number of studies that have identified the importance of medication non-adherence, there are relatively few studies reporting and designing effective strategies to improve adherence. The aim of this article was to report and describe non-adherence in the topical treatment of psoriasis, the factors that might contribute to this phenomenon, and which interventions have so far been developed for the management of chronic conditions. This article proposes that given that the barriers to medication adherence are complex and varied, solutions to improve adherence and thus clinical outcomes must be multifaceted and must also provide the possibility to be tailored according to each patient's individual needs. Such an individualized and comprehensive adherence-enhancing intervention would probably enable the successful long-term management of this disabling chronic condition.

A Consensus on Acne Management Focused on Specific Patient Features

Background:

Most treatment guidelines for acne are based on clinical severity. Our objective was to expand that approach to one that also comprised individualized patient features: a case-based approach.

Methods:

An expert panel of Canadian dermatologists was established to develop demographic and clinical features considered to be particularly important in acne treatment selection. A nominal group consensus process was used for inclusion of features and corresponding appropriate treatments.

Results:

Consensus was achieved on the following statements: follicular epithelial dysfunction contributes to acne pathogenesis; inflammation from underlying disease(s) or prior treatment may impact further patient management; management focusing on specific patient features and on addressing psychosocial factors, including impact on quality of life, may improve treatment adherence and outcomes; and case-based scenarios are a practical approach to illustrate the effect of these factors. To address the latter, eight case profiles were developed.

Conclusions:

Management of acne should be based on multifactorial considerations beyond clinically determined acne severity and should include patient-reported impact, gender, skin sensitivity (including preexisting dermatoses), and phototype.

Development of an adherence-enhancing intervention in topical treatment termed the topical treatment optimization program (TTOP)

Psoriasis is a common, disabling, chronic, relapsing, inflammatory disorder of the skin with a worldwide prevalence of 2-3 % in which adherence to treatment is often poor. The majority of individuals have limited disease that is being treated with topical medication according to existing guidelines. Adherence rates are lower for topical compared with systemic treatment. Low medication adherence is a major problem for patients with chronic disorders as it results in suboptimal treatment outcomes, increased risk for development of concomitant diseases, inefficient use of health resources and considerable losses to society. However, to date no adherence-enhancing intervention has been developed for psoriasis patients under topical treatment. In this article, we report the development of the topical treatment optimization program (TTOP). The TTOP intervention aims to improve the information given to the patients and to result in an engaged patient-physician relationship. Application of the TTOP intervention in daily clinical practice may lead to a significant increase of adherence and the successful management of psoriasis and other chronic skin disorders.

Carrier-based drug delivery system for treatment of acne

Approximately 95% of the population suffers at some point in their lifetime from acne vulgaris. Acne is a multifactorial disease of the pilosebaceous unit. This inflammatory skin disorder is most common in adolescents but also affects neonates, prepubescent children, and adults. Topical conventional systems are associated with various side effects. Novel drug delivery systems have been used to reduce the side effect of drugs commonly used in the topical treatment of acne. Topical treatment of acne with active pharmaceutical ingredients (API) makes direct contact with the target site before entering the systemic circulation which reduces the systemic side effect of the parenteral or oral administration of drug. The objective of the present review is to discuss the conventional delivery systems available for acne, their drawbacks, and limitations. The advantages, disadvantages, and outcome of using various carrier-based delivery systems like liposomes, niosomes, solid lipid nanoparticles, and so forth, are explained. This paper emphasizes approaches to overcome the drawbacks and limitations associated with the conventional system and the advances and application that are poised to further enhance the efficacy of topical acne formulations, offering the possibility of simplified dosing regimen that may improve treatment outcomes using novel delivery system.

Topical treatments for chronic plaque psoriasis

BACKGROUND

Chronic plaque psoriasis is the most common type of psoriasis, and it is characterised by redness, thickness, and scaling. First-line management of chronic plaque psoriasis is with topical treatments, including vitamin D analogues, topical corticosteroids, tar-based preparations, dithranol, salicylic acid, and topical retinoids.

OBJECTIVES

To compare the effectiveness, tolerability, and safety of topical treatments for chronic plaque psoriasis, relative to placebo, and to similarly compare vitamin D analogues (used alone or in combination) with other topical treatments.

SEARCH METHODS

We updated our searches of the following databases to February 2011: the Cochrane Skin Group Specialised Register, CENTRAL in The Cochrane Library (2011, Issue 2), MEDLINE (from 1948), EMBASE (from 1980), Science Citation Index (from 2008), Conference Proceedings Citation Index - Science (from 2008), BIOSIS (from 1993), Dissertation Abstracts via DialogClassic (all publication years), and Inside Conferences (all publication years).We identified ongoing and unpublished studies from the UK Clinical Research Network Study Portfolio and the metaRegister of Controlled Trials. We checked the bibliographies of published studies and reviews for further references to relevant trials, and we contacted trialists and companies for information about newly published studies.A separate search for adverse effects was undertaken in February 2011 using MEDLINE and EMBASE (from 2005).Final update searches for both RCTs and adverse effects were undertaken in August 2012. Although it has not been possible to incorporate RCTs and adverse effects studies identified through these final searches within this review, we will incorporate these into the next update.

SELECTION CRITERIA

Randomised trials comparing active topical treatments against placebo or against vitamin D analogues (used alone or in combination) in people with chronic plaque psoriasis.

DATA COLLECTION AND ANALYSIS

One author extracted study data and assessed study quality. A second author checked these data. We routinely contacted trialists and companies for missing data. We also extracted data on withdrawals and on local and systemic adverse events. We defined long-term trials as those with a duration of at least 24 weeks.

MAIN RESULTS

This update added 48 trials and provided evidence on 7 new active treatments. In total, the review included 177 randomised controlled trials, with 34,808 participants, including 26 trials of scalp psoriasis and 6 trials of inverse psoriasis, facial psoriasis, or both. The number of included studies counted by Review Manager (RevMan) is higher than these figures (190) because we entered each study reporting a placebo and an active comparison into the 'Characteristics of included studies' table as 2 studies.When used on the body, most vitamin D analogues were significantly more effective than placebo, with the standardised mean difference (SMD) ranging from -0.67 (95% CI -1.04 to -0.30; 1 study, 119 participants) for twice-daily becocalcidiol to SMD -1.66 (95% CI -2.66 to -0.67; 1 study, 11 participants) for once-daily paricalcitol. On a 6-point global improvement scale, these effects translate into 0.8 and 1.9 points, respectively. Most corticosteroids also performed better than placebo; potent corticosteroids (SMD -0.89; 95% CI -1.06 to -0.72; I² statistic = 65.1%; 14 studies, 2011 participants) had smaller benefits than very potent corticosteroids (SMD -1.56; 95% CI -1.87 to -1.26); I² statistic = 81.7%; 10 studies, 1264 participants). On a 6-point improvement scale, these benefits equate to 1.0 and 1.8 points, respectively. Dithranol, combined treatment with vitamin D/corticosteroid, and tazarotene all performed significantly better than placebo.Head-to-head comparisons of vitamin D for psoriasis of the body against potent or very potent corticosteroids had mixed findings. For both body and scalp psoriasis, combined treatment with vitamin D and corticosteroid performed significantly better than vitamin D alone or corticosteroid alone. Vitamin D generally performed better than coal tar, but findings relative to dithranol were mixed. When applied to psoriasis of the scalp, vitamin D was significantly less effective than both potent corticosteroids and very potent corticosteroids. Indirect evidence from placebo-controlled trials supported these findings.For both body and scalp psoriasis, potent corticosteroids were less likely than vitamin D to cause local adverse events, such as burning or irritation. Combined treatment with vitamin D/corticosteroid on either the body or the scalp was tolerated as well as potent corticosteroids, and significantly better than vitamin D alone. Only 25 trials assessed clinical cutaneous dermal atrophy; few cases were detected, but trials reported insufficient information to determine whether assessment methods were robust. Clinical measurements of dermal atrophy are insensitive and detect only the most severe cases. No comparison of topical agents found a significant difference in systemic adverse effects.

AUTHORS' CONCLUSIONS

Corticosteroids perform at least as well as vitamin D analogues, and they are associated with a lower incidence of local adverse events. However, for people with chronic plaque psoriasis receiving long-term treatment with corticosteroids, there remains a lack of evidence about the risk of skin dermal atrophy. Further research is required to inform long-term maintenance treatment and provide appropriate safety data.

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.

A new taxonomy for describing and defining adherence to medications

Interest in patient adherence has increased in recent years, with a growing literature that shows the pervasiveness of poor adherence to appropriately prescribed medications. However, four decades of adherence research has not resulted in uniformity in the terminology used to describe deviations from prescribed therapies. The aim of this review was to propose a new taxonomy, in which adherence to medications is conceptualized, based on behavioural and pharmacological science, and which will support quantifiable parameters. A systematic literature review was performed using MEDLINE, EMBASE, CINAHL, the Cochrane Library and PsycINFO from database inception to 1 April 2009. The objective was to identify the different conceptual approaches to adherence research. Definitions were analyzed according to time and methodological perspectives. A taxonomic approach was subsequently derived, evaluated and discussed with international experts. More than 10 different terms describing medication-taking behaviour were identified through the literature review, often with differing meanings. The conceptual foundation for a new, transparent taxonomy relies on three elements, which make a clear distinction between processes that describe actions through established routines ('Adherence to medications', 'Management of adherence') and the discipline that studies those processes ('Adherence-related sciences'). 'Adherence to medications' is the process by which patients take their medication as prescribed, further divided into three quantifiable phases: 'Initiation', 'Implementation' and 'Discontinuation'. In response to the proliferation of ambiguous or unquantifiable terms in the literature on medication adherence, this research has resulted in a new conceptual foundation for a transparent taxonomy. The terms and definitions are focused on promoting consistency and quantification in terminology and methods to aid in the conduct, analysis and interpretation of scientific studies of medication adherence.

Do automated text messages increase adherence to acne therapy? Results of a randomized, controlled trial

BACKGROUND

Acne is a common skin condition often requiring complex therapeutic regimens. Patient nonadherence to prescribed medication regimens is a factor in treatment failure.

OBJECTIVE

The goal of this study was to determine if daily automated text messages would result in increased adherence to recommended use of topical acne medication and consequently greater improvement in acne.

METHODS

Forty patients with mild to moderate acne were prescribed clindamycin/benzoyl peroxide 1%/5% gel in the mornings and adapalene 0.3% gel in the evenings for 12 weeks. Each medication tube was fitted with an electronic Medication Event Monitoring System cap (MEMS, Aardex Group, Sion, Switzerland) (to record the date and time of every opening/closing of the tube). Twenty patients were randomly assigned to receive customized twice-daily text messages instructing them to apply their morning and evening medication. The remainder of patients (N = 20), who did not receive text messages, served as control subjects.

RESULTS

Mean adherence rates for the correct application of both medications on a daily basis over 12 weeks was 33.9% for patients in the reminder group and 36.5% for patients in the control group (P = .75). Patients in both groups had similar clinical improvement of their acne.

LIMITATIONS

The small sample size may limit the ability to detect differences between the study groups.

CONCLUSIONS

Electronic reminders in the form of daily, customized text messages were not associated with significant differences in adherence to topical medications in patients with mild to moderate acne and had no significant effect on therapeutic response.

A new taxonomy for describing and defining adherence to medications

Interest in patient adherence has increased in recent years, with a growing literature that shows the pervasiveness of poor adherence to appropriately prescribed medications. However, four decades of adherence research has not resulted in uniformity in the terminology used to describe deviations from prescribed therapies. The aim of this review was to propose a new taxonomy, in which adherence to medications is conceptualized, based on behavioural and pharmacological science, and which will support quantifiable parameters. A systematic literature review was performed using MEDLINE, EMBASE, CINAHL, the Cochrane Library and PsycINFO from database inception to 1 April 2009. The objective was to identify the different conceptual approaches to adherence research. Definitions were analyzed according to time and methodological perspectives. A taxonomic approach was subsequently derived, evaluated and discussed with international experts. More than 10 different terms describing medication-taking behaviour were identified through the literature review, often with differing meanings. The conceptual foundation for a new, transparent taxonomy relies on three elements, which make a clear distinction between processes that describe actions through established routines ('Adherence to medications', 'Management of adherence') and the discipline that studies those processes ('Adherence-related sciences'). 'Adherence to medications' is the process by which patients take their medication as prescribed, further divided into three quantifiable phases: 'Initiation', 'Implementation' and 'Discontinuation'. In response to the proliferation of ambiguous or unquantifiable terms in the literature on medication adherence, this research has resulted in a new conceptual foundation for a transparent taxonomy. The terms and definitions are focused on promoting consistency and quantification in terminology and methods to aid in the conduct, analysis and interpretation of scientific studies of medication adherence.

Are we giving patients enough information on how to use topical treatments? Analysis of 767 prescriptions in psoriasis

BACKGROUND

Unclear instructions probably contribute to the suboptimal efficacy and adherence to topical agents in psoriasis.

OBJECTIVES

To analyse the quality of prescriptions for topical therapy in psoriasis and to determine factors associated with high-quality prescription writing.

METHODS

We made a systematic analysis of 767 topical prescriptions written by dermatologists and general practitioners (GPs). The following parameters were recorded: writing mode (electronic vs. hand written), indication of formulation, frequency of administration, duration of treatment, indication of areas to be treated, and indication of amount of product to be used. We considered prescriptions of high quality to be those including at least four of the five prospectively defined quality parameters.

RESULTS

Only 35·7% of prescriptions fulfilled the definition of a high-quality prescription. Quality of prescription writing was significantly influenced by two factors: electronic writing [odds ratio (OR) 3·04, 95% confidence interval (CI) 2·2-4·21; P < 10(-4) ] and specialty of the prescriber, dermatologists writing higher quality prescriptions compared with GPs (OR 1·61, 95% CI 1·54-2·14; P < 10(-4) ).

CONCLUSIONS

Almost two-thirds of topical prescriptions are not adequately written and do not include the required information to help patients manage their topical treatment in psoriasis correctly. The quality of topical prescriptions could be improved by making the use of electronic prescriptions widespread and by the development of aids for easy evaluation of the right amount of topical treatment to be applied according to body surface area involved.

Comparison of drug survival rates for adalimumab, etanercept and infliximab in patients with psoriasis vulgaris

BACKGROUND

Adherence to treatment is an indicator of treatment success. Long-term data on adherence to biologic treatment in psoriasis are lacking.

OBJECTIVES

To compare the tumour necrosis factor (TNF)-α inhibitors regarding drug survival rate and safety in patients with psoriasis.

METHODS

This study is based on data from the Danish nationwide database DERMBIO covering patients with psoriasis treated with a biologic agent. All patients who received anti-TNF-α treatment in academic referral centres were included. Baseline data, adverse events, time on treatment and reason for stopping treatment were recorded. Hazard ratios (HRs) for factors determining drug survival were calculated by logistic regression.

RESULTS

In total, 882 treatment series with etanercept (n = 311), adalimumab (n = 427) or infliximab (n = 144) were administered to 747 patients. Significant predictors of drug survival were: sex, the anti-TNF-α agent and the previous response to an anti-TNF-α agent. In the group of anti-TNF-α-naïve patients the longest drug survival was observed for infliximab, followed by adalimumab [HR vs. infliximab 3·70, 95% confidence interval (CI) 1·99-6·89] and etanercept (HR vs. infliximab 3·18, 95% CI 1·72-5·86). The 4-year drug survival is in the range of 40% for etanercept or adalimumab vs. 70% for infliximab. There was no difference in number of adverse events.

CONCLUSIONS

The overall efficacy of anti-TNF-α drugs diminishes with time, as envisaged by the progressive loss of patient adherence to treatment. The major reasons for stopping treatment were loss of efficacy, followed by adverse events. Infliximab had the best patient retention ability, with 70% of patients still being on the drug after 4 years of treatment.

Online video improves clinical outcomes in adults with atopic dermatitis: a randomized controlled trial

BACKGROUND

Atopic dermatitis (AD) is a chronic inflammatory skin disorder characterized by intense pruritus that causes significant disease and psychosocial burden in patients. Patient education has the potential to improve clinical outcomes and patient knowledge of this condition.

OBJECTIVES

We sought to assess the effectiveness of online video education at improving AD knowledge and disease severity compared with a written pamphlet, and to determine the usefulness and appeal of the two educational delivery vehicles.

METHODS

In a randomized controlled trial, 80 participants were randomized to receive either online video-based patient education or written pamphlet education about AD and its management. We assessed AD disease severity using the patient-oriented eczema measure (POEM) scale. AD knowledge was assessed with standardized questionnaires at baseline and after the 12-week intervention.

RESULTS

All participants had similar baseline knowledge and AD severity at the beginning of the study. On study completion, improvements in AD knowledge assessed by questionnaire were significantly greater in the video group than the pamphlet group (3.05 vs 1.85, P = .011). Online video-based education resulted in greater improvement in clinical outcome, as measured by POEM, compared with pamphlet-based education (POEM score reduction of 3.30 vs 1.03, P = .0043). Finally, although the usefulness of both interventions was rated equally (P = .77), the online video was significantly more appealing than the pamphlet (P = .0086).

LIMITATIONS

This study is limited to AD in adults.

CONCLUSION

Online video for patient education is an effective and appealing tool for improving clinical outcomes in adult patients with AD.

Effect of Quality of Life Impact and Clinical Severity on Adherence to Topical Acne Treatment

Background:

Topical medications are the most commonly prescribed treatments for acne patients. However, adherence to these treatments and possible associations with clinical severity and quality of life (QoL) impact are unclear.

Purpose:

We evaluated the association between sociodemographic factors, clinical severity, and QoL impact and adherence to topical acne treatments.

Methods:

This was an observational study of acne patients referred for usual care to community-based dermatologists. Adherence was assessed with questionnaires after 2 months of acne therapy. The associations of adherence with factors of interest were evaluated by chi-square analysis and Spearman rank correlation.

Results:

In 152 acne patients treated with topical medications, low adherence was observed in 26%, medium in 49%, and high in 24%. Age, gender, duration of acne, education level, third-party drug plan coverage, smoking history, recreational drug use, ingestion of alcohol, and number of prescribed topical agents were not significantly associated with adherence. Adherence was significantly positively correlated with QoL impact ( r = .24, p = .003), with the role-emotional and self-perception domains having the highest correlations. In contrast, adherence was weakly negatively correlated with facial acne severity ( r = .16, p = .047).

Limitations:

This study focused on facial acne, and adherence was based on patient reporting.

Conclusions:

Adherence to topical acne therapy increases with impact on QoL but decreases with increasing acne severity.