Long-term Adherence to Topical Psoriasis Treatment Can Be Abysmal

A 1-year Randomized Intervention Study Using Objective Electronic Adherence Monitoring

H. Alinia; S. Moradi Tuchayi; J.A. Smith; I.M. Richardson; N. Bahrami; S.C. Jaros; L.F. Sandoval; M.E. Farhangian; K.L. Anderson; K.E. Huang; S.R. Feldman

Disclosures

The British Journal of Dermatology. 2017;176(3):759-764. 

In This Article

Abstract and Introduction

Abstract

Background Most people with psoriasis have limited disease that could be treated with topicals, but topical efficacy is limited by low short-term adherence. Psoriasis is a chronic disease, and long-term adherence is an even bigger problem.

Objectives To determine how well medication is used in the long-term topical treatment of psoriasis and to assess the potential of an internet-based reporting intervention to improve treatment adherence and outcomes.

Methods An investigator-blinded, prospective study evaluated topical fluocinonide adherence in 40 patients with mild-to-moderate psoriasis over 12 months. Subjects were randomized in a 1 : 1 ratio to standard-of-care or internet-based reporting group. Adherence was objectively monitored with Medication Event Monitoring System® caps.

Results Fifty per cent of subjects discontinued the treatment. Greater adherence was seen in the intervention group compared with the standard-of-care group (50% vs. 35%, P = 0·08). Psoriasis Area and Severity Index improved more in the intervention group at month 1 (1·61 vs. −0·12, P = 0·003), month 3 (2·50 vs. 0·79, P = 0·025) and month 12 (3·32 vs. 0·34, P = 0·038) than in the standard-of-care group.

Conclusions This study likely underestimates the challenge of long-term adherence, as adherence tends to be better in research studies than in clinical practice. This study also did not fully account for primary nonadherence. Adherence to topical treatment is low in the short term and decreased further in the long term, a considerable challenge for dermatologists to address. A reporting intervention may be one of the ways we can improve our patients' treatment outcomes.

Introduction

Psoriasis is a chronic inflammatory skin disease that has a severe impact on patients' quality of life.[1] Most patients have limited disease that, like many other chronic skin diseases, can be treated with topical treatments. Adherence issues are a major barrier to topical treatment.[2,3] Despite the impact of psoriasis on patients' quality of life, patients commonly report that they do not follow their physicians' topical treatment recommendations.[4]

Most studies of adherence to topical treatment have evaluated short-term adherence or have used unreliable self-reported measures. One survey of 1281 patients with psoriasis found that 73% of the patients were not adherent to their topical treatment.[5] Another survey of 839 patients reported an adherence rate of 51%.[6] Using electronic monitoring, adherence to topical psoriasis therapy decreased from 85% initially to 51% at the end of 8 weeks.[7] Long-term adherence, which is crucial for the management of chronic skin disease, is largely unexplored.

Many strategies for improving adherence to topical treatment have been suggested – simplifying treatment, using patient-preferred vehicles, patient education and reminders – but few have been rigorously tested. One approach to improving adherence to topical treatment – having patients report their medication experience weekly – was tested in patients with acne, finding 74% adherence at week 2 for patients randomized to complete a weekly internet survey about the treatment, vs. 32% for patients receiving standard-of-care treatment.[8] This supports the potential usefulness of a reporting intervention for adherence to topical therapy, although this approach was not tested in patients with psoriasis.

The goal of this study was to provide novel information on long-term adherence to a fairly standard topical treatment regimen (over a period of a year) and to evaluate the potential usefulness of a weekly internet-based reporting intervention to improve adherence and treatment outcomes.

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