Q&A: Improved Adherence to Topical Drugs Boosts Treatment Outcome

Drug adherence is one of the biggest barriers to topical psoriasis treatment. Messy vehicles, multiple daily applications and cost factors can all impact a patient’s adherence rates. Mathias Tiedemann Svendsen, MD, PhD, specialist in dermato-venereology and clinical assistant for the department of dermatology and allergy center at Odense University Hospital in Denmark, regularly conducts research regarding patient adherence to topical medications. We spoke to him to discuss the reasons behind adherence difficulties and how clinicians can best address these issues.

Q: What are some of the reasons drug adherence can be difficult for those on topical medications?

Svendsen: Topical drugs are recommended first-line treatment of major chronic dermatoses like psoriasis and eczema, which are characterized by periods of flare-ups and remissions. However, low adherence to topical drugs is the main barrier for treatment success. Even though adherence rates are low to all treatment regimens administered by patients suffering from chronic diseases, it is especially bothersome sticking to a topical treatment plan.

I would like to highlight four reasons why adherence to topical medication is such a challenge: Firstly, topical drugs are often greasy and mess up clothes and furniture. Secondly, preparations for topical use often contain corticosteroids, and many patients suffer from cardiophobia (fear of using corticosteroids). Thirdly, patients often receive contradictory information from doctors, nurses and pharmacists regarding how to use the drugs, which leaves them confused about the treatment plan. And lastly, patients tend to forget to use the topical drugs when the diseases are in remission, which leads to disease exacerbation.

Q: How does a drug’s formulation (cream, lotion, foam) affect adherence?

Svendsen: All patients are unique and have different skin types and ethnic origins, so it’s no wonder that patients’ preferences for formulation of the topical drugs differ. I would like to illustrate this with an example from my research: Patients with darker skin types from the African continent are often bothered by a drier scalp and therefore prefer to apply ointment to treat inflammatory scalp conditions. In contrary, many Caucasians living in the Western world often suffer from oilier scalp and therefore prefer foam or lotion when treating inflammatory scalp conditions. As preferences differ, the prescribing doctor needs to individualize the topical prescription by listening to the patient and inform them about the available types of formulation of the topical drugs. Choosing a formulation less tolerated by the individual patient leads to nonadherence.

Q: How do you council your patients who are having difficulty sticking to a topical treatment regime?

Svendsen: Most of the patients have difficulties when it comes to sticking to the topical treatment regimen. Based on the adherence research I have led for more than 7 years, I have developed a five-step counselling guide that I use for all my patients which includes: ensuring patients have a reminder system to use their medication; keeping the patient accountable for using their medication; patient empowerment in regard to adherence; building trust in the patient-health care provider relationship; and increasing ease via favorable comparisons with other treatment options. The five-steps counselling system can be given by the physician but can also be delivered by dermatology nurses.

Q: Why is it important that these patients continue to use their drugs properly?

Svendsen: Topical drugs only work in patients who use them. The efficacy of topical treatments and lack thereof can only be measured if the patients are fully adherent to their treatment plans. Moreover, the preliminary results from our ongoing trials show that patients that are fully adherent to their topical treatments have a better quality of life and improved treatment efficacy. Further, adherence to topical treatments reduces the use of systemic drugs, which is associated with more side effects and have a higher socioeconomic burden as they are more pricey than topical drugs.

Q: Can technology such as smartphone apps help patients adhere to their treatments?

Svendsen: Technologies such as smartphone apps can be designed to improve adherence. However, patients must keep using the apps for extended periods of time. My previous research has shown that the adherence-improving effects of the app drops quickly over time. Further, more research is needed to investigate if smartphone apps are superior and more cost-effective compared to support from health care professionals when it comes to helping patients adhere to their treatment.

Q: How can clinicians work toward ensuring better patient adherence?

Svendsen: First, prescribe a potent drug in a tolerable formulation. Secondly, clinicians can actively contribute to better patient adherence by scheduling follow-up visits. To ensure patients fill their prescription, I often use a strategy, which I learned from Professor Steven R. Feldman, MD, PhD, of the Wake Forest School of Medicine in Winston-Salem, North Carolina: I hand out my business card to my patients and write down my personal number and ask the patient to call me and leave a message within 48 hours to tell me how the drug works. Doing this, I seek to ensure the patients go to the pharmacy and fill the prescription. Further, as close follow-ups the first year after starting the topical drugs, I like to schedule either out clinic appointments with the dermatology nurse or arrange telephone calls every 4 weeks, where the patient and health care provider can go through the topical medication and treatment progress.

Q: What would you like to see in future drug formulations to assist in ensuring adherence?

Svendsen: I would like to especially see less greasy drug formulations delivering highly efficacious active ingredients. It should be pleasant and not bothersome for the patient to apply the topical drugs.

Q: Do you have any additional information to add?

Svendsen: According to WHO, low adherence to patient-administered medications in chronic diseases is among the biggest challenges to human health. Now it is time to design and test adherence improving interventions in well conducted superiority randomized controlled trials including a health-economic evaluation, so we have strong arguments for future implementations of the adherence improving interventions in dermatology clinics.

• For more information:
• Mathias Tiedemann Svendsen, MD, PhD, can be reached at Odense University Hospital, J. B. Winsløws Vej 4, 5000 Odense, Denmark; email: mtsvendsen@health.sdu.dk.