In a literature review published in JEADV Clinical Practice 2024, a team from the Center for Dermatology Research at Wake Forest University School of Medicine (North Carolina, USA) summarized the current state of knowledge on the topic of poor compliance/adherence in the context of skin diseases and used study findings to show which countermeasures have proven effective.
The terms “compliance” and “adherence” are often used as largely synonymous in practice, with “adherence” being the more modern term for treatment compliance – i.e. the patient’s implementation of a therapy. According to the World Health Organization (WHO), adherence is defined as “the extent to which a person’s behavior – taking medication, following a diet, and/or executing lifestyle changes, corresponds with agreed recommendations from a health care provider” [1]. A lack of adherence impairs the effectiveness of drug therapies and is associated with poorer clinical outcomes. Adherence is often not ideal not only for systemic treatments, but is often particularly poor for topical therapies frequently prescribed in the dermatological context. The following is an overview of some key statements by Lo et al. on measures that promote adherence [2].
Empathic communication and patient education
Educating patients about the etiopathogenesis, comorbidities and treatment options of their disease can provide reassurance and strengthen their health-related personal responsibility. Several studies have been conducted to evaluate the relationship between information campaigns, patient education programs and treatment adherence. It was found that interventions that improved patient knowledge through clear communication contributed to better adherence. For example, an educational program for caregivers of pediatric patients with atopic dermatitis (AD) led to a doubling of adherence rates [3].
Timing of follow-up consultations
Patient adherence to oral and topical medications appears to improve around medical appointments. This was shown, for example, in an eight-week study of 26 AD patients treated with 0.1% triamcinolone ointment: adherence was found to be high shortly before/after medical appointments, but declined rapidly in the following days [4]. This phenomenon was described with the term “white coat compliance”. Arranging a follow-up consultation or telephone call shortly after starting a newly prescribed therapy can increase long-term adherence, as better adherence in the initial phase of treatment can have a favorable effect on efficacy and thus strengthen the patient’s will to continue treatment [5].
| Accompanying measures to reduce side effects |
| Systemic and topical dermatological treatments can be associated with undesirable side effects, which may have a negative impact on adherence to treatment [2]. It has been shown that measures that reduce these side effects lead to an improvement in adherence. An example of this is provided by a study of 566 acne patients by de Lucas et al., in which adherence to specific adjuvant treatment steps (facial cleansing, application of emollients and other moisturizing/skin care products) was associated with a 2.4 times higher likelihood of adherence to the actual pharmacological therapy containing the active ingredient [8]. |
| In another study, the use of heparin-containing moisturizers in parallel with adapalene led to a reduction in adapalene-related side effects (e.g. dry skin, erythema, burning) and correlated positively with the duration of continued treatment [9]. |
| Lu et al. point out that complicating treatment plans by prescribing a large number of medications at the same time can also have a counterproductive effect. It is therefore always important to take the patient’s individual circumstances into account and adapt measures as necessary. |
Simplify treatment regimes
Most dermatology studies investigating treatment regimen simplification in terms of treatment adherence have been conducted in acne patients. In a study investigating the once-daily topical application of a combination of clindamycin phosphate and tretinoin in patients with mild to moderate acne vulgaris, the median adherence was significantly higher than with separate daily application of the two preparations (88% compared to 61%) [6]. A fixed combination of adapalene and benzoyl peroxide in the form of a gel approved for the once-daily treatment of acne also showed good adherence (63.2%) in an observational study with 2780 patients [7]. In view of the fact that lack of adherence to treatment is often due to forgetfulness and a hectic lifestyle, simplifying treatment regimens and prescribing easy-to-use products is a pragmatic approach that cannot be implemented in all clinical situations.
In addition to the adherence promotion measures already mentioned, the original article by Lo et al. mentions other strategies, such as the use of digital communication channels (e.g. sms, email) and health applications (e.g. apps) [2]. Interactive eHealth interventions in the form of weekly questionnaires also had a positive effect on adherence.
Literature:
- Sabaté E: Adherence to long-term therapies: evidence for action. Geneva, Switzerland: World Health Organization 2003.
- Lo A, et al: Adherence to treatment in dermatology: Literature review. JEADV Clinical Practice 2024; Volume3, Issue2: 401-418.
- Chen HW, et al: Efficacy of a lay community health worker (promotoras de salud) program to improve adherence to emollients in Spanish-speaking Latin American pediatric patients in the United States with atopic dermatitis: a randomized, controlled, evaluator-blinded study. Pediatr Dermatol 2023; 40(1): 69-77.
- Krejci-Manwaring J, et al: Stealth monitoring of adherence to topical medication: adherence is very poor in children with atopic dermatitis. JAAD 2007; 56(2): 211-216.
- Heaton E, Levender MM, Feldman SR: Review: timing of office visits can be a powerful tool to improve adherence in the treatment of dermatologic conditions. J Dermatol Treat 2013; 24(2): 82-88.
- Esposito M, et al: Survival rate of antitumor necrosis factor-α treatments for psoriasis in routine dermatological practice: a multicentre observational study. Br J Dermatol 2013; 169(3): 666-672.
- Yentzer BA, et al: Adherence to acitretin and home narrowband ultraviolet b phototherapy in patients with psoriasis. JAAD 2008; 59(4): 577-581.
- de Lucas R, et al: Adherence to drug treatments and adjuvant barrier repair therapies are key factors for clinical improvement in mild to moderate acne: the actuo observational prospective multicenter cohort trial in 643 patients. BMC Dermatol 2015; 15: 17.
- Hayashi N, Kawashima M: Study of the usefulness of moisturizers on adherence of acne patients treated with adapalene. J Dermatol 2014; 41(7): 592-597.
DERMATOLOGIE PRAXIS 2024; 34(4): 33 (published on 30.8.24, ahead of print)
