CUSTOM DERMATOLOGY SEARCH:
The Noncompliant Patient with Acne
Emil A. Tanghetti, MD
It is hard to imagine why patients with acne, particularly adolescents who are concerned with their appearance, are noncompliant with effective acne treatments that can significantly improve their condition in a 3 to 4 month period of time. In fact, recent data shows that patients in nonclinical trial settings have an adherence rate of approximately 50%.1 These findings suggest that most of our patients are not adherent. This is accurately reflected in my clinical practice where patients in clinical trials do significantly better than patients who are on routine follow-up at 3 to 4 month intervals. Furthermore, it is a mistake to assume that patients who are distraught with their disease are more compliant than those who are not.2,3
Frequency of Patient–physician Contact
A recent study demonstrated that compliance is enhanced by more frequent office visits at 1 to 2-week intervals even though the effects of the topical acne treatments take 8 weeks to significantly impact the patient's acne.1 In this investigation, parental reminders were counterproductive, implying that "nagging" elicits opposition, which in turn causes the patient to be less compliant. Therefore, we should not underestimate the effect of a positive therapeutic relationship with positive transference between the patient and health care provider. Hopefully, dermatologists will review these data and consider more frequent visits, especially during the initiation of acne treatments and utilize electronic reminders, such as tweets, to achieve better results.
Fixed-dose Topical Combinations
In this busy world, simplifying an acne program with oncea-day treatment would help with encouraging adherence.4 There are a number of combination products (e.g., benzoyl peroxide with clindamycin, adapalene with benzoyl peroxide, and tretinoin with clindamycin) that utilize multi-agents with complementary modes of action. The concern with the daily use of clindamycin without benzoyl peroxide (BPO) is the welldocumented occurrence of bacterial resistance with clindamycin monotherapy.5 The advent of fixed combination preparations consisting of BPO with a topical antibiotic assures that the patient will not use clindamycin as a single agent. The combination of a topical retinoid with clindamycin is problematic for maintenance therapy where resistance will emerge without the concurrent use of BPO. Ideally in the future, we will have a topical combination product that will include BPO, clindamycin, and a retinoid. These products do simplify the treatment regimen, but the current array of agents are relatively weak and do not well serve our patients with moderate to severe forms of acne. In these patients, adapalene 0.3% gel and tazarotene 0.1% cream are clearly more effective.6 Currently, we utilize these agents in the morning/ evening, or with layering techniques, though I am concerned about adherence and proper use. It would be ideal to have multiagent products with the stronger retinoids in combination with BPO or BPO/clindamycin.
Potential for Devices in Managing Nonadherence
A device administered by a provider to treat acne has a great deal of appeal. This mode of treatment would preclude the development of bacterial resistance with a mechanical, not an antibiotic, mechanism of action. This would be convenient if the therapy could be delivered intermittently with a limited number of treatments. Finally, a machine or mechanical device would almost certainly have a better record of reliability than a teenage patient. Theoretically, it would be ideal if this device produced isotretinoin-like results with permanent or long-lived effects. An intriguing study done by Dr. Rox Anderson's group at the Wellman Center for Photomedicine with aminolevulinic acid and highdose red light demonstrated dramatic and durable improvement that appeared to be associated with sebaceous gland destruction.7 Unfortunately, the inflammation elicited by the first few treatments was severe, resulting in a vigorous inflammatory response that was likely mediated by the liberation and alteration of the lipids in the sebaceous glands. Others have attempted to reproduce these results by using less light and shorter incubation periods with apparent success, but without the long-lived response that was seen in the original study. Blue light alone has limited utility.8 It activates the porphyrins that are generated in the skin by the host bacteria, which include Propionibacterium acnes, resulting in a mild photodynamic response. Unfortunately, the results are generally modest and require the addition of topical and/or systemic medication to achieve a satisfactory outcome.
Gender Differences Associated with Adherence
Some have proposed that adherence or compliance has a great deal to do with the sex of an individual, suggesting that boys by nature are less likely to apply their medication. However, this view is naïve and perhaps sexist since there is absence of data that looks specifically at application adherence with topical agents in males versus females. We have recently completed a study with topical dapsone that showed significantly superior results in females over males.16 While this could be due to compliance, there is also the possibility that females respond differently than males to certain treatments. This could result from hormonal differences, subtle compositional issues with sebum, or other yet to be discovered findings.
Patient-specific Dosing Considerations
Understanding the daily activities that an individual usually performs and tying acne treatment to them often ensures better compliance, e.g., applying a topical medication in the period after a daily wash is often convenient. Alternatively, some patients do not wash regularly, but most individuals brush their teeth 1-2 times a day. Attaching the acne treatment to this type of activity often reminds patients to perform their therapeutic regimen. Finally, using topical products with emollients might be difficult for patients who apply makeup after their morning wash.
The noncompliant acne patient is in fact the most common patient in our practices. A strong and positive therapeutic relationship with our patients is extremely important in achieving adequate adherence to a specific treatment protocol. Even though it takes 8-12 weeks to see significant improvement in most acne regimes, an initial 3-5 week visit often can provide an opportunity to encourage our patients and reinforce the importance of the therapeutic agents and their proper use. Alternatively, a device treatment performed weekly to every other week during the first 5-6 weeks can result in more rapid results and positive reinforcement, which will lead to better efficacy. The supportive role of the physician and other providers is critical in achieving success with the noncompliant patient.
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Last modified: Thursday, 20-Feb-2014 17:47:12 MST