Skin Therapy Letter HOME
Written for dermatologists by dermatologists. Indexed by the US National Library of Medicine.
Skin Information
NETWORK
Skin Therapy Letter About STL Subscribe Today SkinCareGuide Network Site Map
CUSTOM DERMATOLOGY SEARCH:
Loading

Topical Treatment Adherence for Psoriasis

L. Kircik, MD
Department of Dermatology, Indiana University School of Medicine, Indianapolis, IN, USA

Background

For many years, clinicians have expressed ongoing concerns about treatment adherence by patients, especially pertaining to those with chronic skin disorders. Although crucial to effective therapeutic outcomes, the issue of patient adherence has been largely ignored in dermatologic disease management until recently. Two types of nonadherence have been defined:

  • Unintentional nonadherence, i.e., a patient’s intention to use medication is defeated by barriers, such as forgetfulness.
  • Deliberate nonadherence, i.e., a patient arrives at a decision (usually planned) not to use the treatment as directed.1
  • More common in chronic diseases, such as psoriasis, when the treatment regimen interferes with daily routines.

Studies have demonstrated that up to 40% of patients with psoriasis do not comply with the recommended treatment regimen. Moreover, experts have suggested that many psoriatic patients do not seek help because they believe that no suitable treatment exists for their condition.1 Furthermore, in a study by Krueger, et al., more than half of the psoriasis patients who were surveyed were unhappy with their treatment.2

Contributing Factors

Although numerous variables affecting patient adherence have been identified, some important factors that engender nonadherence include:

  • sociodemographic factors such as gender, marital status and employment status.
  • treatment-related factors, i.e.,
    • the type of treatment, i.e., systemic, light, or topical:
      • A survey of psoriasis patients reported a greater preference for systemic treatments over topical or light therapies.3
      • In a later study, patients using topical therapy were more compliant than those on systemic or phototherapy, despite having less favorable perceptions of the medical care received and treatment outcomes.4
      • In another study, patients receiving topical treatments adhered to their therapy in 51% of cases due to the frequency of application and in 71% of cases because of the duration of treatment.5
    • the duration of the treatment:
      • Adherence with a treatment decreases if the duration of a treatment is long.6
    • the time point, e.g., starting a new treatment
    • the delivery mechanism, i.e., cream, ointment, foam, gel
    • the frequency of the treatment:
      • Treatment adherence rates for a once daily regimen were significantly higher than twice daily dosing (82% vs. 44%, respectively).7
      • Once daily treatments include fluticasone propionate or betamethasone dipropionate plus calcipotriol.
    • the side-effects:
      • Adherence is significantly higher for treatment regimens without adverse-effects.7
    • the time taken to use treatments
    • disease distribution factors, e.g., age of onset, severity.
    • the patient’s perceptions of the care provided, i.e.,
      • satisfaction with the consultation
      • opinion about the clinician’s interpersonal skills
      • optimism about the treatment process
      • knowledge about psoriasis and the adopted therapeutic approach
      • beliefs about the safety of their treatment, which may conflict with the clinician’s views.
      • recognition that the patient's active participation is essential to treatment success.

Adherence has also been reported to be higher for patients who are being treated for the first time7 and for those who are facing a shorter treatment duration.8,9 It appears that initiating a new therapy may present a unique opportunity to establish an effective working relationship and improve patient adherence.

Strategies for Improvement

A number of strategies have been suggested to address the issue of nonadherence:
  • Simplify the regimen, i.e., minimize the number of medications and frequency of use.
  • Devote time to patient education. Patients armed with adequate and accurate information will enable them to understand the objectives of the therapy and the impact of nonadherence.
  • Ensure that patients understand both written and verbal instructions for using the medications.
  • Provide clarity regarding patients’ concerns on the safety and efficacy of long-term therapy.
  • Encourage behavioral methods, such as reminders and environmental cues (e.g., apply immediately after showering).

Topical Therapies

Treatment Comments
Anthralin
  • Reduces the rapid acceleration of skin growth.
  • Effective for mild-to-moderate disease, however, patients are slow to respond.
  • Skin irritation and staining are common side-effects.
  • Limited availability; rarely used by outpatients.
Calcineurin
Inhibitors
  • Immunosuppressive agents interfere with T-cell signaling, which affect inflammatory responses.
  • Studies indicate therapeutic benefits for psoriasis, especially on the face and intertriginous areas.
Calcipotriol
  • A vitamin D analogue that acts to modulate both epidermal proliferation and differentiation.
  • Twice daily application of calcipotriol has been shown to be more effective than tar, short contact anthralin, and some corticosteroids.
  • Use in combination with steroids enhances efficacy.
  • Ad hoc mixtures of calcipotriol plus steroids (including betamethasone dipropionate and betamethasone valerate) have been shown to be unstable; compounding is not recommended.
Calcipotriol plus
Betamethasone
Dipropionate
  • Available as a stable commercial preparation.
  • This combination therapy can increase the rate and degree of improvement for patients undergoing treatment with UVB, PUVA, methotrexate, cyclosporine, retinoids, or biologic agents.
  • Combined use may be synergistic and exert a dose sparing effect that can reduce some of the sideeffects produced by many antipsoriatic treatments.
  • Can be considered as first-line topical therapy due to once daily application, quick onset of action, and favorable safety and efficacy profiles over 52 weeks of “as needed” use.10
Corticosteroids
  • Potent compounds used for their anti-inflammatory, immunosuppressive, and antiproliferative effects.
  • Confirmed efficacy and safety for monotherapy in short-term courses and for intermittent longerterm use.
Tar
  • Slows the proliferation of skin cells and reduces inflammation, itching and scaling.
  • Effective for treating scalp psoriasis.
  • Limitations include being odiferous, and having the potential to cause irritation and staining.
  • Can cause folliculitis; may be carcinogenic.
Tazarotene
  • A retinoid with the ability to mediate skin cell proliferation and differentiation; mostly used in acne.
  • Can cause irritation to psoriatic lesions.
  • Efficacy is enhanced when used in combination with topical corticosteroids, calcipotriol or phototherapy.
Table 1: Common topical treatment options11

Conclusion

Maintaining a partnership with patients should involve3:
  • a continuous assessment of their quality of life.
  • a continuous assessment of their implicit standards of regimen acceptability.
  • a move toward a more collaborative model of self-management behavior.

Planning the treatment together with the patient, and allowing him or her to play a central role in its establishment, will likely foster treatment adherence.

References

  1. Richards HL, et al. J Eur Acad Dermatol Venereol 20(4):370-9 (2006 Apr).
  2. Krueger G, et al. Arch Dermatol 137(3):280-4 (2001 Mar).
  3. Richards HL, et al. J Am Acad Dermatol 41(4):581-3 (1999 Oct).
  4. Richards HL, et al. Br J Dermatol 147(5):1070 (2002 Nov).
  5. Fogh K, et al. Vitamin D3 analogues. In: van de Kerkhof PCM, ed. The Management of Psoriasis: Clinics in Dermatology. New York: Elsevier. 15:705-14 (1997).
  6. Rosenstock IM. Diabetes Care 8(6):610-6 (1985 Nov-Dec).
  7. Zaghloul SS, et al. Arch Dermatol 140(4):408-14 (2004 Apr).
  8. van de Kerkhof PC, et al. Dermatology 200(4):292-8 (2000).
  9. Bell RA, et al. J Gen Intern Med 17(11):817-24 (2002 Nov).
  10. Toole JWP, Skin Therapy Lett 12(4):1-3 (2007 May).
  11. Kircik L, et al. Skin Therapy Lett FP 3(3):4-5 (2007 Aug).