Derm Week Review: Managing Poor Adherence to Topical Psoriasis Treatments

On the first day of Dermatology Week 2022, Steven R. Feldman, MD, PhD, kicked off the first session “Managing Limited Psoriasis with Topicals: It’s All About Adherence to the Treatment” to “describe how bad adherence is to topical treatments for psoriasis, some of the implications of poor adherence, why adherence is poor, and ways to improve outcome of topical psoriasis treatment.”

Dr Feldman explained, “Despite all the existing treatment for localized psoriasis, we have a lot of patients whose localized psoriasis is not clearing up.” According to him, poor adherence to treatment is the number one reason psoriasis is resistant to topical therapy. “Patients tell us that they’re using the medicines, but they’re not really doing it.”

Dr Feldman explained what adherence is: “Adherence, we give people a prescription, they may fill up the prescription and start on the therapy, that’s called primary adherence. Then they use [the prescribed medication] well/poorly for various periods of time, that’s secondary adherence. Then they stop using the medicine often before the treatment ends.” Additionally, he cleared up the reference of the term “tachyphylaxis” and said, “the less you use the steroid, the less the medicine works.”

Next, Dr Feldman discussed the implications of poor adherence. He gave an example of a small study and said, “It strongly suggests that the vast majority of the patients are failing topical steroids because they’re not using it.”

On the topic of managing resistant atopic dermatitis, Dr Feldman suggested that “it would be better to get [the patients] to use the triamcinolone.” He gave an example of a case and said, “Just getting [patients] to use the medicine can help.”

Dr Feldman countered the common opinion on ointments and said, “The implication of adherence is that ointments aren’t always more effective. [Patients] don’t need ointments to moisturize psoriasis.”  He further shared that “the most potent topical agent I ever invented for psoriasis was a spray.” The main reason it was most effective was because patients used it. “It was a spray and not a greasy ointment. And they paid for [the spray] themselves. When people pay for it themselves, I think they use it better,” he added.

Dr Feldman proceeded to cover cases with other types of psoriasis. For coral reef psoriasis, he mentioned that “the psoriasis was gone with just the clobetasol alone. You don’t need penetration enhancers. They just complicate the regimen.” For scalp psoriasis implications, he noted, “You want [treatment for scalp psoriasis] to be affective. Give [the patients] topical clobetasol…and give it to them in a vehicle that they’re willing to use. Use the dental floss effect…see patients back in 3 to 5 days and then use other psychological tricks.”

Regarding the topic of why people aren’t using the medicine and what can be done about it, Dr Feldman stated the number one reason is that “the doctors are pretty lousy at getting [the patients] to use the medicine.” He added, “In the clinical trials to get the drugs approved, [the doctors] bring patients back in weeks 1, 2, 4, 6, 8 and [therefore, the patients] use the medicine much better than they do in the real life.”

To get the patients to use the medicine, Dr Feldman gave various suggestions. He recommended frequent return visits and suggested that “return visits make people get the medicine and use it.”

Another suggestion from Dr Feldman was to tell patient to call with updates. “If you’re academic and do not see a lot of patients…give them your cell phone number and say, ‘Call me in 3 days and let me know how this is working for you.’”

Furthermore, Dr Feldman also suggested putting a clock behind the patient. “When [doctors are] looking at the clock, [patients] think they are looking at them in the eye. It helps build that foundation so that [patients] trust you.”

Moreover, Dr Feldman recommended getting feedback from patients. “Traits people didn’t like [from doctors are] poor access, poor communication, poor follow-up, and lack of interpersonal skills.” He added, “If you make the patients believe that you’re a friendly, caring doctor, they’ll be happy with their treatment and they’ll be more likely to use the treatment.”

Continuing with the topic, Dr Feldman pointed out that “the context has a huge impact on how people perceive things.” He added, “The better context is a sign that doesn’t say we want your money, but that says we appreciate your trust and confidence.”

Dr Feldman listed some of the basics physicians can implement to get patients to use medicine better, such as:

• Simplify the treatment
• Do once-a-day dosing
• Keep to vehicle preference (ointment, cream, emollient, gel)
• Use fluocinonide for 3 days
• Address cost issues
• Recognize the things that are simple for doctors are complicated for patients
• Give written and personalized instructions
• Prescribe only ‘all natural’ treatments

Dr Feldman briefly discussed the psychological approaches he uses to improve outcomes of topical psoriasis treatments. “Side effects may also be an opportunity; sticker charts are useful for children; for teenagers, tell them that this is the medicine most teenagers are using in this situation; anecdotes are more powerful than data; and anchoring.”

In conclusion, Dr Feldman reminded that “the goal is not just to get the right diagnosis and prescribe the right treatment, the goal is to get patients well. And to do that, [the doctor] also has to have the skill to get patients to use their medicine well.” He added, “In addition to having new topical therapies, you have to do the things you need to do to get patients to use their medicine well.”

Reference
Feldman SR. Managing Limited Psoriasis with Topicals: It's All About Adherence to the Treatment. Presented at: Dermatology Week 2022; May 11-14, 2022; Virtual.