Assessing adherence to dermatology treatments: a review of self-report and electronic measures

Nonadherence to prescribed medications is a common problem in dermatology, and assessing adherence can be difficult. Electronic monitors are not always practical, but self-report measures may be less reliable.To review the literature for self-report instruments and electronic monitors used to measure medication adherence in patients with chronic disease.A PubMed literature search was conducted using the terms ‘scale,’‘measure,’‘self-report,’‘electronic,’ and ‘medication adherence.’ Relevant articles were reviewed and selected if they addressed self-report or electronic measures of adherence in chronic disease.Eleven self-report instruments for the measurement of adherence were identified. Four were validated using electronic monitors. All produced an estimate of adherence that correlated with actual behavior, although this correlation was not strong for any of the measures. None of the scales was tested in patients who had dermatologic disease and/or used topical medications. Several electronic monitoring systems were identified, including pill counts, pharmacy refill logs, and the Medication Event Monitoring System (MEMS ® ). Validity was higher among electronic monitoring systems compared with self-report measures.While several self-report measures of adherence have been validated in chronic disease populations, their relevance in dermatology patients has not been studied. A dermatology-specific instrument for the measurement of adherence would contribute to improved outcomes; until such a tool exists, researchers and clinicians should consider nonadherence as a possible factor in skin disease that is not responsive to treatment. Electronic monitoring provides the most reliable means of measuring adherence, and may provide additional clues to identify barriers to adherence.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/79087/1/j.1600-0846.2010.00431.x.pd

Keratolytics for psoriasis: Are they necessary?

It is a common belief that keratolytic agents are required to enhance the penetration of topical medications into thick psoriatic plaques. However, is this belief evidence-based

Keratolytics for psoriasis: are they necessary?

It is a common belief that keratolytic agents are required to enhance the penetration of topical medications into thick psoriatic plaques. However, is this belief evidence-based

Comparison of skin concentrations following topical versus oral corticosteroid treatment: reconsidering the treatment of common inflammatory dermatoses.

BACKGROUND: Topical corticosteroids are often considered to have greater safety and poorer efficacy than oral corticosteroids in treating psoriasis and atopic dermatitis. There are limited data for assessing relative efficacy of topical and systemic corticosteroids, however. The concentration of corticosteroid in skin, adjusted for the relative potency of the active compound, may be a predictor of clinical efficacy and can be estimated for both topical and oral administration. PURPOSE: To analyze the assumption that oral corticosteroid therapy should be more potent than topical therapy by comparing relative corticosteroid concentrations in the skin expected with topical versus systemic administration. METHODS: The estimated skin concentration of prednisone following oral dosing was calculated based on data showing 70-100% bioavailability and an even tissue distribution. Data on the concentration of corticosteroids found in skin after topical application were obtained from the literature. The relative potencies of corticosteroid molecules were then used to compare skin concentrations of corticosteroid following topical versus oral treatment. RESULTS: Data derived from the existing literature demonstrated that hydrocortisone 2.5% ointment, triamcinolone 0.1% ointment, and clobetasol 0.05% foam achieved effective skin concentrations greater than the effective concentration achieved by oral prednisone. Betamethasone 0.1% cream achieved effective concentrations in skin within the range created by oral prednisone. LIMITATIONS: This analysis was limited by the paucity of data regarding cutaneous concentrations of corticosteroids after topical application, and by the differing experimental designs utilized in the available studies. CONCLUSION: Most topical corticosteroids have the potential to achieve greater effective drug levels in the superficial layers of skin than those achieved with standard doses of oral prednisone. The apparently greater efficacy of oral corticosteroid therapy may be attributable, in part, to poor patient compliance with topical therapy. Systemic alterations in immune function following oral, but not topical, corticosteroid use may also play a role

Explicit and implicit copayments for phototherapy: examining the cost of commuting

Background: Whereas phototherapy is a safe and cost-effective treatment modality for psoriasis, economic disincentives discourage its use, including both direct and indirect costs to the patient.Purpose: To determine when it may be cost-effective for patients to purchase a home light unit versus driving to clinic for outpatient phototherapy sessions.Methods: Estimates of expenses associated with 3 months of outpatient phototherapy were determined and compared to the price of a home phototherapy unit. Factors examined included the cost of gasoline (based on the national average), fuel efficiency of the vehicle, cost of owning and operating a motor vehicle, lost wages, and copayments.Results: The cost for a standard 6-bulb narrowband UVB home unit is approximately $2600. Direct and indirect expenses imposed on patients increase with distance travelled to the dermatologist. If a patient lives 20 or more miles away from the dermatologist, the expenses associated with travel can total more than the out of pocket expense of purchasing a home phototherapy unit.Limitations: This small analysis only accounted for the first 3 months of treatment and likely underestimates the total costs that patients would experience over a lifetime of treatment.Conclusions: It may be beneficial for physicians to educate patients on the cost-burden of in-office versus home phototherapy because patients can use these parameters to determine which option would be more cost-effective for them

Do topical retinoids cause acne to flare ?

BACKGROUND: Guidelines support this use of topical retinoids as a fundamental part of acne treatment regimens. However, existing dogma holds that topical retinoids may initially worsen acne. PURPOSE: To review the available data from clinical trials for evidence of initial worsening of acne with topical retinoids. METHODS: A PubMed and Google Internet search was performed for sources indicating or refuting worsening of acne with topical retinoids. RESULTS: No primary data from clinical trials were identified to support the dogma of acne worsening secondary to topical retinoids. Available data point to topical retinoids improving acne, even during the first couple weeks of treatment. CONCLUSION: It is unlikely that acne worsens or flares due to the initiation of topical retinoids. Some acne patients may have worsening of acne during the first week or two as part of the natural disease process

Home ultraviolet light therapy for psoriasis: Why patients choose other options

Background: Psoriasis is a common inflammatory skin condition for which office-based and home phototherapy are safe and effective treatments. However, patients who are prescribed home phototherapy devices often choose other treatment options.Objective: To determine the reasons why patients do not purchase a home phototherapy device after it has been recommended and prescribed by their physician.Methods:  Patients who were written a prescription for a home phototherapy device but did not fill the prescription were identified and contacted by the National Biological Corporation to participate in a telephone survey consisting of 4 questions regarding why they did not pursue a prescribed home ultraviolet device and how they were currently treating their psoriasis.Results: The most common reason for not obtaining the prescribed home phototherapy device was using a biologic agent (31%). The second and third most frequently reported reasons were “cost share too high” and “insurance will not cover” (18% and 17%, respectively), together accounting for 35%.Limitations: The reason why patients were prescribed biologics while having an unfilled home phototherapy device prescription was not obtained.Conclusions: Out of pocket cost is a significant barrier to home phototherapy, even to patients who are well insured

Home ultraviolet light therapy for psoriasis: Why patients choose other options

Background: Psoriasis is a common inflammatory skin condition for which office-based and home phototherapy are safe and effective treatments. However, patients who are prescribed home phototherapy devices often choose other treatment options.Objective: To determine the reasons why patients do not purchase a home phototherapy device after it has been recommended and prescribed by their physician.Methods:  Patients who were written a prescription for a home phototherapy device but did not fill the prescription were identified and contacted by the National Biological Corporation to participate in a telephone survey consisting of 4 questions regarding why they did not pursue a prescribed home ultraviolet device and how they were currently treating their psoriasis.Results: The most common reason for not obtaining the prescribed home phototherapy device was using a biologic agent (31%). The second and third most frequently reported reasons were “cost share too high” and “insurance will not cover” (18% and 17%, respectively), together accounting for 35%.Limitations: The reason why patients were prescribed biologics while having an unfilled home phototherapy device prescription was not obtained.Conclusions: Out of pocket cost is a significant barrier to home phototherapy, even to patients who are well insured