Compliance Key to Topical Psoriasis Treatment Efficacy

Improving psoriasis outcomes with the use of topical treatments is largely dependent on patient compliance, according to Dr. Joseph S. Eastern.

"In other words, you can have the best treatment in the world, but if a patient doesn't apply it, then it's not going to work," Dr. Eastern said at the annual Hawaii Dermatology Seminar sponsored by Skin Disease Education Foundation.

Compliance has to be discussed with patients before treatment effectiveness is even addressed. Tachyphylaxis, or the decrease in a patient's response to a drug or active agent with increased use, may often be cited as the reason why a topical treatment is not effective. But the new line of thinking should be "the less you use the steroid, the less it works," said Dr. Eastern, who practices dermatology and dermatologic surgery in Belleville, N.J.

To support this assertion, Dr. Eastern noted a study that assessed adherence in 30 patients with psoriasis. In this university-based clinical trial, the participants were asked to apply 6% salicylic acid twice a day and fill out an at-home log to record their medication activity. The patients were told they were going to be monitored but not informed the individual medication bottles would be encrypted with a microchip in the caps that could record each day and time the bottle was opened. MEMS (Medication Electronic Monitoring System) caps were used for this purpose (J. Am. Acad. Dermatol. 2004;51:212-6).

The participants recorded higher compliance than what was actually recorded by the MEMS caps, with the exception of one participant whose self-reporting mirrored that of the electronic MEMS data. Eighty percent of patients used the product less than they noted in their compliance log. After only 4 days of treatment, the compliance rate dropped to 60%, and there was another 20% drop in compliance after 5 weeks of treatment.

"If this is what 'highly motivated patients' are doing, patients who are being paid to be in the study and were told they are being monitored, what do you think your patients in a private practice are doing? Do you think they are doing better than these university trial patients? Not bloody likely," Dr. Eastern said.

The study did find that there was a spike in use 1-2 weeks before a follow-up office visit. Dr. Eastern referred to this as the "floss effect," noting that people tend to floss a couple days prior to a dentist appointment.

"What works best is follow-up patient visits," he said. "You have to get them back fairly frequently and re-motivate them." Dr. Eastern admitted that regular follow ups can be difficult, as some insurance plans simply will not cover frequent visits.

Follow-up visits also can help physicians learn about any over-the-counter treatments patients are using and provide guidance on which treatments have a greater incidence of efficacy versus others that have no proven effects.

While a combination of drug efficiency, patient compliance, and regularly scheduled follow-up visits is the best recipe for a successful outcome, the only factors in determining efficacy of topical medications are "compliance, compliance, compliance," said Dr. Eastern.

Dr. Eastern reported the following disclosures: Abbott, Aqua Pharmaceuticals, Amgen, Galderma, Genentech, Graceway Pharmaceuticals, Medicis, Quinnova Pharmaceuticals, and Warner Chilcott. SDEF and this news organization are owned by Elsevier.

Improving psoriasis outcomes with the use of topical treatments is largely dependent on patient compliance, according to Dr. Joseph S. Eastern.

"In other words, you can have the best treatment in the world, but if a patient doesn't apply it, then it's not going to work," Dr. Eastern said at the annual Hawaii Dermatology Seminar sponsored by Skin Disease Education Foundation.

Compliance has to be discussed with patients before treatment effectiveness is even addressed. Tachyphylaxis, or the decrease in a patient's response to a drug or active agent with increased use, may often be cited as the reason why a topical treatment is not effective. But the new line of thinking should be "the less you use the steroid, the less it works," said Dr. Eastern, who practices dermatology and dermatologic surgery in Belleville, N.J.

To support this assertion, Dr. Eastern noted a study that assessed adherence in 30 patients with psoriasis. In this university-based clinical trial, the participants were asked to apply 6% salicylic acid twice a day and fill out an at-home log to record their medication activity. The patients were told they were going to be monitored but not informed the individual medication bottles would be encrypted with a microchip in the caps that could record each day and time the bottle was opened. MEMS (Medication Electronic Monitoring System) caps were used for this purpose (J. Am. Acad. Dermatol. 2004;51:212-6).

The participants recorded higher compliance than what was actually recorded by the MEMS caps, with the exception of one participant whose self-reporting mirrored that of the electronic MEMS data. Eighty percent of patients used the product less than they noted in their compliance log. After only 4 days of treatment, the compliance rate dropped to 60%, and there was another 20% drop in compliance after 5 weeks of treatment.

"If this is what 'highly motivated patients' are doing, patients who are being paid to be in the study and were told they are being monitored, what do you think your patients in a private practice are doing? Do you think they are doing better than these university trial patients? Not bloody likely," Dr. Eastern said.

The study did find that there was a spike in use 1-2 weeks before a follow-up office visit. Dr. Eastern referred to this as the "floss effect," noting that people tend to floss a couple days prior to a dentist appointment.

"What works best is follow-up patient visits," he said. "You have to get them back fairly frequently and re-motivate them." Dr. Eastern admitted that regular follow ups can be difficult, as some insurance plans simply will not cover frequent visits.

Follow-up visits also can help physicians learn about any over-the-counter treatments patients are using and provide guidance on which treatments have a greater incidence of efficacy versus others that have no proven effects.

While a combination of drug efficiency, patient compliance, and regularly scheduled follow-up visits is the best recipe for a successful outcome, the only factors in determining efficacy of topical medications are "compliance, compliance, compliance," said Dr. Eastern.

Dr. Eastern reported the following disclosures: Abbott, Aqua Pharmaceuticals, Amgen, Galderma, Genentech, Graceway Pharmaceuticals, Medicis, Quinnova Pharmaceuticals, and Warner Chilcott. SDEF and this news organization are owned by Elsevier.

Improving psoriasis outcomes with the use of topical treatments is largely dependent on patient compliance, according to Dr. Joseph S. Eastern.

"In other words, you can have the best treatment in the world, but if a patient doesn't apply it, then it's not going to work," Dr. Eastern said at the annual Hawaii Dermatology Seminar sponsored by Skin Disease Education Foundation.

Compliance has to be discussed with patients before treatment effectiveness is even addressed. Tachyphylaxis, or the decrease in a patient's response to a drug or active agent with increased use, may often be cited as the reason why a topical treatment is not effective. But the new line of thinking should be "the less you use the steroid, the less it works," said Dr. Eastern, who practices dermatology and dermatologic surgery in Belleville, N.J.

To support this assertion, Dr. Eastern noted a study that assessed adherence in 30 patients with psoriasis. In this university-based clinical trial, the participants were asked to apply 6% salicylic acid twice a day and fill out an at-home log to record their medication activity. The patients were told they were going to be monitored but not informed the individual medication bottles would be encrypted with a microchip in the caps that could record each day and time the bottle was opened. MEMS (Medication Electronic Monitoring System) caps were used for this purpose (J. Am. Acad. Dermatol. 2004;51:212-6).

The participants recorded higher compliance than what was actually recorded by the MEMS caps, with the exception of one participant whose self-reporting mirrored that of the electronic MEMS data. Eighty percent of patients used the product less than they noted in their compliance log. After only 4 days of treatment, the compliance rate dropped to 60%, and there was another 20% drop in compliance after 5 weeks of treatment.

"If this is what 'highly motivated patients' are doing, patients who are being paid to be in the study and were told they are being monitored, what do you think your patients in a private practice are doing? Do you think they are doing better than these university trial patients? Not bloody likely," Dr. Eastern said.

The study did find that there was a spike in use 1-2 weeks before a follow-up office visit. Dr. Eastern referred to this as the "floss effect," noting that people tend to floss a couple days prior to a dentist appointment.

"What works best is follow-up patient visits," he said. "You have to get them back fairly frequently and re-motivate them." Dr. Eastern admitted that regular follow ups can be difficult, as some insurance plans simply will not cover frequent visits.

Follow-up visits also can help physicians learn about any over-the-counter treatments patients are using and provide guidance on which treatments have a greater incidence of efficacy versus others that have no proven effects.

While a combination of drug efficiency, patient compliance, and regularly scheduled follow-up visits is the best recipe for a successful outcome, the only factors in determining efficacy of topical medications are "compliance, compliance, compliance," said Dr. Eastern.

Dr. Eastern reported the following disclosures: Abbott, Aqua Pharmaceuticals, Amgen, Galderma, Genentech, Graceway Pharmaceuticals, Medicis, Quinnova Pharmaceuticals, and Warner Chilcott. SDEF and this news organization are owned by Elsevier.