First Refusal

Treatment success in psoriasis, as in any dermatologic condition, is dependent on many factors. The willingness of patients to follow our suggested therapeutic plans certainly is one of the most important components of this process.

Halioua et al¹ analyzed the issue of treatment refusal, which they defined as “a patient actively refusing to take treatment despite physician recommendations,” among psoriasis patients. Treatment refusal is a more complex phenomenon than nonadherence, as it requires an affirmative act that goes beyond more passive acts of not filling prescriptions, taking a medication sporadically, or forgetting to take a medication. Their objective was to investigate refusal of topical treatments by patients living with psoriasis in France as well as the factors that influence such refusal.¹

The authors evaluated responses to an Internet study.¹ Responses from participants who refused topical therapy (n=50) were compared to individuals who successfully applied topical treatment (n=205). Individuals receiving phototherapy, biologic therapy, and oral treatment were not included in the analysis. Spearman rank correlations completed by Fisher exact tests and Student t tests were performed.¹

The researchers found that objective aspects of psoriasis, including comorbidities, localization of lesions, and symptoms associated with psoriasis, were not significant predictors of treatment refusal. The factors that did appear to influence refusal related more to patient perception of disease and its treatment.¹

First, treatment refusal was defined by patient attitude toward treatment. In the treatment refusal group, significantly fewer participants reported believing that psoriasis can be managed (20.0% vs 38.5%; P<.01), and significantly more participants in the treatment refusal group reported believing that topical psoriasis treatments never work (58.0% vs 27.5%; odds ratio, 2.09; P<.0001). Additionally, significantly fewer participants in the treatment refusal group were willing to stay on prescription medications long-term (30.0% vs 77.6%; P<.001), and significantly more patients in the treatment refusal group believed that all creams (prescription or over-the-counter) work the same (54.0% vs 31.7%; odds ratio, 1.07; P=.003).¹

The physician-patient relationship also influenced refusal. In the treatment refusal group, 60% of participants reported no longer consulting physicians for psoriasis treatment. The main reasons for cessation of medical care were lack of improvement of psoriasis (40%) and feeling that the physician did not take psoriasis seriously (20%). In the treatment acceptance group, only 10% of participants no longer consulted physicians.¹ Among participants who continued to consult their physician (40% for the treatment refusal group and 90.2% for the treatment acceptance group), significantly fewer participants in the treatment refusal group reported that they were substantially helped by their physician (50.0% vs 73.0%; P=.03) and that they always followed physician recommendations (65.0% vs 85.4%; P=.02). Additionally, significantly fewer participants in the treatment refusal group considered that their physician took the time to listen to what he/she had to say (65.0% vs 85.9%; P=.02) and that their physician had provided clear instructions on how to utilize the treatment (65.0% vs 83.2%; P=.046).¹

Therefore, treatment refusal is an important factor to be considered in the management of psoriasis. The findings of this study indicate possible strategies to reduce patient refusal. For example, enhanced education about the therapeutic options for psoriasis and their benefits could counter negative perceptions about these therapies. It also appears that increased focus on the physician-patient relationship may have a positive impact in this area.