GOTHENBURG, SWEDEN - Compliance with topical dermatologic therapies is worse than most physicians realize, according to a new study.
Through a series of Danish studies utilizing the nation’s comprehensive electronic medical and pharmacy records system, investigators concluded that more than one in three new prescriptions for creams and ointments for dermatologic diseases is never picked up. And for those who actually do fill their prescriptions, treatment adherence just goes downhill from there.
Dr. Jørgen Serup
"I would say that even an optimistic estimate would be that only one in five patients truly follows the treatment advice and takes their treatment at home. It's really an alarming figure. The typical result is that the patient comes in complaining, 'It didn't work, doctor,' and now they expect another prescription," Dr. Jørgen Serup said.
"Creams and ointments are truly messy, greasy, cumbersome, and patients can only treat a limited number of lesions on a limited area, and only on certain anatomic sites. These are serious limitations. This is a lot more difficult than just taking a pill," added Dr. Serup, professor of dermatology at Copenhagen University. "Maybe the creams and ointments are really obsolete because they are so difficult to use in clinical practice. Maybe we should be using much more systemic therapy."
He and his colleagues examined all new prescriptions for previously untried medications issued for dermatologic outpatients at Copenhagen University Hospital every 15th day during 2006. Thirty-one percent of the 322 eligible patients exhibited what Dr. Serup termed "primary nonadherence," meaning they never collected their medication. Patients with psoriasis were the biggest offenders; they failed to pick up their medications 44% of the time. This was also the case for 31% of atopic dermatitis patients, 12% being treated for skin infections, and 9% of acne patients.
Thirty-five percent of prescriptions for topical preparations remained behind the pharmacy counter. Prescriptions for systemic agents fared much better; only 14% went unredeemed (J. Am. Acad. Dermatol. 2008;59:27-33).
In another study, the Danish dermatologists visited the homes of 17 first-time dermatologic outpatients who had been given prescriptions for previously untried topical medications. Upon weighing the patients' drug containers, the investigators found only 1 of the 17 patients used the directed dosage. Two patients never picked up their prescriptions, 13 used too little drug, and 1 patient used too much (J. Am. Acad. Dermatol. 2008;59:975-80).
Inadequate application of topical agents is another problem. In a joint study conducted with Swedish dermatologists, the Danish investigators found that highly motivated volunteers applied a fluorescent test cream to only 69% of the skin surface as directed. Areas prone to neglect included the upper breast, axilla and surrounding skin, posterior trunk, legs, and soles of the feet (Br. J. Dermatol. 2007;156:974-8).
Yet another form of treatment noncompliance results from patients’ failure to show up for scheduled appointments. Dr. Serup and coworkers recently reviewed 3,592 patient appointments at the university hospital’s outpatient dermatology clinic and found that 13% of patients didn’t keep their appointments. Patients failed to show for about 10% of all appointments because of forgetfulness or a variety of excuses; this was most common in patients under age 30. The rest of the no-shows were caused by booking mistakes by the clinic staff.
Poor physician-patient communication plays a role in noncompliance as well, as underscored in a study in which Dr. Serup’s colleagues taped and studied 57 dermatologic consultations with 17 dermatology patients, all of whom received new prescriptions for topical agents. At follow-up 2 weeks later, only 41% of patients were familiar with their diagnosis, 71% understood the recommended number of treatment applications per day, and 35% knew the planned duration of treatment. Just 12% of patients understood the proper quantity of the topical agent to be applied; their ignorance on this score was understandable, since dermatologists covered that key issue in only 18% of the recorded clinic visits. Moreover, dermatologists provided a clear explanation of the diagnosis in only 65% of cases (J. Dermatolog. Treat. 2009;20:190-3).
On a more optimistic note, Dr. Serup believes mobile phones and other modern tools can be better utilized to boost compliance among dermatology patients, especially the younger ones, who tend to have the lowest compliance rates. The literature shows that text message reminders and email consultations are effective in this regard, at least within general medicine. A system recently developed in Sweden allows patients to install software on their mobile phone so they can monitor their disease and phone their physician for data transfer and to communicate about therapy. Dr. Serup has utilized this technology to follow the course of treatment in patients with atopic dermatitis.