Original Research
Improving Adherence to Topical Treatment
The efficacy of topical medications generally increases when they are used as directed. To help patients achieve optimal therapeutic outcomes, it...
Comment
Poor adherence to treatment is a pervasive problem in patients with AD. Our review of the literature confirmed that patients generally are not accurate historians of their medication usage, often reporting near-perfect treatment adherence even when actual adherence is poor. Rates of adherence from clinical trials are likely higher than those seen in clinical practice due in part to study incentives and differences between how patients in a study are treated compared to those in a physician’s clinic; for example, research study participants often have additional follow-up visits compared to those being treated in the clinical population and by virtue of being enrolled in a study are aware that their behavior is being monitored, which can increase treatment adherence.7
The dogma suggesting that tachyphylaxis can occur with long-term use of topical corticosteroids is not supported by clinical trials.14 Furthermore, in our review of the literature patient adherence was highest in the shortest study11 and lowest in the longest study.7 Given that AD patients cannot benefit from a treatment if they do not use it, the supposed decrease in efficacy of topical corticosteroids over time may be because patients fail to use them consistently.
Our review of the literature was limited by the small body of research that exists on treatment adherence in AD patients, especially relating to topical medications, and did not reveal any studies evaluating systemic medications in AD. Of the studies we examined, sample sizes were small and treatment and follow-up periods were short. Our review only covered adherence to prescribed topical medications in AD, chiefly corticosteroids; thus, we did not evaluate adherence to other therapies (eg, emollients) in this patient population.
The existing research also is limited by the relative paucity of data showing a correlation between improved adherence to topical treatment and improved disease outcomes, which may be due to the methodological limitations of the study designs that have been used; for instance, studies may use objective monitors to describe daily adherence to treatment, but disease severity typically is measured over longer periods of time, usually every few weeks or months. Short-term data may not be an accurate demonstration of how participants’ actual treatment adherence impacts disease outcome, as the data does not account for more complex adherence factors; for example, participants who achieve good disease control using topical corticosteroids for an 8-week study period may actually demonstrate poor treatment adherence overall, as topical corticosteroids have good short-term efficacy and the patient may have stopped using the product after the first few weeks of the treatment period. In contrast, poorly adherent patients may never use the medication well enough to achieve improvement and may continue low-level use throughout the study period. Therefore, studies that measure disease severity at more regular intervals are required to show the true effect of treatment adherence on disease outcomes.
Since AD mainly affects children, family issues can pose special challenges to attaining good treatment adherence.15,16 The physician–patient (or parent) relationship and the family’s perception of the patient’s disease severity are strong predictors of adherence to topical treatment.16 Potential barriers to adherence in the pediatric population are caregivers with negative beliefs about treatment, the time-consuming nature of applying topical therapies, or a child who is uncooperative.15,17 In the treatment of infants, critical factors are caregiver availability and beliefs and fears about medications and their side effects, while in the teenage population, the desire to “fit in” and oppositional behavior can lead to poor adherence to treatment.17 Regardless of age, other barriers to treatment adherence are forgetfulness, belief that the drug is not working, and the messiness of treatment.17
Educational tools (eg, action plans, instructions about how to apply topical medications correctly) may be underutilized in patients with AD. If consistently implemented, these tools could have a positive impact on adherence to medication in patients with AD. For example, written action plans pioneered in the asthma community have shown to improve quality of life and reduce disease severity and may offer the same benefits for AD patients due to the similarities of the diseases.18 Since AD patients and their caregivers often are not well versed in how to apply topical medications correctly, efforts to educate patients could potentially increase adherence to treatment. In one study, AD patients began to use medications more effectively after applying a fluorescent cream to reveal affected areas they had missed, and clinicians were able to provide additional instruction based on the findings.19
Adherence to topical treatments among AD patients is a multifactorial issue. Regimens often are complex and inconvenient due to the need for multiple medications, the topical nature of the products, and the need for frequent application. To optimize prescription treatments, patients also must be diligent with preventive measures such as application of topical emollients and use of bathing techniques (eg, bleach baths). A way to overcome treatment complexity and increase adherence may be to provide a written action plan and involve the patient and caregiver in the plan’s development. If a drug formulation is not aesthetically acceptable to the patient (eg, the greasiness of an ointment), allowing the patient to choose the medication vehicle may increase satisfaction and use.12 Fear of steroid side effects also is common among patients and caregivers and could be overcome with education about the product.20
Conclusion
Treatment adherence can have a dramatic effect on diseases outcomes and can be particularly challenging in AD due to the use of topical medications with complex treatment regimens. Additionally, a large majority of patients with AD are children, from infants to teenagers, adding another layer of treatment challenges. Further research is needed to more definitively develop effective methods for enhancing treatment adherence in this patient population. Although enormous amounts of money are being spent to develop improved treatments for AD, we may be able to achieve far more benefit at a much lower cost by figuring out how to get patients to adhere to the treatments that are already available.