Steven Feldman, MD, PhD
Professor of Dermatology, Pathology, Social Sciences and Health Policy
Wake Forest University School of Medicine, Wake Forest Baptist Health
Winston-Salem, North Carolina, United States
As Professor of Dermatology, Pathology, and Social Sciences and Health Policy at Wake Forest University School of Medicine, Board-Certified Dermatologist and Dermatopathologist at Wake Forest Baptist Health, member of the Medical Board of the National Psoriasis Foundation, and recipient of the Foundation’s Outstanding Educator in Psoriasis Disease Award, Dr. Steven Feldman has been rated the number one expert on psoriasis in the world by ExpertScape.com. He is also the chief medical editor of The Dermatologist, editor-in-chief of the Journal of Dermatological Treatment, and writes a column for PM360 on medical adherence. Dr. Feldman publishes prolifically on many dermatology topics, including psoriasis, specifically around patient adherence to psoriasis treatments, and has published books titled Practical Ways to Improve Patients’ Treatment Outcomes and Practical Ways to Improve Patient Adherence.
In a recent interview, Dr. Feldman shares the clinical pearls he has garnered through the years in improving patients’ quality of life and overall health by motivating patients to adhere to psoriasis therapies.
Patients Improve When They Adhere to Prescribed Treatment Regimens
Despite the advancements in psoriasis treatments, patients are not constantly improving. The lack of improvement may be beyond the prescription itself; rather, it may be due to patient-related factors such as lack of adherence.
Dr. Feldman explains, “Getting patients well takes more than making the right diagnosis and prescribing the right therapies. You also have the responsibility to get patients to take their medications. If they don’t take the medication, the medication is not going to work.”
Building a Foundation of Trust and Accountability Between the Provider and Patient Relationship
Understanding adherence means understanding human nature. Dr. Feldman explains that there is no other area of human endeavor where people are told to do something every day and evaluated months later. For example, in piano lessons, most people have weekly lessons before a big recital. In drug studies, patients are asked to visit the clinic at weeks 0, 1, 2, 4, 6, 8, and 12 to check and confirm adherence to an investigational drug. In real-life clinical care, patients are asked to return several weeks to months later to see the clinician again.
In Dr. Feldman’s clinical practice, he encourages patients to contact him a few days after the appointment to check for clinical improvement to his prescribed regimens to increase patient adherence. He finds that patients improve when motivated to pick up their medications and start the treatment expeditiously. Patients then become empowered when they see results. Over time, they will usually require fewer follow-ups.
Physicians need to appear empathetic and trustworthy and instill a sense of accountability in patients. To do this, Dr. Feldman recommends physicians provide clear and simple written instructions, assuage patients’ fears, and motivate people to follow prescribed treatment regimens.
Newer Medications Have Improved Adherence, But There is Still Room for Improvement
Adherence to topicals is “abysmal,” according to Dr. Feldman, but topical steroids are very effective and affordable for treating psoriasis. In a study of clobetasol propionate 0.05% spray in treating psoriasis, 78% of subjects were clear to almost clear in four weeks.1 Thus, Dr. Feldman knows that topicals work, but many patients are likely not using them correctly or using them at all. Getting patients to use topical agents requires work on the physicians’ part.
According to Dr. Feldman, there is better adherence to biologics requiring less frequent administration. Doctors have even more control over adherence to biologics that (in the United States) require in-office or injection center administration, such as tildrakizumab (Ilumya) or infliximab (Remicade). To assess adherence to the at-home administration of biologics, Dr. Feldman suggests asking patients, “Are you keeping the extra injectors you’ve accumulated refrigerated?” If the patient doesn’t answer, “I don’t know what you are talking about. I don’t have any extras,” they are most likely not adhering to the injection schedule. When patients are adherent, they should use their injectors as they come in the mail.
Future Technologies and Innovations to Assist in Patient Adherence
There is a lot of improvement that the health care industry can do to improve patient adherence. Dr. Feldman states, “There are endless things we can do better.” Patient adherence is essential as nonadherence leads to continued suffering and increases health care costs. Dr. Feldman’s ideas include creating more memorable pill boxes rather than the current status quo of beige color pill containers that blend into the environment.
Further, technology in the form of mobile applications and artificial intelligence (AI) plays a role in helping remind patients to take their medications promptly. If one can digitalize tools to improve patient adherence, there will be little to no added cost to the patient or physician, and many stakeholders may benefit. “Humans are interpersonal beings… AI can appear personal,” says Dr. Feldman. AI-assisted interventions may help improve communication between patients and physicians, monitor drug use, empower patients, and increase adherence levels, leading to better outcomes and quality of life for patients with psoriasis and other chronic illnesses.
Evaluation of the Efficacy and Safety of Clobetasol Propionate Spray in the Treatment of Plaque-type Psoriasis. Jarratt MT, Clark SD, Savin RC, et al. Cutis. 2006 Nov;78(5):348-54. PMID: 17186795.