- Allison Truong, MD, FAAD
- Expert Insights, Quality of Life, Research, Treatment
THE 101
- Topical agents are the cornerstone of many psoriasis treatment algorithms. Numerous creams, ointments, lotions, suspensions, foams, gels, solutions, and shampoos are available for improving acute flares and sustaining these improvements with maintenance control.
- Despite the advancements in systemic agents available for psoriasis, many patients still prefer topical agents as a first-line treatment for their perceived safety and tolerability compared to its counterparts, such as orals or injectables.
- Certain patients, such as those considering or currently pregnant, undergoing chemotherapy or organ transplantation, often choose topicals to limit their systemic medication exposure.
- Topicals continue to be particularly important in caring for psoriasis patients and many other chronic skin conditions in dermatology.
Challenges in Psoriasis Treatment Adherence
Despite the initial interest in topical treatments by many patients, suboptimal treatment outcomes often ensue, leaving disillusionment for both providers and patients. This may lead to several switches to other available topical agents or even to systemic agents altogether during any individual patient’s treatment journey. There may be various possible explanations for these suboptimal results, such as inefficacy of the medication, side effects from the medication leading to early termination, patients’ aversion to the consistency of the product, and others. However, these explanations often lead back to the conclusion that the likely cause of the lack of efficacy may be patient nonadherence due to various factors.
Understanding Medical Adherence
Medical adherence, previously referred to as “compliance,” is the degree to which patients use medications as prescribed by their health care professionals (HCPs). In a Cochrane systematic review of medication adherence, it is estimated that patients were only adherent 50% of the time in the setting of chronic diseases.1 A similar finding was seen in topical treatment adherence among psoriasis patients in an 8-week clinical trial of 30 psoriasis patients who utilized medical logs and medical weights versus electronic monitors to measure adherence to their use of topical agents.2 Overall adherence decreased from 84.6% to 51% by the end of the 8-week treatment period with the most treatment gaps occurring on the weekends and slight upticks in use observed around trial visit dates, a phenomenon labeled the “white coat effect.”2 Interestingly, female sex and older age were statistically significant factors in adherence.2 Of note, patient adherence in daily clinical practice is predicted to be likely lower than these reported numbers, given that patients in the study were compensated and notified that they were being monitored.2
The Cost of Nonadherence
In an anonymous postal survey study sent to psoriasis patients from a tertiary psoriasis specialty clinic, patients reported a 39% rate of noncompliance with treatment, stating that they “sometimes” or “never” complied with treatment.3 These patients with intentional noncompliance also believed their psoriasis impacted their quality of life and overall well-being.3 Thus, nonadherence costs are immense to our healthcare industry, not only to patients’ overall health, but they also create an enormous financial burden. Over $100 billion in the United States annually is attributed to patient nonadherence in hospital stays, excess treatments, and unused medications.4
Strategies to Improve Adherence
To facilitate improvement in adherence, it is crucial to consider factors such as improving communication between HCPs and patients, incorporating patients’ preference for certain attributes of topical medications, and considering medication vehicles in patient convenience and adherence.5 Working in partnership with patients in a collaborative model where patients have a more central role in establishing their treatment regimen may help patients adhere with their psoriasis treatments.3,7 Additionally, it is important to simplify topical treatment regimens as much as possible to improve adherence. In an acne study, a once-daily combination product showed better adherence rates and efficacy than the daily application of the same two pharmacological agents.6
Topical Agents in Psoriasis Treatment
Topical corticosteroids in various strengths and formulations continue to be an essential part of psoriasis treatment regimens, often prescribed for use once a day or twice daily for acute flares for several weeks at a time to limit side effects of dyspigmentation, skin atrophy, and tachyphylaxis. Other agents that have similar remittive effects without steroid effects include tar and dithranol, vitamin D3 analogs such as calcitriol or calcipotriene, retinoids such as tazarotene, calcineurin inhibitors such as tacrolimus or pimecrolimus, and combination therapies, i.e. corticosteroid-vitamin D analogs.
New Steroid-Free Topical Agents
With the advent of additional new steroid-free topical agents, such as roflumilast (Zoryveâ), a phosphodiesterase-4 (PDE4) inhibitor, and tapinarof (Vtamaâ), a hydrocarbon receptor agonist, both recently U.S. Food and Drug Administration (FDA) approved in 2022, it may be easier to help patients improve adherence and their psoriasis long-term. Both these newer agents are once daily use, and both topicals come in the form of a cream, which is not oily or sticky compared to ointments, allowing patients who prefer this vehicle to have more success with their psoriasis treatment journey. Also, given its steroid-free property, this allows for its continuous use in all affected areas, including elbows, knees, axillae, and groin.
Overcoming Adherence Challenges in Psoriasis Care
Patient adherence may be the largest barrier to treatment success in caring for patients with chronic skin diseases such as psoriasis. Psoriasis is a complex skin disease that can be treated effectively with topical agents if patients use the prescribed agents. Previously, topical steroids were the mainstay of the topical treatment armamentarium for psoriasis. Nowadays, newer topical agents are available to add to our ability to improve patient care and adherence. By incorporating patients’ preferences and improving communication between HCPs and patients, psoriasis patients will adhere more to their topical treatments, which may improve their skin and overall health.
References
- Interventions for Helping Patients to Follow Prescriptions for Medications. Haynes RB, McDonald H, Garg AX, Montague P. Cochrane Database Syst Rev. 2002;(2):CD000011.
- Adherence to Topical Therapy Decreases During the Course of an 8-week Psoriasis Clinical Trial: Commonly Used Methods of Measuring Adherence to Topical Therapy Overestimate Actual Use. Carroll CL, Feldman SR, Camacho FT, Manuel JC, Balkrishnan R. J Am Acad Dermatol. 2004 Aug;51(2):212-6.
- Patients with Psoriasis and Their Compliance with Medication. Richards HL, Fortune DG, O’Sullivan TM, Main CJ, Griffiths CE. J Am Acad Dermatol. 1999 Oct;41(4):581-3.
- Medication Compliance: A Healthcare Problem. Berg JS, Dischler J, Wagner DJ, Raia JJ, Palmer-Shevlin N. Ann Pharmacother 1993;27:S1-24.
- Engaging Psoriasis Patients in Adherence and Outcomes to Topical Treatments: A Summary from the Symposium ‘Tailoring Topical Psoriasis Treatments to Patients’ Needs and Expectations’ of the 30thEADV Congress 2021. Bewley A, van de Kerkhof P. J Eur Acad Dermatol Venereol. 2023 Jan;37 Suppl 1:9-13.
- Simplifying Regimens Promotes Greater Adherence and Outcomes with Topical Acne Medications: A Randomized Controlled Trial. Yentzer BA, Ade RA, Fountain JM et al. Cutis 2010; 86: 103–108.
- Psoriasis: Improving Adherence to Topical Therapy. Feldman SR, Horn EJ, Balkrishnan R, et al. J Am Acad Dermatol. 2008 Dec;59(6):1009-16. doi: 10.1016/j.jaad.2008.08.028. Epub 2008 Oct 2. PMID: 18835062.
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