July 17, 2007 Patients not complying with their dermatologic treatment is a universal problem that doctors need to address, according to Steven Feldman, M.D., Ph.D., from Wake Forest University School of Medicine in an editorial published in the current issue of Archives of Dermatology. He said non-compliance can explain why some conditions may seem resistant to treatment.
"Physicians must develop practical measures to improve patients' compliance behavior: establishing strong, trusting physician-patient relations, choosing medications that can fit patients' lifestyles, using patient education materials designed to motivate without overly stressing risks, and scheduling a follow-up visit shortly after initiating a new treatment," writes Feldman, a professor of dermatology.
Feldman says that dermatology research studies that involve electronically recording patients' usage of a treatment, without them being aware of it, show that non-compliance is more pervasive that previously estimated.
"Understanding that non-adherence to treatment is widespread is essential for addressing many of the difficult-to-manage skin disease dilemmas seen in dermatology," Feldman said. "By addressing adherence, we can achieve better success for patients with psoriasis and other chronic skin diseases."
Feldman says he has had personal experience with patient noncompliance. He had acne and wanted to see how well current anti-acne medications work. He planned to take a photo of the rash, put the medicine on once a day and then take a photograph one week later.
"I wanted to make sure I didn't forget to apply the medication, so I put it on top of my toothbrush," he said. "The first night I used the medication. The second night I managed to brush my teeth and still forget to put the medication on. The third and fourth nights I went out of town and forgot to bring the medication with me. And I tend to be on the obsessive compulsive side!"
Patient forgetfulness is just one part of the problem, he said. Sometimes, patients consider treatment the worst part of the disease. For example, scalp psoriasis may seem resistant to treatment, he said. Actually, psoriasis treatments probably work better on the scalp than on other areas of the skin, if patients would just apply the medication.
Rather than having patients continually try new treatments for scalp psoriasis, he suggests having patients try the treatment for three to four days.
"It is much easier to be compliant for three or four days than for eight weeks," Feldman said. "After that, patients will know they have a treatment that works and will use it as needed to keep their scalp psoriasis under control."
He said that when prescribing medications, physicians need to consider which form is most likely to be used. Many patients prefer pills over creams and ointments, he said. Another option is physician-administered treatments, such as injections, that will assure adherence.
Feldman says doctors shouldn't be surprised by poor adherence to using creams and ointments in the home environment, especially involving pediatric patients.
"Those of us who are parents will recognize how difficult it is to apply sunscreen or other topical agents to our own children," he said.
In addition to considering the form of therapy that patients are most likely to use, Feldman said the patient-physician relationship is an important part of the equation. He said research shows that if patients are satisfied with their physician visit three days afterwards, they are more likely to report an improvement in their condition a month later.
"Patients who are more satisfied with their visit are more trusting of their doctor, worry less about adverse effects and use their medication more regularly," he said.
Feldman's co-authors are Saba M. Ali, B.S., Robert T. Brodell, M.D., and Rajesh Balkrishnan, Ph.D., all with Wake Forest.
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