Dermatology Online Journal

Poor compliance with topical corticosteroids for atopic dermatitis despite severe disease
Katherine L Brown, MD MPH¹ Jennifer Krejci-Manwaring MD², Mark G Tusa MD³ Fabian Camacho MS³, Alan B Fleischer Jr MD³, Rajesh Balkrishnan PhD⁴, Steven R Feldman MD PhD⁵
Dermatology Online Journal 14 (9): 13

1. University of Massachusetts Medical School, Worcester, Massachusetts
2. Department of Dermatology, University of Kansas Medical Center, Kansas City, Kansas
3. Center for Dermatology Research, Department of Dermatology, Wake Forest University School of Medicine, Winston-Salem, North Carolina
4. Ohio State School of Medicine and Public Health, Columbus, Ohio
5. Departments of Dermatology, Pathology, and Public Health Sciences, Wake Forest University School of Medicine, Winston-Salem, North Carolina. sfeldman@wfubmc.edu

---

Abstract

Electronic monitoring of adherence provides opportunities for new insights into the relationship between adherence and treatment outcomes. We report a patient who was non-adherent to treatment despite a high degree of atopic dermatitis severity. Such patients may be better managed by measures that increase adherence rather than use of more potent, potentially toxic medications.

---

Introduction

Topical corticosteroids and other topical treatments are widely used for atopic dermatitis but are not uniformly effective in clinical practice [1, 2, 3]. Adherence refers to the extent to which the patient's behavior coincides with the treatment regimen [4, 5, 6]. Poor adherence may account for at least some atopic dermatitis treatment failures. We report a case where topical treatment was poorly used, despite a high level of atopic dermatitis severity.

Case Report

A three-year-old female presented with poorly controlled atopic dermatitis. She had been treated previously with topical triamcinolone, diflorasone, pimecrolimus, tacrolimus, hydrocortisone, and desonide without improvement in her condition. She was entered into a study assessing adherence in patients with atopic dermatitis. Triamcinolone 0.1 percent ointment was provided in a bottle fitted with an electronic monitor. The parents were instructed to apply the medication twice daily and to return in four weeks and eight weeks; the child and her parents were not told that adherence was being monitored, nor were they told that this was a formal study (in order to assess patient [as opposed to research subject] adherence) [7]. The study was approved by the Institutional Review Board of Wake Forest University School of Medicine. At each visit, disease severity was assessed using the Eczema Area and Severity Index (EASI). Adherence behavior questionnaires were administered at the final study visit, at which time adherence monitoring was disclosed and data on the patient's adherence behavior were used to provide individualized treatment advice.

During the two-month study, the child used only eight percent of the recommended triamcinolone doses. She had medication use holidays lasting nineteen days, thirteen days, and seven days, with a few days of use in between each period of non-use. Her EASI score was 10.8 at baseline, 14.4 at week four, and 12.6 at week eight. In the medication use survey completed at the end of the study, the patient's parent expressed concerns about medication side effects and admitted sometimes not wanting to use the medication. However, the parent had also stated that she never refused to apply her child's medications and never applied less medication than prescribed.

Conclusions

Non-adherence can result in substantial costs due to repeated visits, multiple medication trials, and use of more risky treatments. Unfortunately, poor use may be difficult to assess. Patients and their caretakers may not be truthful or forthcoming with their actual medication use, and adherence measures that rely on patients' memory (e.g., interviews and surveys) often result in overestimations of medication use [7, 8, 9]. One limitation of adherence research studies is the possibility that people decrease their adherence as their disease improves. This complicates attempts to assess whether improved adherence results in better outcomes. Nevertheless, as this patient exemplifies, poor use is not always due to patients getting well - treatment may be stopped even while the patient is still suffering from the skin condition. Our patient had failed multiple topical treatments and might have been considered a good candidate for aggressive systemic treatment. Interventions that would improve adherence to topical treatment may be a safer approach for such patients.

Purported reasons for medication nonadherence include forgetfulness, lack of efficacy, inconvenience, change in disease severity, and fear of medication side effects [7, 8, 9, 10, 11, 12, 13]. In addition, patients may find topical treatments to be particularly unpleasant and time consuming relative to other types of medications [7, 11, 14]. Prior studies suggest that more frequent patient contact [7] (e.g., office visits or phone calls), less messy medication formulations, clear instructions, and education about the natural course of the disease and the rationales for different therapeutic strategies [12, 15] could be viable means for increasing adherence.

Parental factors affecting adherence are also important to consider, especially with patients who are too young to administer their own medications. According to a questionnaire-based study of 200 dermatology patients with atopic eczema, 73 percent of people worried about using corticosteroids on their own or their child's skin and 24 percent admitted to having been non-compliant with topical corticosteroids treatment because of these worries [13]. In this regard, it may be beneficial if physicians do not overly frighten patients and parents at the initial office visit with the potential side effects of topical corticosteroids [7].

References

1. Darsow U, Lübbe J, Taïeb A, Seidenari S, Wollenberg A, Calza AM, Giusti F, Ring J; European Task Force on Atopic Dermatitis. Position paper on diagnosis and treatment of atopic dermatitis. J Eur Acad Dermatol Venereol. 2005 May;19(3):286-95. PubMed

2. Raimer SS. Managing pediatric atopic dermatitis. Clin Pediatr (Phila). 2000 Jan;39(1):1-14. Review. PubMed

3. Torok HM, Maas-Irslinger R, Slayton RM. Clocortolone pivalate cream 0.1% used concomitantly with tacrolimus ointment 0.1% in atopic dermatitis. Cutis. 2003 Aug;72(2):161-6. PubMed

4. Balkrishnan R, Carroll CL, Camacho FT, Feldman SR. Electronic monitoring of medication adherence in skin disease: results of a pilot study. J Am Acad Dermatol. 2003 Oct;49(4):651-4. PubMed

5. McDonald HP, Garg AX, Haynes RB. Interventions to enhance patient adherence to medication prescriptions: scientific review. JAMA. 2002 Dec 11;288(22):2868-79. Review. Erratum in: JAMA. 2003 Jun 25;289(24):3242. PubMed

6. Cork MJ, Britton J, Butler L, Young S, Murphy R, Keohane SG. Comparison of parent knowledge, therapy utilization and severity of atopic eczema before and after explanation and demonstration of topical therapies by a specialist dermatology nurse. Br J Dermatol. 2003 Sep;149(3):582-9. PubMed

7. Krejci-Manwaring J, Tusa MG, Carroll C, Camacho F, Kaur M, Carr D, Fleischer AB Jr, Balkrishnan R, Feldman SR. Stealth monitoring of adherence to topical medication: adherence is very poor in children with atopic dermatitis. J Am Acad Dermatol. 2007 Feb;56(2):211-6. Epub 2006 Nov 13. PubMed

8. Carroll CL, Feldman SR, Camacho FT, Manuel JC, Balkrishnan R. 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. J Am Acad Dermatol. 2004 Aug;51(2):212-6. PubMed

9. Tusa MG, Ladd M, Kaur M, Balkrishnan R, Feldman SR. Adapting electronic adherence monitors to standard packages of topical medications. J Am Acad Dermatol. 2006 Nov;55(5):886-7. Epub 2006 Sep 1. PubMed

10. Murphy J, Coster G. Issues in patient compliance. Drugs. 1997 Dec;54(6):797-800. Review. PubMed

11. Richards HL, Fortune DG, O'Sullivan TM, Main CJ, Griffiths CE. Patients with psoriasis and their compliance with medication. J Am Acad Dermatol. 1999 Oct;41(4):581-3. PubMed

12. Brown KK, Rehmus WE, Kimball AB. Determining the relative importance of patient motivations for nonadherence to topical corticosteroid therapy in psoriasis. J Am Acad Dermatol 2006;55(4):607-13. PubMed

13. Charman CR, Morris AD, Williams HC. Topical corticosteroid phobia in patients with atopic eczema. Br J Dermatol. 2000 May;142(5):931-6. PubMed

14. Rapp SR, Exum ML, Reboussin DM, Feldman SR, Fleischer A, Clark A. The Physical, psychological and social impact of psoriasis. J Health Psychol 1997;2:525-37.

15. Feldman S, Behnam SM, Behnam SE, Koo JY. Involving the patient: impact of inflammatory skin disease and patient-focused care. J Am Acad Dermatol 2005;53(Suppl):S78-85. PubMed

© 2008 Dermatology Online Journal