For psoriasis, which affects up to 5% of the Western population, topical drugs are still the preferred treatment for cases of mild-to-severe disease activity or as a supplement to systemic or biologic anti-psoriatic drugs, explains
Mathias Tiedemann Svendsen, MD, PhD. “However, treatment outcomes for use of the topical drugs are low, due
largely to poor adherence,” Dr. Svendsen says. “During the past 7 years, our study team conducted extensive research on patients with psoriasis, examining patterns of topical drug use. We not only observed a low adherence to use of topical drugs, but a rapid decline in the use of topical drugs and a rise in the use of systemic drugs such as methotrexate plus the more expensive biologics with unknown potential for long-term adverse effects. Therefore, we investigated how we could improve long-term use of topical anti-psoriatic drugs.” For a study published in Clinical and Experimental Dermatology, Dr. Svendsen and colleagues explored whether regular support from dermatology
nurses improves outcome and treatment adherence to topical medications in patients with psoriasis.

An Intervention Was Designed to Be Used in Clinical Practice

“Our study team previously assessed the potential of a smartphone app in improving short-term adherence to topical drugs,” Dr. Svendsen says. “Interestingly, the use of the smartphone app successively increased short-term utilization of topical anti-psoriasis drugs. Unfortunately, it was not possible to implement the use of the smartphone
in the clinical practice due to technical issues. We therefore decided to design an intervention that would improve long-term adherence to topical drugs and that could be used in clinical practice.” Together with a behavioral psychologist, the team identified five key elements that were considered crucial in improving the use of topical medication: 1) providing a reminder system, 2) keeping patients accountable for taking the medication, 3) rewarding patients for fulfilling the treatment plan, 4) building trust in the treatment, and 5) increasing ease of use by favorable comparison to other treatment options. Based on these key elements, they designed and tested an adherence improving intervention delivered by dermatology nurses in a randomized controlled trial.

Standard Care Group Compared With Intervention Group

A total of 103 patients with mild-to-moderate were randomized into a non-intervention group receiving standard care, which consisted of seeing a dermatologist every 12 weeks, or an intervention group receiving support from a dermatology nurse every 4 weeks for 20 minutes, focusing on the five central themes. The intervention was provided by three different nurses who followed the same patient throughout the entire study period.
The outcomes measured included severity of psoriasis, QOL, and adherence. “Overall, we found that topical anti psoriatic drug treatment needs to be accompanied by long term regular support to provide a minimal clinically significant difference from baseline values,” Dr. Svendsen says. “Our study emphasizes the importance of the patient-healthcare professional relationship, which is considered fundamental in the attempt to help patients follow their treatment plans. This was evident in one of our subgroup analyses, where one nurse significantly improved patients’ severity of psoriasis compared with the two other nurses.”

Reasons for Non-Adherence Are Multifactorial

The reasons why patients do not take their medications as prescribed are multifactorial and there is no ‘one size fits all’ when it comes to improving medical adherence, Dr. Svendsen notes. “Therefore, interventions aiming to improve medical adherence should be tailored to individual patient needs, and various factors should be taken into consideration when delivering adherence-improving interventions (Figure).” Increased and structured support from dermatology nurses for patients with psoriasis significantly improves treatment outcomes, Dr. Svendsen notes. “We recommend that dermatologists collaborate with nurses when aiming to improve patients’ medical adherence,” he says. Dr. Svendsen and colleagues would like to see future research focus more on patients’ preferences for the vehicle by which a drug is delivered and investigate the optimal regimen for proactive treatment to prevent the frequent flares seen in patients who use topical treatments.