A Review of Patient Adherence to Topical Therapies for Treatment of Atopic Dermatitis

Atopic dermatitis (AD) is a chronic inflammatory skin disease that typically begins in early childhood (Figure). It is one of the most commonly diagnosed dermatologic conditions, affecting up to 25% of children and 2% to 3% of adults in the United States.^1,2 The mainstays of treatment for AD are topical emollients and topical medications, of which corticosteroids are most commonly prescribed.³ Although treatments for AD generally are straightforward and efficacious when used correctly, poor adherence to treatment often prevents patients from achieving disease control.⁴ Patient adherence to therapy is a familiar challenge in dermatology, especially for diseases like AD that require long-term treatment with topical medications.^4,5 In some instances, poor adherence may be misconstrued as poor response to treatment, which may lead to escalation to more powerful and potentially dangerous systemic medications.⁶ Ensuring good adherence to treatment leads to better outcomes and disease control, averts unnecessary treatment, prevents disease complications, improves quality of life, and decreases treatment cost.^4,5 This article provides a review of the literature on patient adherence to topical therapies for AD as well as a discussion of methods to improve patient adherence to treatment in the clinical setting.

Atopic dermatitis on the bilateral popliteal fossae. Photograph printed with permission from the Graham Dermatopathology Archive, Wake Forest University School of Medicine, Winston-Salem, North Carolina.

Methods

A PubMed search of articles indexed for MEDLINE from January 2005 to May 2015 was conducted to identify studies that focused on treatment adherence in AD using the search terms atopic dermatitis and medication adherence and atopic dermatitis and patient compliance After excluding duplicate results and those that were not in the English language, a final list of clinical trials that investigated patient adherence/compliance to topical medications for the treatment of AD was extracted for evaluation.

Results

Our review of the literature yielded 7 quantitative studies that evaluated adherence to topical medications in AD using electronic monitoring and/or self-reporting (Table).^7-13 Participant demographics, disease severity, drug and vehicle used, duration of treatment, and number of follow-up visits varied. All studies used medication event monitoring system caps on medication jars to objectively track patient adherence by recording the date and time when the cap was removed. To assess disease response, the studies used such measures as the Investigator Global Assessment scale, Eczema Area and Severity Index score, or other visual analog scales.

In all of the studies, treatment proved effective and disease severity declined from baseline regardless of the rate of adherence, with benefit continuing after treatment had ended.^7-13 Some results suggested that better adherence increased treatment efficacy and reduced disease severity.^8,9 However, one 10-day trial found no difference in severity and efficacy among participants who applied the medication at least once daily, missed applications some days, or applied the medication more than twice daily.¹³

Study participants typically overestimated their adherence to treatment compared to actual adherence rates, with most reporting near 100% adherence.^7-9,11,12 Average measured adherence rates ranged from 32% to 93% (Table). Adherence rates typically were highest at the beginning of the study and decreased as the study continued.^7-13 The study with the best average adherence rate of 93% had the shortest treatment period of 3 days,¹¹ and the study with the lowest average adherence rate of 32% had the longest treatment period of 8 weeks.⁷ The study with the lowest adherence rate was the only study wherein participants were blinded to their enrollment in the study, which would most closely mimic adherence rates in clinical practice.⁷ The participants in the other studies were not aware that their adherence was being monitored, but their behavior may have been influenced since they were aware of their enrollment in the study.

Many variables affect treatment adherence in patients with AD. Average adherence rates were significantly higher (P=.03) in participants with greater disease severity.⁷ There is conflicting evidence regarding the role of medication vehicle in treatment adherence. While Wilson et al⁹ did not find any difference in adherence based on medication vehicle, Yentzer et al¹² found vehicle characteristics and medication side effects were among patients’ top-ranked concerns about using topical medications. Sagransky et al¹⁰ compared treatment adherence between 2 groups of AD patients: one control group received a standard-of-care 4-week follow-up, and an active group received an additional 1-week follow-up. The mean adherence rate of the treatment group was 69% compared with 54% in the control group.¹⁰