Adherence Challenges and Solutions in Psoriasis Treatment

Dr. Turck: 

You’re listening to DermConsult on ReachMD. I’m Dr. Charles Turck. And joining me to discuss medication adherence in patients with psoriasis is returning guest Dr. Steven Feldman. He’s a Professor of Dermatology, Pathology, Social Sciences, and Health Policy at the Wake Forest University School of Medicine in Winston Salem, North Carolina. 

Dr. Feldman, welcome to the program.

Dr. Feldman:

It’s such a pleasure to be here with you.

Dr. Turck:

So why don’t we start, Dr. Feldman, by examining some of the key factors associated with nonadherence. First, what can you tell us about disease-related factors?

Dr. Feldman:

Yeah, I think adherence is bad no matter what kind of disease you have. I had the impression that primary care providers think that adherence is a real issue in patients who have those silent diseases, like hypertension and diabetes, but if you had something that acutely bothered you, that was itchy or painful, and you could see it like psoriasis, you would be motivated to use your treatments. Well, motivation doesn’t do the trick, so across all diseases, poor adherence is a problem. I remember learning about this in medical school. I read that you could cure gonorrhea by taking an antibiotic pill for a week, and we don’t treat people with gonorrhea that way. We give them an injection because you can’t count on people to take a pill reliably for just one week. And what we ask psoriasis patients to do, especially with topical therapy, is much harder than taking a pill for a week. So across all diseases, we should be thinking no matter how bothersome the disease is to the patient, we need to make sure patients use their medications well.

Dr. Turck:

Are there are any other factors at all that you can think of that might affect adherence to psoriasis?

Dr. Feldman:

Oh gosh, yes. I think that far and away, the number one biggest factor is how the doctor treats the patient, you know, what they do to get patients to use the medicine. I like to illustrate this with what I call “the parable of the piano teacher.” You know, my kids took piano lessons. The piano teacher gave them some sheet music, had a lesson with them once a week, and at the end of 8 to 12 weeks, there was a recital, and this recital sounded pretty good because all the kids were practicing every week. Now what would happen if a new piano teacher says, “Well, this is a very inefficient system; the reason they sound good is because they’re practicing every week, not because of the weekly lessons; I tell you what I’m going to do; I’m going to give them the sheet music, not have weekly lessons; just tell them to practice every day; see them at the recital in 8 to 12 weeks.” Now if a piano teacher did that—of course, no piano teacher would do that because they know it would be insane to do that—the recital would sound execrable because nobody’s going to practice until three days before the recital. Drug studies are like that first piano teacher because they bring the patients back at weeks one, two, four, six, eight, and they show us these graphs of patients with psoriasis getting better over time. Real-life practice is often worse than that second piano teacher. You know, real-life practice would be like a piano teacher saying, “Here’s a prescription for some sheet music. Take it to the sheet music store. I don’t know if your insurance company’s going to cover it or how much it’s going to cost, but I want you to fill this prescription. I want you to practice every day. Practicing may cause rashes, diarrhea, possibly a serious infection, but I want you to practice every day. I’ll see you at the recital in two to three months, and if the recital doesn’t sound good, well, I’ll give you a second and possibly a third musical instrument to practice at the same.” That’s what we’ve been doing. I think when we see poor adherence, it’s largely our fault because we just give people a prescription and just assume that they will use it. We don’t create that sense of accountability that you have with piano lessons, you have with drug studies, and I have with my weekly lab meetings with my students that make people do what they’re supposed to do.

Dr. Turck:

For those just tuning in, you’re listening to DermConsult on ReachMD. I’m Dr. Charles Turck, and I’m speaking with Dr. Steven Feldman about adherence to psoriasis treatments.

So, Dr. Feldman, now that we know about factors that can influence nonadherence, what steps can we take to overcome those challenges and improve adherence in our patients?

Dr. Feldman:

All right, let’s think about this as a pyramid, and the foundation of this adherence pyramid is making sure patients trust us and holding them accountable. So I’m a nerdy test tube scientist, but when I’m with patients, I do everything I can to make them feel like I’m an empathetic, caring physician. Most of your listeners probably already are empathetic, caring physicians, but that doesn’t matter. What matters is patients realize you are or at least think you are because that’s what changes their behavior. And then we have to hold them accountable. Telling them, “Do this,” or “See you in two to three months,” makes no sense. When I give them a new treatment, I tell them, “You call me later this week; let me know how this is working for you,” because I want to force them to fill the prescription and use the medicine real well.

Okay, once you’ve done all that foundational work, then the usual stuff they teach us in medical school about reminder systems and making sure the cost isn’t too high is important. If there’s side effects, you have two approaches.  You could use treatments that minimize side effects, or you just tell the patients, “You may experience X. In my experience, people who have X tend to do really well on the treatment,” which is true because it’s a sign they’re using the medicine. So if I’m giving somebody clobetasol solution for their scalp, which may sting, I tell the patient, “Now, this may sting. The stinging is a sign that it’s working,” which it is because it’s a sign they actually got it down to the scalp.

Okay. Then you’ve done all those basic things they teach us about. Then you can go to the top of the pyramid and do fun things. For young children, you can give them a sticker chart. You get some pink Frozen stickers and some blue Teenage Mutant Ninja Turtle stickers. And then you get a chart, and you give this kid a sticker every time they put their medicine on. Kids will jump through hoops of fire for a sticker. For teenagers, that’s probably not the best approach. For teenagers, you want to tell them, “This is the medicine most teenagers use in this situation.” Because what do teenagers want to be like? They want to be like most other teenagers. There’s a host of things you can do.

Dr. Turck:

And are there any technological advances available that can help us monitor patients’ adherence to psoriasis treatments?

Dr. Feldman:

My whole focus on adherence began when I was walking down the hall one day with my research colleague Raj Balkrishnan, and he told me there was a company selling medicine bottle caps that contained computer chips that recorded the day and time you open and close the bottles, and I’m like, “They make what?” I turned to my minions, and I said, “I don’t care what they cost. We have to find out what my psoriasis patients are doing.” Sure enough, their use of topicals was abysmal. In the long term, their adherence was so abysmal that the British Journal of Dermatology let me use the word “abysmal” in the title of the paper describing patients’ long-term adherence to topical therapy. There’s newer technology. I’ve been working with a company Sensal Health. Their computer chip caps have bells and whistles that will remind patients that it’s time to use the medicine. It shows patients how often they’ve been using the treatment. It records the day and time patients open and close the bottle. It records the temperature of the room. In addition, it records the weight of medication dispensed, and using the weight of medications dispensed, you could tell how many pills patients are taking out of the bottle. For tubes of cream, you could tell how much patients are using. This is great technology, not just for me to know what my patients are doing, but to educate my patients on how much to use. So if the computer chips and cap are telling the patient initially that “you’re using too much,” then the patient uses less. And then if they get to using too little, the computer chips say, “No, no, use a little more,” and it focuses the patient on not just the accurate timing, but the accurate dosing of medications. We live in fabulous times.

Dr. Turck:

Now before we wrap up, Dr. Feldman, is there anything else you’d like to add about improving treatment adherence or supporting patients with psoriasis?

Dr. Feldman:

Yeah. I think the key thing to note is patients’ adherence to treatment, especially topical treatment, is often abysmal, and do not blame the patient. Okay? There is an amazing quote taught to me by dermatologist Danny Berg. It’s a quote by the Vietnamese Buddhist monk Thích Nhất Hạnh. This may be the most important thing I tell you all, and I’m going to paraphrase him. It was something like, “If the lettuce is not growing well, you don’t blame the lettuce.” You have to take personal responsibility. Our patients aren’t lettuce, but when they’re not using their medicine well, it does us no good to blame the patient. We have to think about what we are doing to make sure patients use their medicine well.

Dr. Turck:

Well, with those key takeaways in mind, I want to thank my guest, Dr. Steven Feldman, for joining me to discuss how we can improve our patients’ adherence to psoriasis treatment plans. Dr. Feldman, it was great having you on the program. 

Dr. Feldman:

My pleasure.

Dr. Turck:

Now, for ReachMD, I’m Dr. Charles Turck. To access this and other episodes in our series, visit DermConsult on ReachMD.com, where you can Be Part of the Knowledge. Thanks for listening.