Practical Strategies for Improving Adherence in Psoriasis Care

Announcer:
You’re listening to On the Frontlines of Psoriasis on ReachMD. And now, here’s your host, Ryan Quigley.

Ryan Quigley:
Welcome to On the Frontlines of Psoriasis on ReachMD. I'm Ryan Quigley, and today, I'm joined by Dr. Steve Feldman to discuss how we can improve patient adherence to psoriasis treatment. Dr. Feldman is a professor of dermatology, pathology, and public health sciences at Wake Forest University School of Medicine as well as a practicing dermatologist at Atrium Health Wake Forest Baptist in Winston-Salem, North Carolina.

Dr. Feldman, thank you so much for joining the program. It's great having you here.

Dr. Feldman:
Ryan, it's my pleasure to be here with you today.

Ryan Quigley:
So, Dr. Feldman, for a little bit of background, how significant are adherence challenges in psoriasis management today?

Dr. Feldman:
It depends on what kind of psoriasis we're talking about. I like to think there are two types: a relatively mild or limited type where there's just a couple spots that need some cream, versus a very severe, extensive kind where we'll give people either total body ultraviolet light treatments or internal medicines to control their disease. The vast majority of people with psoriasis have mild psoriasis—just a few spots. In doctors' offices, the percentage of people who have moderate-to-severe disease is actually considerably higher than it is in the population because a lot of the people with mild disease don't even come in.

The adherence challenges are actually the greatest in the patients with milder, limited involvement. It turns out that patients' use of topical therapy is abysmal. We learn in medical school that people won't take a pill, but rubbing something on your skin is much more time-consuming, messier, and harder to do than just taking a pill every day, so it just doesn't get done.

We did one long-term study in psoriasis patients where we gave them a topical steroid to use every day for the whole year. The adherence to the treatment was so abysmal that the British Journal of Dermatology, when we published the paper there, let me put the word "abysmal" in the title of the paper.

When people have more severe involvement and we're giving them pills and injections, they're more adherent to those, but there's still adherence challenges even there.

The adherence to topicals is limited by how messy they are. Sometimes, patients have a fear of side effects, which may be a problem for topicals as well as for internal medicines—maybe more so. From personal experience, I think forgetfulness is the biggest issue. Unless it is your habit to use or take your medication, there's a very good chance you're not going to do it. I think it's really easy to forget these things. A big hurdle is the limited sense of accountability that people have to others for their use of treatment.

Ryan Quigley:
For those just tuning in, you're listening to On the Frontlines of Psoriasis on ReachMD. I'm Ryan Quigley, and I'm speaking with Dr. Steve Feldman about patient adherence in psoriasis care.

So, Dr. Feldman, what communication strategies can clinicians use to set expectations with their patients and improve that long-term adherence?

Dr. Feldman:
There are studies of patient education, and those things have limited, modest, and marginal effects on patients’ use of their medicine. I went to an adherence meeting, and the top expert in the field got up in front of people and said, "Doctors can't make patients use their medicines." And I said, "That can't be right. I can get people to use the medicine." I went up to him after the meeting, and I asked him about it. He said, "Well, we doctors have been trying so hard. If it was something we could do, we'd have gotten it done by now." And his focus was on maybe changing aspects of the healthcare system.

But there is nothing more potent than what the doctor can do. And I'm going to prove this to you without any data whatsoever; I’m just going to tell you a parable. My kids took piano lessons. The piano teacher gave them some sheet music and told the kids, "Practice every day. I'm going to meet with you once a week. We'll have a recital in three to six months." The recital sounded great because the kids were practicing every week.

What would happen if a new piano teacher said, "Well, that's an inefficient system. The reason they sound so good at the recital is not because of the weekly lessons; it's because they practice every day. So, I will tell them to practice every day, and I won't have weekly lessons with them. I'll just tell them to practice every day.” Now, everybody knows if you did that, the recital would sound execrable. Nobody would hire that piano teacher. You must have those weekly lessons to make people practice.

Now, which of these two piano teachers is like a drug study where they bring the patient back at weeks one, two, four, six, eight, and 12, and they show you graphs showing the drug working great over time? Well, obviously, it's the first piano teacher. Which of these is how we doctors practice? A lot of doctors say, laughingly, “It's the second piano teacher.” No. We are worse than that second piano teacher. We're like a piano teacher who says, "Here's a prescription for some sheet music. Take it to the sheet music store. I have no idea how much it's going to cost, whether your insurance company's going to pay for it, or how much paperwork you're going to have to go through to get reimbursed for this. But I want you to take it to the sheet music store and fill the prescription. I want you to practice this sheet music every day, but be aware that practicing this sheet music may cause rashes, diarrhea, and possibly a serious infection. We're not going to have weekly lessons. You don't need that. Just practice every day. I will see you at the recital in three to six months, and if the recital doesn't sound good, which it often doesn't, I will give you a second and possibly third musical instrument to practice at the same time."

We're scratching our heads wondering why patients aren't taking their medicines. We're giving them written instructions, motivational interviewing, and reminder devices. If that piano teacher who didn't have the weekly lessons went to the medical literature and said, "My piano students aren't practicing, I'm going to go to the medical literature and find out what doctors do to get people to take their medicines. When I give them the sheet music, I'll also give them a reminder device or tell them to get one. I'll motivationally interview them. I'll give them written instructions to practice every day. I'll make sure they don't have any side effects. I'll make sure they own a piano. But I won't have weekly lessons with them." Is the recital going to sound that much better? No. It's not going to help. You have to create a sense of accountability in patients.

Humans are social beings, and so I would say the key thing for adherence is to have contact with your patient a few days to a week after starting that new prescription.

I started all this with the treatment of patients with scalp psoriasis. Scalp psoriasis was the mother of all compliance problems. I couldn't get anybody’s scalp cleared up because they weren't putting the medicine on. You have to simplify the treatment and make it really easy. I would tell patients, "It's just for three days. Come back in three days. Let me see how it's doing." They'd come back in three days with this big bag of stuff that wasn't working. I'd pull out one, which was still full, and I'd say, "Let's use this. But just for three days. Just do this one thing twice a day with the help of your spouse for three days. I'll see you back in the office in three." They'd come back in three days, 95 percent clear and ecstatic with how they were doing.

Then, I thought, "Hey, I don't need to see them back. I'll just give them my cell phone number and tell them to call me in three days." They would call in three days, and whether I answered the phone or not didn't matter. All that mattered was that they thought they were going to speak to me, and they'd leave me messages like, “I'm so glad you didn't pick up the phone because I really didn't want to bother you, but you said I had to call. You're right. It's 90 percent better already." Then, they see that it works. They're in the habit of using their medicine. I don't think you need to keep seeing them every week, but it's so much more efficient to see the patients once at one week than it is to see them back every eight weeks doing poorly and having to change the therapy.

Ryan Quigley:
To that point, what other supportive resources can clinicians integrate into psoriasis care?

Dr. Feldman:
I think a very simple tool is the concept of triggers. My son and I did taekwondo together, barefoot on the mats. Of course, I got a fungus. It was curable if I would just put the over-the-counter antifungal cream on my feet every day, which I did not do. I wanted to do it, but I'd wake up in the morning and, like Pavlov's dogs, I'd put my shoes and socks on, then I would see the cream and say, "I'm too lazy to take my shoes and socks off. I'll do it tomorrow." And tomorrow would come, and I'd put my shoes and socks on. Then I moved the cream from my dresser to be on top of my socks in the drawer so that I couldn't get to my socks without seeing the cream first, and suddenly, I never forgot. My tinea pedis was cured instantly.

This is a tool that I use regularly. If somebody's got something that I need to treat, I want to put their treatment in the course of their life. That forces them to see the treatment before they move on to the next thing.

I'll tell you another thing. Packaging of drugs is largely horrible. There is one exception: birth control pills. In the 1960s, birth control pills only worked so-so. The chemistry has barely changed, but the drugs are dramatically more effective because the packages tell you what pill to take, what day. The idea of giving people pills in a beige bottle that blends in with any environment so that it's designed for you not to notice that they're there is absurd. I think what we doctors can do is tell people to use a seven-day pillbox. It just should be automatic.

The other supportive resource that I think is phenomenally beneficial for our patients with psoriasis is our National Psoriasis Foundation, which you can find at psoriasis.org. They've just got a wealth of educational information for patients. They tell patients about all their treatment options, and on top of everything else, they're so supportive of doctors. They tell patients, "If you want to get well, listen to what your doctor is suggesting." Adherence is critically important.

Ryan Quigley:
A final question for you, Dr. Feldman: looking ahead, what emerging strategies might further improve adherence to psoriasis treatments in the future?

Dr. Feldman:
I think the main thing is this sense of accountability I think that's a key driver. Here at Wake Forest, we have a center for the use of artificial intelligence and technology for improving patients' lives. My research team has a small grant from them to work on this accountability concept but scale it up so that it doesn't actually involve any human contact. We'll have the electronic medical record system have an avatar of me, with my face, my voice, and my lips moving as it speaks. Whenever the EMR sees that I wrote a prescription for a new medicine, it would automatically send my avatar to the patient saying, "Hey, we're starting you on this new medicine. I want to know how it's working for you, so I'm going to check in with you next week and see how the drug's working." Patients will think they're going to be talking to me next week.

I think this is essential because I don't think I'm going to get other physicians to hand out their cell phone numbers to every patient like I do. It'd be so much more efficient for the EMR to do this than to rely on my memory to even do it with patients.

Ryan Quigley:
Well, as those insights bring us to the end of this program, I want to thank my guest, Dr. Steve Feldman, for joining me to share his insights on treatment adherence among patients with psoriasis. Dr. Feldman, thank you so much.

Dr. Feldman:
Absolutely. My pleasure.

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