In severe cases of atopic dermatitis (AD) unresponsive to topical based therapies, the use of systemic treatment has historically relied on medications like methotrexate, cyclosporine and azathioprine (Citation1,Citation2). In the past decade, advances in pharmacology have been fueled in part by the concept of a biological approach, using medications targeting dysfunctional cellular pathways. These therapies are expensive: Kuznik et al. estimated the annual net cost of dupilumab treatment above $30,000, presenting potential economic barriers to patients seeking relief (Citation3). Are these medications always necessary?
We know that for moderate-to-severe AD both biologic and traditional systemic treatments are effective: The SOLO trials for dupilumab showed that more patients achieved 75% improvement in Eczema Area and Severity Index compared to placebo, with similar improvements in quality of life (Citation4). These therapies should be used when needed, but how often are patients resistant to topical corticosteroids? If we admit patients to the hospital with horrific, total body atopic dermatitis and put topical triamcinolone ointment on them a few times a day, don’t they all improve over the course of only a few days? Perhaps treatment failures are better explained by failures in adherence rather than by medication ineffectiveness. Nonadherence rates range from 15% to as high as 93%, with annual costs to the United States healthcare system estimated to be $300 billion (Citation5). Even highly effective biologic therapies are not immune to the poor adherence phenomena: only 47% of patients fill their prescription for injectable biologics within the first month and 39% do not fill their prescription within 6 months of their original appointment (Citation6). Using medication event-monitoring system (MEMS) bottle caps that record the day and time when patients open and close the medication containers, overall adherence rates for AD declined to 32% over 8 weeks with frequency of use correlated to how far away the next office visit was scheduled (Citation7). A similar study of adherence to topical treatment performed with psoriasis patients measured overall adherence at 51%, vastly different than patient reported adherence rates of greater than 90% (Citation8).
Targeting adherence is effective: “white coat compliance” improves adherence immediately prior to and after office visits (Citation7). Increasing the number of treatment visits may not be sustainable, however online follow-up visits were also effective for AD management, and pilot studies using information delivered via text message reported increased knowledge about AD (Citation9–11). Increasing patient education is vital: fear of topical therapy side effects was cited as a reason for nonadherence in 49% of patients, with 53% stating they desired more information about side effects (Citation12). We supplement office visits by having patients check in with their progress by phone or secure electronic messaging, giving them a direct line to ask questions that arise. This notion of accountability appears to be a driving force for adherence, and electronic medical records have made automated messaging and patient interaction easier (Citation13). Advancements in targeted therapeutics for AD continue to yield exciting results for patients suffering from severe AD, however physicians should consider prioritizing adherence in patients who will likely achieve improvement with milder and more cost-effective treatments.
Michael S. Heath, Edward W. Seger, and
Steven R. Feldman
Department of Dermatology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
[email protected]
References
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