Treating a chronic disease without chronic adherence

Atopic dermatitis (AD) is common, chronic inflammatory dermatosis affecting children and adults. Treatment of atopic dermatitis typically involves combinations of topical agents including corticosteroids and calcineurin inhibitors as well as nonmedicated moisturizers (1). For cases that are unresponsive to topical therapies, biologic and systemic treatments are effective alternatives (2). In this issue of the Journal of Dermatological Treatment, Bruin-Weller et al. assess and characterize the disease burden of atopic dermatitis patients receiving systemic therapy (3). They found that moderate-to-severe atopic dermatitis places a high and longstanding burden on adult patients, despite prolonged use of topical and systemic therapies. The disease impacts patients’ quality of life, including mental health, work, and daily activities, for a majority of their lives.

According to the study, a majority of patients starting systemic therapy indicated a lack of efficacy of previous topical treatments. The authors concluded, “Adults with moderate-to-severe AD starting/switching systemic treatment enrolled in EUROSTAD have a high burden of longstanding disease despite continuous use of topical drugs, emollients, and systemic therapies.” Clearly, patients with AD have a high burden of disease with an enormous impact on their quality of life. But we need to be reticent about concluding they are continuously using their prescribed topical and systemic treatment. Patients with AD tend to be poorly adherent to treatment despite the large impact AD has on patients’ lives.

Studies examining adherence to topical AD treatments have observed large discrepancies between patient-reported and actual adherence rates. Additionally, mean adherence decreased over time – although AD is chronic, adherence to medication regimens often isn’t. Even when treatments are used, patients may fail to use the needed amount of medication; fear of side effects may contribute to underuse of therapy and to poor outcomes (4).

Poor adherence may be attributed to a variety of factors including forgetfulness, poor education by the prescribing physician, fear of side effects, inconvenience, and cost (4). In addition to addressing these barriers, increasing accountability may be an effective intervention to increase adherence. The concept of accountability is illustrated by the example of dental visits – patients are likely to floss and brush their teeth right before a dentist appointment. Also known as “white coat compliance,” the expectation of a follow-up visit motivates individuals to adhere to their medication regimen. This phenomenon may explain why adherence in clinical practice is so much worse than that in clinical trials; clinical trials include frequent follow-ups (5). Scheduling follow-up visits (in-person, video call, audio call, or even text-based) shortly after prescribing new medications can increase a sense of accountability and thereby improve adherence. Ultimately, addressing adherence may be an effective way to reduce the burden of AD while maintaining a conservative, cost-effective treatment regimen. We may be mistaken if we think that new medications – that will be used as poorly as the medications we currently have – are going to solve the AD problem.

Disclosure statement

No potential conflict of interest was reported by the author(s).