Dear editor
Kowalski et al describe various treatment approaches to achieve better outcomes in treatment-resistant prurigo nodularis in an article entitled, “Treatment-resistant prurigo nodularis: challenges and solutions.”Citation1 Many excellent approaches are suggested, but the issue of nonadherence to topical therapies may be an overlooked issue commonly contributing to “treatment-resistance.” Often, in the face of “resistant” disease, patients may be prescribed more complicated or risky treatment regimens that make adherence even more difficult. Such strategies may not be the most effective ones when poor adherence underlies seemingly treatment-resistant prurigo nodularis.
Treatment-resistance can often be overcome by measures that improve adherence. Even patients with severe, refractory atopic dermatitis respond rapidly to mid-potency topical corticosteroids applied in the inpatient setting. Prurigo nodularis is often secondary to atopic dermatitis and psoriasis. In patients with atopic dermatitis or psoriasis that was “resistant” to topical corticosteroids, all patients treated with an easy to use topical corticosteroid spray improved rapidly when coupled with adherence promoting measures (telephone reminders, patient education and frequent office visits).
Adherence to topical treatments is bad in the short-term and abysmal in the long-term.Citation2–Citation4 Perhaps one of the best approaches when faced with treatment-resistant disease is to simplify the treatment regimen and encourage good use of treatment, or better yet, bring patients in to assure the treatment is administered.
Disclosure
Dr Steven Feldman is a speaker for Janssen and Taro. He is a consultant and speaker for Galderma, Stiefel/GlaxoSmithKline, Abbott Labs, Leo Pharma Inc. Dr Feldman has received grants from Galderma, Janssen, Abbott Labs, Amgen, Stiefel/GlaxoSmithKline, Celgene and Anacor. He is a consultant for Amgen, Baxter, Caremark, Gerson Lehrman Group, Guidepoint Global, Hanall Pharmaceutical Co. Ltd, Kikaku, Lilly, Merck & Co. Inc., Merz Pharmaceuticals, Mylan, Novartis Pharmaceuticals, Pfizer Inc, Qurient, Suncare Research and Xenoport. He is on an advisory board for Pfizer Inc. Dr Feldman is the founder and holds stock in Causa Research and holds stock and is majority owner in Medical Quality Enhancement Corporation. He receives Royalties from UpToDate and Xlibris. Dr Steven Feldman reports personal fees from Menlo, personal fees from Sanofi, grants, personal fees from Pfizer, outside the submitted work; and has received research, speaking and/or consulting support from a variety of companies including Galderma, GSK/Stiefel, Almirall, Alvotech, Leo Pharma, BMS, Boehringer Ingelheim, Mylan, Celgene, Pfizer, Ortho Dermatology, Abbvie, Samsung, Janssen, Lilly, Menlo, Merck, Novartis, Regeneron, Sanofi, Novan, Qurient, National Biological Corporation, Caremark, Advance Medical, Sun Pharma, Suncare Research, Informa, UpToDate and National Psoriasis Foundation. Dr Steven Feldman also consults for others through Guidepoint Global, Gerson Lehrman and other consulting organizations. Dr Steven Feldman is founder and majority owner of www.DrScore.com. Dr Steven Feldman is a founder and part owner of Causa Research, a company dedicated to enhancing patients’ adherence to treatment. The authors report no other conflicts of interest in this communication.
References
- Kowalski EH, Kneiber D, Valdebran M, Patel U, Amber KT. Treatment-resistant prurigo nodularis: challenges and solutions. Clin Cosmet Investig Dermatol. 2019;12:163–172. doi:10.2147/CCID.S188070
- Carroll CL, Feldman SR, Camacho FT, Manuel JC, Balkrishnan R. Adherence to topical therapy decreases during the course of an 8-week psoriasis clinical trial: commonly used methods of measuring adherence to topical therapy overestimate actual use. J Am Acad Dermatol. 2004;51(2):212–216. doi:10.1016/j.jaad.2004.01.05215280839
- Krejci-Manwaring J, Tusa MG, Carroll C, et al. Stealth monitoring of adherence to topical medication: adherence is very poor in children with atopic dermatitis. J Am Acad Dermatol. 2007;56(2):211–216. doi:10.1016/j.jaad.2006.05.07317224366
- Alinia H, Moradi Tuchayi S, Smith JA, et al. Long-term adherence to topical psoriasis treatment can be abysmal: a 1-year randomized intervention study using objective electronic adherence monitoring. Br J Dermatol. 2017;176(3):759–764. doi:10.1111/bjd.1508527664969