PracticalDermatology

Adherence and patient compliance can play a critical role in treatment effectiveness. Ahead, experts share their pearls for working with patients to get the best outcomes possible.

When devising a treatment plan, what steps do you take to try to enhance patient compliance?

In devising a treatment plan, it is important to make it simple, explains Mark Bechtel, MD, Professor of Dermatology-clinical, Department of Dermatology, University of Pennsylvania. He says you should minimize the number of medications and frequency of application and try to avoid irritating medications initially. “Over time, the treatment plan can become more complex. Compliance is enhanced if the patients are aware of the treatment options and play a role in the treatment selection,” he advises.

Gary Goldenberg, MD, Assistant Clinical Professor, Dermatology, Icahn School of Medicine at Mount Sinai, Medical Director of the Dermatology Faculty Practice, says he makes sure to explain the diagnosis in a language the patients can understand. “We talk about treatment options and I usually will present one or two that I think are viable and make sure the patient is part of the decision making process,” adds Dr. Goldenberg.

Andrew C. Krakowski, MD, a pediatric dermatologist at Rady Children’s Hospital, in San Diego, CA, says he actually prefers the term concordance over compliance. Compliance “implies, too much, a paternalistic relationship—one in which the physician instructs the patient to follow a specific regimen and then expects it happens, only to be disappointed when it does not. That sentiment is particularly striking when you read studies that suggest our patients may only be filling one out of every three prescriptions we write,” says Dr. Krakowski. He says concordance suggests that through a partnership between the patient and the physician a mutually agreed-upon regimen can be implemented and long-term success can be achieved. “This model, from the start, considers factors such as selecting a vehicle that works for everyone (choosing an ointment versus a cream, for example); financial cost of prescriptions; ease-of-use of the overall regimen; and side effects—both anticipated and unexpected.”

How important is it to set and manage realistic expectations?

“If you subscribe to the concordance model, then you likely already engage your patients in treatment decisions from the start,” says Dr. Krakowski. “Knowing why we prescribe a particular medication, how it works, what side effects to watch for, and how long it takes to show an effect are all part of building reasonable expectations and mutual trust and respect.

Dr. Goldenberg concurs. “The timeline of treatment is important to improve compliance—I always tell patients what to expect and when, and why we are doing a specific treatment. This is especially important when using a treatment that may be irritating in the beginning. I often say that things have to get worse before they get better,” adds Dr. Goldenberg.

“Setting treatment expectations is critical in conditions such as acne and psoriasis where clinical improvement may take time,” says Dr. Bechtel. “Patients often abandon therapy after two to three weeks, if they don’t appreciate the potential delay in visible clinical response. If a typical agent is potentially irritating early on in therapy, such as calcineurin inhibitors, it is important to explain the potential anticipated discomfort and that the symptoms will go away. The importance of continuing the medication for further improvement needs to be stressed.”

Dr. Krakowski agrees. “Take acne, for example. I cannot tell you how often I ask my adolescent patients to “guess how long it will take” for their acne regimens to make a positive change on their skin. I get the full spectrum of answers: From “two years” to “next Friday, because I have a hot date,” he says. “I try to use this variation to my advantage by couching acne management in a tangible, stepwise timeline: About two weeks after initiating therapy, your skin will start to get a little pink, maybe a little irritated, maybe a little scaly. Push through that!” He tells his patients that if necessary, they can back-down to “every night” or even “every other, other night” application, and directs them to make sure to use your moisturizer and sunscreen at least three times a day. He typically tells these patients that he can promise they will see a difference in six to eight weeks.

“In essence, I turn the negative side effects of skin irritation into tangible treatment points that my acne patients not only know to expect but even start to look forward to as proof that something is happening deep in their skin,” adds Dr. Krakowski. “Then, I usually have my acne patients come back for a follow-up in two to three months, knowing that should give both of us plenty of time to see a true difference or address factors that would influence a positive effect.”

When treating atopic dermatitis, Dr. Krakowski takes a different approach as pediatric patients may present with flares that may be complicated by superinfection or psychosocial factors that cannot simply be tackled in a single 15-minute patient encounter. “In this situation, I try to keep things simple. I focus on fixing what is broken,” explains Dr. Krakowski. “My mentor, Lawrence Eichenfield, in San Diego, CA, stresses the analogy of fixing a broken down car: ‘You don’t pull over to the side of the highway to wax the car when it’s the engine that is broken. The first priority is to get the car running again.’ That always made sense to me. So, in this scenario I set a much shorter return visit—maybe 10-14 days.”

When patients have to come back sooner, the families tend to work harder to do the regimen more successfully. “They also start to see real clinical improvement, so they buy into the concept that we can help and that we know what we are talking about. That makes the ‘education as intervention’ process much easier,” he adds. “I can also prescribe a stronger potency medication, without refills, knowing that it will be effective and relatively safe in this short amount of time. Then, when I see the patient back again I can adjust potency or frequency as needed.

During the follow-up appointment Dr. Krakowski impresses upon the family the importance of using the right amount of medication knowing that “apply liberally” means many things to many people. He provides instruction about concrete amounts of medication to use over specified amounts of time. For example, he tells patients, “If you are using this medication correctly, you will go through this 30-gram tube of medication in about a week. If it lasts you longer than that, then you are not using enough of it.”

He says he also never writes prescriptions as “Sig: AAA BID x M-F x 4-6 weeks.” Instead, he takes the extra time to write out exactly how he wants patients to use the product, such as: “Apply to both cheeks only, avoiding the areas around the eyes, twice a day, for 10 days straight.” That language is more useful to a busy parent trying to deal with a squirming child while keeping the regimen straight, he explains.

How important is it to provide clear, concise directions to follow with a treatment regimen? What has worked best in your practice?

“Open communication is key,” offers Dr. Goldenberg. “It’s important to explain why we are doing a certain treatment, what kind of results the patient can expect, the course of the treatment, and appropriate follow up. I often tell patients to come in or call if what they are seeing during treatment is different than what we discussed.”

When treating a condition like eczema, concise, simple directions are key to treatment success, adds Dr. Krakowski. “I have seen plenty of expert physicians tweak a regimen so that, in theory, everything is textbook perfect: ‘I want you to combine this 30-gram tube of prescription corticosteroid with a 1-pound tub of emollient, put it in your refrigerator, and apply it to the second and fourth digits of the right hand only on Tuesdays and Fridays and to the third and fifth digits of the left hand on Mondays and Wednesdays.’” While this may be ideal in theory, it may overcomplicate the treatment process and set the patient up for failure.

“When I treat eczema, I look to paint in three simple ‘broad strokes’: First, we need to cleanse your child’s skin. Second, we need to heal the damage and repair the immune dysfunction with something like a corticosteroid or topical calcineurin inhibitor. Third, we need to repair the barrier and add moisture back to the skin,” he says,

He also reviews with all families the specific point that if the barrier repair product goes on before the corticosteroid, then the steroid will likely be blocked from fully reaching the skin, which can lead to less efficacy, which could result in a break down in trust and respect. He says it is worth taking the few extra minutes to review this process upfront so that patients get it right the first time and experience the confidence that comes with doing it correctly.

Dr. Bechtel adds, “At the end of the visit, it is important to review the treatments that were prescribed prior to discharge. This includes treatment in regard to topicals: sites of application, how frequent, and how they will be beneficial. Our EMR provides written directions, but verbal communication is important.”

How do you follow-up to see if patients are adhering to treatment?

Dr. Bechtel says that after an initial visit, compliance can be enhanced by scheduling a follow-up visit within four weeks, especially if patient compliance is a concern and the case is challenging. “Patients tend to be more compliant after the initial visit, if they are re-evaluated fairly soon,” he explains. “Often, I will have patients call me after two to three weeks to make sure they are tolerating therapy and showing some clinical response. A request for a phone update in three weeks demonstrates the importance of the therapeutic regimen and your concern for the patient.”

Dr. Goldenberg also always schedules regular follow up, but adds that the timing of the follow-up appointment depends on how long it would typically take a patient to see improvement.

Dr. Krakowski agrees that regular follow-up is very important. “Ablative fractional laser resurfacing of scars is a huge part of my practice. If you perform laser surgery on enough large hypertrophic burn scars, especially in a pediatric population, you are almost certainly going to have some complications. I go to sleep some nights thinking about what could go wrong,” says Dr. Krakowski, explaining that complications may range from a simple misunderstanding of the postoperative treatment instructions to a true superinfection of the wound—or worse. “In these cases, I find that it is wholly more effective to give my personal cell phone number to the family at the time of treatment, proactively.” He tells families to call him directly with any concerns, advising that he would much rather look at a texted photo or get a call after hours about a healing wound then hear about it the next day from a colleague who is not familiar with the procedures.

“Many times with scar surgery, I call or text my patients the first few days after their procedures, checking in simply to make sure everything is okay. Fever? Increasing redness or pain? Foul smell? I want to know about it before it becomes a problem,” explains Dr. Krakowski. “As the families become more familiar with the procedures I employ, I tend to give them more space, but I try to remain just a phone call away.”

When a patient returns for follow-up and says treatment isn’t working, how do you try to determine if it’s really the treatment that isn’t working or if non-adherence is the problem? If the issue is non-compliance, what steps do you take?

“One way to determine compliance is asking how many pills they have left in their bottle or how much cream in their tube was used,” says Dr. Bechtel. “If non-compliance is a concern, evaluating barriers to compliance is critical. Sometimes this necessitates making the regimen more simplified, minimizing irritation of therapy, and especially defining expectations.”

Dr. Goldenberg says he reviews with the patient exactly how they used the treatment and how much of the agent they used. “I often ask patients to bring all their medication so I can see how much was used. Sometimes it’s compliance and sometimes they really need something stronger or different,” he explains.

When treating a teenager, Dr. Krakowski says he’s found that that a direct approach tends to work best and asks patients to tell him how many days out of a full week they actually put Medicine #1 on their face. “If they answer anything less than four days, then I know I need to make an active intervention,” he says.

For atopic dermatitis, he focuses on how much medication and moisturizer families are applying in a specified amount of time. “If they are using too much corticosteroid, I usually try to support their hard work and effort and get them to understand the hazards of overtreatment. A simple discussion of the known risk of topical corticosteroid overuse is usually enough to get any parent to back down,” he adds. “In reality, though, most eczema families are not using enough medication. So, in this case, I impress upon my families the importance of treatment to prevent infection and the possible need for hospitalization, for example. I also prescribe specific medications, in specific amounts of usage, over specific periods of time. I use “times refilled” as a gauge of adherence; if patients are not refilling medications for a chronic and relapsing condition like atopic dermatitis, then they are likely not using those resources correctly.”

What strategies have you tried to enhance compliance that you’ve found have not worked at all?

“If a patient cannot afford a particular medication—even if it magically combines 8 steps into one 30-gram tube—then it is not worth the paper it was ‘e-prescribed’ on,” cautions Dr. Krakowski.

Dr. Bechtel adds, “I have not found writing out complicated directions on how to use multiple topical agents for acne and psoriasis to be helpful. It is better to limit the medications and make it simple.”

“It’s all about communication and open communication channels,” says Dr. Goldenberg. “Patients really want to get better. So if they have a question or concern about treatment, I ask them to come in or call so that we can review.” n