Optimizing Adherence in Psoriasis: Pearls from the Front Line

Have you identified any verbal cues that help you to connect with patients? Any words or phrases that may be helpful in trying to ensure adherence?

Ronald Prussick, MD: “I understand your frustration having a chronic disease. Although we can’t cure psoriasis, if you follow these instructions you should look and feel better.” Set clear goals, for example, the plan is to try to get it clear so you can go into remission and hopefully stop topical treatments or phototherapy. This helps patients understand they don’t have to do this forever.

Moderate/severe patients need to understand this is a systemic inflammatory disease. There is some new evidence that clearing the skin may reduce inflammation inside the body, so treatment is worthwhile. If you stop treatment, then inflammation may also reappear inside your body including the joints.

Patients with psoriasis frequently suffer from depression. We need to identify these people and refer them for help, as depressed patients are less likely to follow through with a treatment plan.

Patients have strong fears about the side-effects of biologics, and we should put these side-effects in perspective so they can make a better and informed decision.

Stefan C. Weiss, MD, MBA: It’s always about understanding the patient goals: speed, convenience, safety, efficacy. Once that is established, choosing a therapy that best matches those goals helps improve adherence. If I believe the patient needs a biologic, and the patient is either concerned about the delivery mechanism or the side effects, adherence will be poor. If the patient wants a systemic treatment because he/she is tired of topicals, and I am only to provide topicals, adherence will be poor. However, if you match therapy with goals, I find adherence (and outcome) to be, more often than not, successful.

Seemal Desai, MD: I think empathizing is so important. One thing I have found useful is to acknowledge and talk about “itch.” We often tend to forget how itchy psoriasis can be. in fact, itch is one of the most important factors in causing morbidity for patients with psoriasis and other skin diseases.

Steven Feldman, MD, PhD: Every word in the entire encounter is important for building the patient’s trust in the physician and their adherence to treatment. I have a lot to work on in this area. There are great articles on how to ensure patients perceive the physician to be empathetic and caring.

From topicals to biologics, do you have any procedures in place to answer patients’ questions at the pharmacy, once they get home with a drug, etc.? Do you provide any preprinted materials, and what type of info has been most helpful?

Dr. Weiss: I always find it helpful to provide the patient with the pre-printed materials from the manufacturer. These have been carefully vetted to offer an explanation of the medication. The manufacturers also offer “nurse-ambassadors” who are extremely helpful in solving many of the patient concerns about the drug or its use. Additionally, I like to see biologic patients at first use and in six weeks to establish treatment and monitor progress.

Dr. Prussick: For topicals, I give them a personalized sheet with instructions on what to do in the morning and then the evening. For drugs, I refer to the NPF website.

Dr. Feldman: I rely heavily on the patient education materials produced by the National Psoriasis Foundation. You can get digital copies free from their website. But we should all be or become professional members.

Dr. Desai: Some of biologic manufacturers now have nurse ambassador programs in place, which are very helpful. In fact, a nurse often will come to a patient’s house and show them how to inject the meds. I think this is great.

Another thing I always share with my psoriasis patients is that I encourage them to come in and see me when they get their medication; we help them actually inject their first dose. This has gone a long way with patient rapport.

Do you have any application pearls that you have learned from or share with patients to ease drug application or administration?

Dr. Desai: The main thing is to encourage patients to be compliant. Another thing I often recommend with greasy ointments is to massage the drug in completely but that patients can use a paper towel to lightly blot the excess. This helps to reduce staining of clothing, linens, etc.

Dr. Weiss: For biologic medicines, I like to bring the patient to the office for the initial dose. I find that this lessens the fear associated with requiring an injectable medicine. It also offers the patient confidence that he/she is self-administering correctly. For topicals, I find most patients are used to applications of creams/ointments and it becomes imperative to explain not to overuse/use as an alternative to emolliation.

Dr. Prussick: Apply topicals on the skin after washing while the skin is still moist to help retain moisture. Consider a foam or spray to improve compliance. For topical steroids, use a taper schedule to prevent rebound effects.

Dr. Feldman: I try to give patients vehicles they are most willing to use.

Please complete the statement: “The best way to encourage patient adherence on psoriasis therapy is…”

Dr. Weiss: To explain them why it is going to help them achieve their personal treatment goals.

Dr. Desai: To tell patients that you are there for them every step of the way on their psoriasis journey.”

Dr. Prussick: Patients need to understand the consequences of not treating. The condition can get worse from scratching and rubbing, which may lead to secondary infection. Patients need to know that moderate/severe disease is a systemic inflammatory condition that can affect internal organs, joints, and blood vessels. Epidemiology studies show moderate/severe disease can reduce lifespan by about five years. Early data shows that successful treatment of the skin may reduce the main causes of early death, i.e. heart attacks and stroke. Treatments may also prevent permanent joint destruction. Patients who continue treatment often have less fatigue and more energy.

Dr. Feldman: Accountability. Have the patient call your office in a week to let you know how a new medication is working. It lights a fire under them to fill and use the medication.