Original Paper
`
` Dermatology 2011;222:363–374
` DOI: 10.1159/000329026
`
` Received: January 19, 2011
` Accepted after revision: April 18, 2011
` Published online: July 13, 2011
`
` Adherence in the Treatment of Psoriasis:
`A Systematic Review
`
` M. Augustin   a B. Holland   a, b D. Dartsch   b A. Langenbruch   a M.A. Radtke   a  
`
` a   German Centre for Health Services Research in Dermatology, Institute for Health Services Research in
`Dermatology and Nursing, and b   Institute for Pharmacy, University of Hamburg, Hamburg , Germany
`
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` Key Words
` Psoriasis outcome ⴢ Medication adherence ⴢ Treatment
`compliance ⴢ Quality of life
`
` Abstract
` Background: Medication adherence and compliance are es-
`sential for disease management and can significantly im-
`prove outcomes and quality of patient care. The literature
`suggests that up to 40% of patients do not use their medica-
`tion as intended. Objective: To elucidate current knowledge
`on adherence/compliance in psoriasis. In particular, meth-
`ods of adherence/compliance evaluation and influencing
`factors were to be identified. Methods: Systematic literature
`review based on a protocol-rooted search in online data-
`bases, followed by a structured critical appraisal and con-
`secutive descriptive report. Results: Thirty-five original pub-
`lications on adherence/compliance in psoriasis were iden-
`tified, addressing the extent and quality of adherence/
`compliance in topical, systemic and UV treatments. Esti-
`mates of compliance varied considerably between 27 and
`97%. Age, sex, psychosocial, disease-specific and treatment-
`specific factors were identified as predictors of adherence/
`compliance. Conclusion: A better understanding of the de-
`terminants of adherence can improve the outcomes of pso-
`riasis treatment and lead to higher patient satisfaction and
`quality of care.
` Copyright © 2011 S. Karger AG, Basel
`
` Introduction
`
` With a prevalence of 2–3% [1–3] in western industrial
`countries, psoriasis vulgaris is an important chronic, re-
`current skin disease which is now categorized as a sys-
`temic inflammatory reaction [4, 5] . The incidence and
`disease burden of psoriasis result in a high need for care
` [6] . There is also a demand for the treatment of comor-
`bidity, such as arthritis, depression, cardiovascular and
`metabolic diseases or chronic inflammatory auto-im-
`mune diseases [7–10] . Accordingly, psoriasis patients are
`at an increased risk for the development of atherosclerosis
`and cardiovascular morbidity [11] and in most cases
`may require early drug treatment. The high consecutive
`costs – which increase with the severity of the disease –
`constitute the great socio-economic relevance of psoriasis
`from a health-political perspective [12–15] . From the pa-
`tient’s perspective, psoriasis represents a huge burden be-
`cause of the marked decrease in quality of life, the often
`refractory course and also the considerable side effects of
`therapy [16–20] .
` Motivation to follow the instructions for treatment
`can be poor particularly in patients who have been suf-
`fering for many years, the consequence being a reduction
`in compliance and adherence [21] . Patient behaviour
`which leads to following the doctor’s instructions is called
`compliance [22] . By contrast, adherence means sticking
`to the therapeutic goals set mutually by patient and doc-
`tor with reference to the individual needs of the patient
`
`Fax +41 61 306 12 34
`E-Mail karger@karger.ch
`www.karger.com
`
` © 2011 S. Karger AG, Basel
`1018–8665/11/2224–0363$38.00/0
`
` Accessible online at:
`www.karger.com/drm
`
` PD Dr. Marc Alexander Radtke, Competenzzentrum Versorgungsforschung in
`der Dermatologie, Institut für Versorgungsforschung in der Dermatologie und bei
`Pflegeberufen, Universitätsklinikum Hamburg-Eppendorf
` Martinistrasse 52 , DE–20246 Hamburg (Germany)
` Tel. +49 40 74105 5428, E-Mail m.radtke   @   uke.de
`
`Medac Exhibit 2035
`Koios Pharmaceuticals v. Medac
`IPR2016-01370
`Page 00001
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`and any factors which make it difficult for the patient to
`achieve these goals [23] . The need for this construct arose
`from the fact that consideration only of compliance fails
`to take due account of the perspective, right of self-deter-
`mination and competence of the informed and auton-
`omous patient. The World Health Organization recog-
`nizes adherence in chronic diseases such as psoriasis as
`one of the most important factors contributing to effi-
`cient therapy [24] . Thus, poor adherence and subsequent-
`ly suboptimum therapeutic results can lead to increased
`costs due to additional office visits and treatments as well
`as a negative impact on work and productivity. Conse-
`quently, any intervention which leads to improved adher-
`ence is beneficial. An objective and valid measurement of
`the two parameters compliance and adherence is difficult
`because they are both modes of patient behaviour which,
`in most cases, are difficult to objectify. An approximation
`can, however, be achieved by the use of established re-
`search methods.
` The aims of the present paper were to (1) identify and
`assess suitable methods for the evaluation of adherence
`in psoriasis patients; (2) determine the extent of adher-
`ence in psoriasis patients within different therapeutic
`procedures; (3) characterize factors influencing adher-
`ence on the basis of a systematic literature search.
`
` Methods
`
` Methodology of Adherence Evaluation
` In the first step, publications on the methodology of assess-
`ments for adherence were identified from the literature by a
`PubMed research using the following terms: Adherence OR Com-
`pliance AND (measurement OR evaluation OR assessment) AND
`(methodology OR methods).
`
` Adherence and Compliance in Psoriasis
` In the second step, systematic literature searches were per-
`formed in the databases PubMed and Cochrane library in May
`2010. The first search was conducted in PubMed with the search
`terms (Psoriasis AND Compliance) and (Psoriasis AND Adher-
`ence). In order to specifically identify publications on adherence
`in systemic therapy, the following search terms were used: [(Fu-
`mar * OR Methotrexate OR Cyclosporine OR Acitretin * OR In-
`fliximab OR Etanercept OR Adalimumab) AND (compliance OR
`adherence) AND psoriasis] in the title or abstract. The Cochrane
`search included the search terms (Psoriasis AND/OR Adherence
`AND/OR Compliance). In addition, further publications that had
`not shown up in the databank searches were selected from the
`bibliographies of the publications identified in the PubMed
`search.
` The searches covered all languages and dates of publication.
`The abstracts had to meet the following criteria for inclusion of
`the publication in the later evaluation: (1) compliance or adher-
`
`ence in the therapy of psoriasis or other dermatological diseases
`as a main criterion; (2) factors influencing compliance as a main
`criterion; (3) a description of the particular methods used to mea-
`sure compliance; (4) influencing factors with indirect effects on
`compliance as a main conclusion of the publication; (5) up-to-date
`information on the management of psoriasis.
`
` Results
`
` Methodology of Adherence Evaluation
`
` The methodology for determining compliance in clin-
`ical and health care studies involved primarily question-
`ing of the patient by means of various questionnaires or
`self-reporting by the patient. Major results can be sum-
`marized as follows below.
`
` Self-Reporting
` In the procedure of patient questioning, compliance is
`documented either during an interview by the physician
`or by the patient himself on previously compiled ques-
`tionnaires. A particular advantage of written documen-
`tation by the patient is that it offers the possibility of
`anonymous data acquisition, which increases the proba-
`bility of obtaining truthful answers [25] . The questions
`can be adapted to each individual study and formulated
`openly or provided with possible responses. Because the
`quality of results is greatly dependent on the wording of
`the questions [26] , validated instruments such as the
`Mirosky Scale [27] and the Medication Adherence Report
`Scale [28, 29] are preferable to non-validated methods.
`Direct questioning by interview tends to show low con-
`cordance with the more objective methods described be-
`low [30] and, consequently, can be recommended for the
`determination of adherence only with reservations. In
`conclusion, there is no gold standard of self-reporting
`techniques for adherence evaluation.
`
` Pharmacy Records of Drug Consumption
` These data are based on a comparison of the theoreti-
`cal number of days a prescription should last and the ac-
`tual frequency with which prescriptions are redeemed.
`Differences between this parameter and the actual adher-
`ence arise when a patient visits several pharmacies or re-
`deems his prescription but does not take the medication.
`Moreover, this method does not provide any indication
`of the regularity of use [31] . The adherence determined in
`this way nevertheless showed acceptable correlation with
`the ‘cumulative’ adherence determined with the Medica-
`tion Event Monitoring System (MEMS) [32] and tends
`
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`
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`
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`
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`

`PubMed
`
`Psoriasis and
`compliance
`184
`
`Psoriasis and
`adherence
`114
`
`Cochrane
`
`Psoriasis and adherence
`and compliance
`55
`
`
`
`
`Title irrel.
`217
`
`298
`
`Abstracts
`81
`
`Overlap with
`PubMed
`31
`
`Title irrel.
`10
`
`24
`
`Abstracts
`14
`
`Studies not meeting inclusion
`criteria 60
`
`Studies meeting inclusion
`criteria 35
`
` Fig. 1. Methodology of the literature
`search.
`
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`less to overestimation of adherence than direct question-
`ing [33] .
`
` Counting/Weighing of Unused Medication
` Counting (in the case of separable forms of presenta-
`tion) or weighing unused medication returned after the
`end of treatment is a way of measuring adherence which
`is independent of information from the patient. Overes-
`timation of the actual adherence is however possible even
`with this method if – intentionally or unintentionally –
`the patient does not return all the unused medication
` [26] .
`
` Clinicochemical Parameters
` In the case of systemic therapy, the determination of
`clinicochemical parameters, e.g. blood level measure-
`ments, can be important and lead to an estimation of ad-
`herence.
`
` Electronic Measuring Systems (MEMS Cap)
` The MEMS consists of a standard bottle with a screw
`cap housing a microprocessor. The time, date and time
`elapsed since the bottle was last opened is recorded every
`time the cap is unscrewed. Provided the pharmaceutical
`formulation is suitable, the bottles can be used not only
`for solid and liquid, but also for semisolid presentation
`forms [34] . This monitoring system tends to furnish low-
`er adherence values than the patient interview [35, 36] or
`
`the determination of medication usage [32] and, conse-
`quently, is often regarded as today’s reference standard
`despite the costs and limited usage.
`
` Adherence and Compliance in Psoriasis
`
` The search term combination (Psoriasis AND Com-
`pliance) produced 184 hits in PubMed, while the combi-
`nation (Psoriasis AND Adherence) achieved 114 hits. Of
`these, 81 abstracts were viewed in addition to 14 abstracts
`from the Cochrane search, which produced 55 hits, 31 of
`which overlapped with the results of the PubMed search.
`In total, 35 publications were chosen for this literature
`study on the basis of the inclusion criteria ( fig. 1 ).
` The main topic in 8 studies was compliance in psoria-
`sis treatment, while 4 studies examined the influencing
`factors and 15 the concomitant circumstances which, in
`turn, affect compliance.
`
` Studies with the Primary Criterion ‘Compliance’ or
`‘Adherence’
` In an anonymous questionnaire survey of 120 patients
`at a specialized psoriasis clinic in Great Britain in 1999,
`61% of the patients with psoriasis said that they were ‘al-
`ways’ compliant, while the other 39% ticked ‘sometimes’
`or ‘never’ [37] . Another similar survey in the USA in 2006
`involving 53 patients under topical corticosteroid treat-
`
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`
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`ment had a comparable compliance rate, with 40% non-
`adherent patients [38] . Higher compliance values were re-
`ported in a study conducted in Turkey in 2008 in which
`103 outpatients were surveyed at the end of 8 weeks of
`treatment. The questionnaire employed elicited data on
`the doses used, the relationship of which to the doses pre-
`scribed (= 100%) allowed a mean medication adherence
`score of 75% to be calculated [39] . In contrast, 73% of
`1,281 active members of several psoriasis patient organi-
`zations in France, the UK, Belgium, Germany and the
`Netherlands stated in a patient questionnaire to deter-
`mine compliance in their psoriasis treatment that they
`had not adhered strictly to the instructions in the last 3
`days and over the previous weekend [40] .
` The results of objectively measured and subjectively
`reported compliance can differ substantially from each
`other, as a study with 201 outpatients conducted in Great
`Britain in 2004 has shown: the mean medication adher-
`ence measured objectively by counting or weighing the
`unused medication was 60.6%, while the patients had an
`adherence score of 92.0% in the questionnaire survey
` [41] . A comparison of the data of a MEMS cap with the
`corresponding patient diaries in 2003 showed a discrep-
`ancy of the same magnitude for patients in the USA: the
`mean compliance was 67% according to the diaries and
`92% according to the MEMS [35] . Another MEMS assess-
`ment conducted in 2004 in a US clinical study of 29 pa-
`tients showed a mean adherence of 55% – a figure similar
`to that obtained from determination of unused medica-
`tion or the use of anonymous questionnaires. The con-
`tinuous data recording also showed that adherence in
`the case of the twice daily application of salicylic acid gel
`was significantly higher on the days close to office visits
`( 8 2 days) than on the other days of the 8-week observa-
`tion period [42] . When the correlation between adher-
`ence and the therapeutic result was examined in 24 pa-
`tients of the same study, it was found that a decrease in
`adherence of 10% was associated with a deterioration of
`the psoriasis of 1 point on a 9-point scale [43] . A further
`study conducted in the USA examined adherence in 27
`patients under combined therapy consisting of acitretin
`and UV phototherapy which was to be performed at
`home. Tablet ingestion was determined with a MEMS
`cap, irradiation with data loggers for the UV lamps. Over
`the 12-week observation period, acitretin ingestion de-
`creased continuously from around 94 to 54%, while ad-
`herence to phototherapy remained constant [44] . A sur-
`vey performed in 2006 also showed that adherence is
`greater under therapy with biologicals than under other
`psoriasis treatments [45] .
`
` While the aim of most studies is to determine medica-
`tion adherence, that of a study conducted in Denmark in
`2008 was primary adherence, i.e. 322 outpatients of a der-
`matology clinic were followed up to determine how many
`redeemed their prescription. The survey was made pos-
`sible by an electronic register so far established only in
`Denmark. Almost 45% of psoriasis patients failed to re-
`deem their prescriptions – a percentage for primary ad-
`herence much lower than in patients with some other
`skin diseases [46] . Table 1 provides an overview of the
`measuring methods used in the individual studies to-
`gether with an assessment of the results by the authors of
`the individual publications.
`
` Sociodemographic Factors with an Influence on
`Compliance
` The main sociodemographic factors examined to date
`are sex, age and marital status. A study by Zaghloul and
`Goodfield [41] found that adherence was higher in the
`women, the study of primary adherence by Storm et al.
` [46] showed that it was higher in the men, while Gok-
`demir et al. [39] were unable to establish any association
`between sex and adherence. With regard to age, Storm et
`al. [46] and Richards et al. [37] both reported that older
`patients tended to be more compliant than younger ones.
`Zaghloul and Goodfield [41] and Gokdemir et al. [39] dis-
`agreed as regards the influence of marital status, employ-
`ment and smoking habits. In the study by Zaghloul and
`Goodfield, adherence was higher in married, employed
`and non-smoking patients, while Gokdemir et al. found
`higher adherence in single patients and no influence on
`adherence for employment and smoking habits. Gok-
`demir et al. also observed a positive association between
`higher educational level and adherence, and Zaghloul
`and Goodfield reported a negative association between
`increased alcohol consumption and adherence. An over-
`view of these findings is presented in table 2 .
`
` Treatment-Specific Factors Influencing Compliance
` Evaluation of the patient questionnaires completed by
`1,281 members of several psoriasis patient organizations
`in Europe shows that the main reasons for non-compli-
`ance were low efficacy, poor cosmetic properties, time-
`consuming use and the occurrence of side effects [40] . The
`results of a questionnaire survey of 567 patients provide
`information about the preferred forms of presentation.
`Distinct differences were found in the satisfaction with
`the mode of administration – injectable agents were pre-
`ferred to oral and oral to topical treatments. Moreover,
`satisfaction increased with the length of treatment in
`
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`
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`Table 1. Studies of topical and systemic psoriasis therapy with the primary criterion ‘compliance’ or ‘adherence’
`
`Perspective/
`rater
`
`Compliance
`
`Authors’ conclusions
`
`Patient
`
`61%
`
`None
`
`First author,
`year
`
`Method
`
`Richards
`[37], 1999
`
`Zaghloul
`[41], 2004
`
`Carroll
`[36], 2004
`
`Carroll
`[36], 2004
`
`Topical, systemic, photo- or combined therapy;
`anonymous patient questioning; subdivision into
`‘compliers’ (always compliant) and ‘non-compliers’
`(sometimes or never compliant)
`Topical or oral therapy; determination of
`‘medication adherence’ from theoretical and actual
`use by weighing/counting unused medication
`(objective method) and patient interview for
`comparison purposes (subjective method)
`Topical therapy; MEMS cap; on salicylic acid gel
`in contralateral comparison salicylic acid gel +
`tacrolimus ointment versus salicylic acid gel + base
`] indirect adherence measurement for tacrolimus
`ointment
`Topical therapy; patient diary versus MEMS with
`salicylic acid gel versus weighing of unused
`medication
`
`Investigator
`Patient
`
`61%
`92%
`
`Investigator
`
`60%
`
`Investigator
`
`Patient
`
`From 85 to 51%
`(after 8 weeks)
`90%
`
`Balkrishnan
`[35], 2003
`Fouéré
`[40], 2005
`
`Topical therapy; patient diary versus MEMS with
`salicylic acid gel
`Topical or combined therapy; patient questionnaire;
`compliance defined as strict adherence to
`instructions in the last 3 days and on the previous
`weekend
`
`Patient
`Investigator
`Patient
`
`92%
`67%
`27%
`
`Brown
`[38], 2006
`
`Topical cortisone therapy; anonymous patient
`questionnaire (inclusion criterion: at least
`1 cortisone therapy in the previous 12 months)
`
`Patient
`
`60%
`
`The resultant Medication Adherence
`Score furnishes objective data; the
`result – a percentage – is preferred to
`the subdivision into ‘compliers’ and
`‘non-compliers’ based on a cut-off limit
`Suitable method for objective
`determination of adherence, as the
`patients were not informed about the
`nature of the adherence measurement
`
`Only the MEMS is a suitable measuring
`method, but not diaries or weighing of
`unused medication because of extreme
`variability of the results
`Electronic determination is more reliable
`than questioning
`The compliance determined is lower than
`in other studies because of different
`definition and measuring instruments;
`errors or bias are inevitable with this kind
`of data generation
`This type of data generation poses the
`risk of memory errors or gaps; however,
`the results agree with those of other
`adherence studies
`Method for the objective determination
`of ‘primary adherence’ (once in
`Denmark)
`
`Adherence rates are often overestimated
`when – as in this case – they are based on
`patients’ reports
`
`Investigator
`
`55%
`
`Patient
`
`75%
`
`Storm
`[46], 2008
`
`Gokdemir
`[39], 2008
`
`Yentzer
`[44], 2008
`
`Bhosle
`[45], 2006
`
`Van de
`Kerkhof
`[47], 2000
`
`A new (not further described) therapy for the
`patient; electronic register: 4 weeks after the visit,
`check on whether the prescription was redeemed
`(‘primary adherence’)
`Oral, topical, photo- or combined therapy;
`patient questionnaires: daily record of drug use
`(actual consumption) and determination of the
`adherence score by established method from
`theoretical and actual consumption
`Oral and phototherapy; MEMS cap (acitretin),
`data loggers (UV lamps)
`
`Systemic therapy; drug consumption data from the
`pharmacy for patients for whom biologicals (inter
`alia) were prescribed
`Topical, photo(chemo)- or systemic therapy;
`patient questionnaires, sent to subscribers to
`Psoriasis (magazine of the Dutch Psoriasis Patient
`Organization)
`
`Investigator
`
`From 94 to 54% after
`12 weeks (acitretin)
`
`Investigator
`
`66% (biologicals) and
`36% (other)
`
`Patient
`
`Compliance relating to
`frequency of use: 51%
`(topical therapy); 90%
`photo(chemo)therapy;
`97% systemic therapy
`
`Both methods determine adherence
`objectively; the loggers are validated for
`recording UV irradiation
`The adherence scores are higher for
`biologicals than for other psoriasis
`therapies
`Selection bias possible by contact
`made via Psoriasis subscription ]
`overestimation of compliance possible
`because of greater interest in or worry
`about the disease
`
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`Table 2. Sociodemographic factors influencing compliance/adherence
`
`First author, year
`
`Construct
`
`I nfluencing factors
`female
`age
`living alone (vs.
`s ex
`in partnership)
`
`Zaghloul [41], 2004
`Storm [46], 2008
`Gokdemir [39], 2008
`Richards [37], 1999
`
`compliance
`primary adherence
`adherence
`compliance
`
`d
`–
`0
`
`f
`
`d
`
`f
`d
`
`d
`
`d = Higher compliance/adherence; f = lower compliance/adherence; 0 = no effect.
`
`employed
`
`nicotine (N),
`alcohol (A)
`
`d
`
`0
`
`A: f, N: f
`
`N: 0
`
`comparison to a treatment time of less than 2 months [48] .
`Treatment satisfaction is, in turn, associated with better
`adherence, as demonstrated in a study with 103 outpa-
`tients. On the other hand, this study failed to find any as-
`sociation between adherence and the type of therapy [39] .
` Among 120 anonymously questioned patients of a spe-
`cialized psoriasis clinic, compliance was poorer in those
`who felt more impaired by the treatment [37] . In keeping
`with this, psoriasis patients from 4 centres in the USA
`expressed a wish for fast-acting treatments. A study with
`201 outpatients showed a significantly higher adherence
`when the treatment was used for the first time and only
`once daily, and a lower adherence on occurrence of ad-
`verse drug effects [41] . The results of an anonymous ques-
`tionnaire survey of 53 patients under topical corticoid
`therapy showed that the main reasons for non-adherence
`were dissatisfaction with the efficacy, inconvenient or
`unpleasant treatment and fear of adverse drug effects.
`The actual occurrence of side effects, on the other hand,
`had as little influence on adherence as did the proposed
`frequency of use of the medication [38] .
` Although a clinical study with 27 patients under com-
`bined therapy with acitretin and narrow-band UVB pho-
`totherapy showed a marked decrease in adherence for
`acitretin over time, this could not be attributed to side ef-
`fects. The frequency of use of the phototherapy remained
`almost constant over the 12-week observation period – an
`indication that the necessary expenditure of time did not
`negatively affect adherence [44] . Biologicals, which have
`now been available in psoriasis therapy for several years,
`display better efficacy than the previously available op-
`tions [49] . Although there are no studies of the correla-
`tion between efficacy and adherence which directly com-
`pare biologicals with classical forms of therapy, the high-
`er adherence under therapy with biologicals suggests that
`good efficacy has a positive effect on adherence ( table 3 ).
`
` Disease-Specific Factors Influencing Compliance
` A distinct correlation between compliance and dis-
`ease-specific factors was demonstrated in a study with
`201 outpatients. Compliance was reduced in lesions of the
`face and in severe disease, i.e. more than 3 disturbing le-
`sions [41] . An anonymous questionnaire study of 120 pa-
`tients under treatment in a specialized psoriasis clinic
`produced similar results: patients who were not compli-
`ant displayed significantly greater severity (by self-as-
`sessment) and were more impaired by the disease [37] .
`Another questionnaire study of 567 patients to determine
`satisfaction with their medication showed a negative cor-
`relation of the severity of the disease and patient satisfac-
`tion [48] with lower treatment satisfaction being associ-
`ated with lower adherence [39] .
` The factors which affect the severity of psoriasis were
`determined in a questionnaire study of 317 outpatients:
`Significant associations were found between the factors
`which affect the severity of psoriasis and itching, burn-
`ing, painful skin, arthritis, psoriatic arthritis and joint
`pain [50] ( table 4 ).
`
` Psychosocial Factors Influencing Compliance
` In keeping with the significance of interactions be-
`tween psoriasis and the patient’s mental state, many stud-
`ies have devoted themselves to researching psychosocial
`determinants of both the disease and treatment compli-
`ance. Table 5 presents an overview of the findings gener-
`ated in this connection. The documentation of health-re-
`lated quality of life was prompted by, among other things,
`the fact that a poor quality of life has a negative effect on
`adherence. Zaghloul and Goodfield [41] , for instance,
`found an inversely proportional relationship between the
`Dermatology Life Quality Index and adherence.
` Resignation on the part of the patients can likewise
`have negative effects on adherence [39] . As the reason for
`
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`216.185.156.28 - 5/27/2016 11:11:18 PM
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`Table 3. Therapy-specific factors influencing compliance/adherence
`
`First author, year
`
`Construct
`
`I nfluencing factors
`topical therapy
`(vs. s ystemic)
`
`satisfaction
`
`side effects
`
`therapy effort
`(time)
`
`Fouéré [40], 2005
`Atkinson [48], 2004
`Gokdemir [39], 2008
`Richards [37], 1999
`Zaghloul [41], 2004
`Brown [38], 2006
`
`Yentzer [44], 2008
`Bhosle [45], 2006
`
`compliance
`adherence
`adherence
`compliance
`compliance
`adherence
`
`adherence
`adherence
`
`f
`0
`
`f
`
`d
`d
`d
`
`d
`
`d
`
`f
`
`f
`f
`f (expected)
`0 (occurred)
`0 (reported)
`
`f
`
`f
`f
`f
`
`0
`
`d = Higher compliance/adherence; f = lower compliance/adherence; 0 = no effect.
`
`their non-adherence, around 22% of such patients report-
`ed that they ‘had had enough’. Depression is a major co-
`morbidity of psoriasis (10–62%) which is accompanied by
`a distinct deterioration of the care indicators of psoriasis
`(number of days ill or unable to work, office visits). Sui-
`cidal thoughts are reported with significantly greater fre-
`quency than in other dermatological diseases. The occur-
`rence of depression correlates negatively with adherence
` [52] . After it had been demonstrated that a poor quality
`of life, depression and resignation on the part of the pa-
`tient had a negative effect on compliance, various studies
`were designed in which the psychosocial characteristics
`were also placed in relation to the milieu. One study with
`22 hospitalized psoriasis patients addressed the question
`of whether their psychosocial characteristics differed
`from those of healthy adults and whether they could be
`influenced positively by special rehabilitation measures.
`The strength of the wish of psoriasis patients for social
`contact, differentiation and self-assertion was signifi-
`cantly below average in comparison with a normal sam-
`ple. After just 3 weeks of rehabilitation, however, in-
`creased interest in social contact was observed as well as
`a distinct reduction in the PASI [53] . In agreement with
`the above findings, a study with 58 psoriasis patients and
`their partners has shown that the patients suffer signifi-
`cantly more from anxiety, depression and worry [54] . Be-
`cause this is often kept hidden from their partners, how-
`ever, the latter underestimate the psychological burden
`and this, in turn, has a negative effect on the patients’
`well-being and, secondarily, on their adherence to thera-
`py. Interviews of psoriasis patients from 4 centres in the
`USA have also shown that they wish for greater acknowl-
`
`Table 4. Disease-specific factors influencing compliance/adher-
`ence
`
`First author, year
`
`Construct
`
`I nfluencing factors
`fa cial lesions
`severity
`
`Zaghloul [41], 2004
`Richards [37], 1999
`Atkinson [48], 2004
`
`f
`
`compliance
`compliance
`adherence
`
`f
`f
`f
`
`d = Higher compliance/adherence; f = lower compliance/
`adherence.
`
`edgement of the psychological distress caused by their
`illness [55] .
` The improvement of the psoriasis symptoms alone did
`not automatically improve the patients’ mental state, as
`was discovered in another study: at the end of a successful
`course of PUVA therapy, the 72 psoriasis patients felt less
`restricted and stressed as a result of being asymptomatic,
`but the disease-related distress, anxiety, depression and
`worry, their attitude to and ability to cope with the dis-
`ease remained unchanged [56] . Denial of the disease can
`help some patients to cope and must also be taken into
`account as a potential factor for non-adherence [51] . It
`was against this background that a questionnaire survey
`of the acceptance of their disease was conducted in 100
`hospitalized patients. It was found that gender, age, dura-
`tion and severity of the disease (self-assessment) and a
`family history of psoriasis had no effect on the accep-
`tance. In contrast, optimism, absence of a ‘why me?’ at-
`
` Adherence in the Treatment of Psoriasis
`
` Dermatology 2011;222:363–374
`
`369
`
`Page 00007
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`216.185.156.28 - 5/27/2016 11:11:18 PM
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`Table 5. Psychosocial factors influencing compliance/adherence
`
`First author, year
`
`Construct
`
`Zaghloul [41], 2004
`Gokdemir [39], 2008
`Richards [52], 2006
`Awadalla [51], 2007
`Horne [28], 1999
`
`compliance
`adherence
`adherence
`adherence
`adherence
`
`I nfluencing factors
`general quality
`of life
`
`d
`
`d = Higher compliance/adherence; f = lower compliance/adherence.
`
`resignation
`
`depression
`
`denial
`
`positive attitude
`to the drug
`
`f
`
`f
`
`f
`
`d
`
`titude, less fixation on (negative) emotions and objective-
`ly severer disease (according to PASI) had a positive effect
` [57] . A study of 324 patients with different diseases has
`shown how the attitudes of the patients to their medica-
`tion affect adherence. The results show that adherence
`was affected negatively when reservations about, for ex-
`ample, dependency on or late sequelae of drug use out-
`weighed the assessment of the need to take the medica-
`tion. A positive attitude to medication, on the other hand,
`resulted in a measurable improvement of adherence [28]
`( table 5 ).
`
` Compliance: Comparison of Topical versus Systemic
`Therapy
` Compliance with topical therapy is influenced by spe-
`cific factors which do not appear in systemic therapy.
`They include the cosmetic and galenic properties (very
`greasy, desiccating or sticky vehicles), the smell of the
`preparation and the time required for its application.
`Moreover, the efficacy of topical medication is often in-
`ferior to that of the systemic agents, and even with effec-
`tive topical therapy only 40% of patients would respond
`‘very well’, while 4