I Parting Thought
`
`J
`
`Medication adherence among acne patients: a review
`
`Robert Lott, MD,1 Sarah L Taylor, MD, MPH,1 Jenna L O’Neill, MD,1 Daniel P Krowchuk, MD,1"4 &
`Steven R Feldman, MD PhD,1’2"3
`1 Department of Dermatoloqy, Center for Dermatology Research, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
`
`2Department of Pathology, Center for Dermatology Research, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
`
`3Department of Public Health Sciences, Center for Dermatology Research, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
`
`4Department of Pediatrics, Center for Dermatology Research, t/rake Forest University School of Medicine, Winston Salem, North Carolina, USA
`
`Su m mary
`
`Background Acne is a chronic disease often requiring the use of medications for extended
`periods of time. In general, adherence decreases over time in patients with chronic
`diseases, and adherence to topical medications is poor compared to adherence to oral
`medications, placing individuals using topical medications at increased risk for
`nonadherence and treatment failure. Poor adherence may also be a common cause of
`treatment failure in teens with acne.
`Purpose We reviewed the current literature on medication adherence in teenagers with
`acne to assess adherence levels and predictors of adherence. We hope to provide a
`foundation |br further research into medication adherence in acne patients.
`Methods A Medline search was conducted using the key words "acne" and "adherence"
`or "compliance." Studies reporting adherence were included in the analysis.
`Results A positive correlation was found between quality of life of patients with acne and
`medication adherence. Weaker predictors of adherence include increased age, female
`gender, and employment. The most commonly reported reason for nonadherence was
`inadequate time to use the treatment medication. Patients taking medications requiring
`less frequent dosing had better adherence, and medication adherence correlated with
`better health status among acne patients. A longer duration between office visits may be
`associated with decreased compliance.
`Limitations Few studies investigating the prevalence and causes of nonadherence in
`acne patients were identified.
`Conclusions Adherence to medications is difficult to measure and rates reported by pa-
`tients often overestimate actual adherence. Patients cite lack of time as a common
`reason lbr nonadherence to topical medications.
`
`Keywords: acne vulgaris, adherence, quality of life, medical therapy
`
`Introduction
`
`Acne vulgaris is a common skin condition affecting
`approximately 85% of people at some time in their lives.1
`
`Acne is linked to poor quality of life and significant
`psychological problems.2’3 The psychological effects of
`acne on an individual may be varied and can include
`anger, sadness, frustration, and social avoidance. While
`acne is likely to eventually clear spontaneously, active
`disease and scarring may continue to persist for years,
`often well into adulthood.
`The first-line treatment of milder forms of acne is
`topical medication with or without oral antibiotics.
`Accepted f or publication January9, 2010
`
`Correspondence: Steven R. Feldman, Department of Dermatology, Wake
`
`Forest University School of Medicine. Medical Center Boulevard. Winston-
`
`Salem, NC 27157-1071, USA. E-mail: sfeldman@wfubmc.edu
`
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`Medication adherence aInong acne patients ¯ R Lott et al.
`
`beginning of 1998 through September 1, 2008. The
`search was limited to articles in English and to studies
`using humans. Studies were included if they reported
`medication adherence (Fig. 1). Of 148 studies initially
`identified, there were 63 English language studies
`excluding review articles. Of those, 13 studies were
`identified which measured adherence to acne treatments
`either subjectively or objectively. Four of these studies
`includcd only paticnts using topical mcdications without
`oral treatment or with stable long-term oral treatment.
`Five of these studies included patients initiating either
`topical or oral medications at the start of the study. No
`review articles were included in the results, but several
`were used as a source of background information. Figure
`1 illustrates the literature search process.
`
`Results
`
`Unfortunately, as is the case in many chronic diseases,
`acne treatment suffers due to poor medication adher-
`ence, a common cause of treatment failure. There are a
`number of reasons for poor adherence, including con-
`cerns about side effects, frustration with previous treat-
`ment failures, difficulty incorporating medication
`regimens into one’s daffy routine, and costs of treatment
`or lack of insurance. Failure of first-line drugs may result
`in costly visits and othcrwisc unncccssary cxposurc to
`higher doses of medications. Alternatively, should the
`patient become frustrated and cease treatment, psycho-
`logical effects of untreated or undertreated acne will
`persist. Thus, further research into the causes of acne
`nonadherence and the development of interventions to
`improve acne adherence are important areas of
`research. The purpose of this article is to describe recent
`studies on rates and predictors of adherence to acne
`medications, and to serve as a basis for development of
`future research.
`
`A Medline search was performed using the keywords
`from
`the
`(acne AND (adherence OR compliance))
`
`148 resulted|
`studiesJ
`
`l
`
`109 studies
`
`3 non-English studies,
`36 non-acne
`
`]
`
`,[
`
`Six studies were identified that measured adherence by
`patient questionnaires, and two studies utilized patient
`Methods diaries. The remaining five studies utilized various
`electronic methods to assess adherence, which are
`discussed below. These findings are summarized in
`Table 1. Tan et al.4 studied 287 teens with acne, of
`which 152 returned for follow-up at two months.
`Adherence was measured by a single question which
`asked subjects to rate as a percentage how often they
`used their medications as prescribed. Subjects reporting
`their medication usage as 100%, between 75% and
`99%, and 74% and below were considered to have high,
`medium, and low adherence, respectively. Of the sub-
`jects returning for follow-up, 24% were rated as having
`high adherence, 49% were found to have medium
`adherence, and 26% were found to have low adherence.
`
`l~
`
`64 studiesJ
`/
`
`61 studies
`
`13 studies
`measuring
`adherence
`
`45 reviews
`
`’I
`
`j The most common reasons given for low adherence by
`subjects were side effects, forgetfulness, and lack of
`improvement. Sex, age, level of third party medication
`coverage, alcohol use, illicit drug use, tobacco use, and
`
`.( non o0,oo,,o0 ) edu a.on, ,we eno, i ni. an. as oda dwi,h
`
`1 basic science
`
`patient adherence. The authors concluded that adher-
`ence to topical acne therapy increases with impact on
`quality of life but decreases with increasing acne
`
`.(11opinion, 37 drug studies ] severity; seemingly contradictory statements since pa-
`tients with more severe acne are likely to have a greater
`not measuring adherence
`negative impact on quality of life. Additionally, those
`subjects who did not return for follow-up at study
`conclusion may have been less adherence than those
`who finished the study.
`Eichenfield et al.5 performed an open-label, nonran-
`domized Phase 4 study to test the efficacy of tretinoin
`microsphere gel at 0.04% and 0.1% when used from a
`pump dispenser. The study population consisted of 544
`
`Figure 1 Acne adherence search results. Results of a Medline
`search using the keywords (acne AND (adherence OR coInpli-
`ance)) from the beginning of 1998 through September 1, 2008.
`Thirteen studies were reviewed that measured ache adherence,
`with results presented in Table 2.
`
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`Medication adherence among acne patients ° R Lott et al.
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`Table 1 Summary of ache adherence study results.
`
`Study author
`
`Adherence
`assessment method
`
`n
`
`Adherence to treatment
`
`Other results related to adherence
`
`Tan et a/.4
`
`Single question
`
`287
`
`Eichenfield et a/.s
`
`Questionnaire
`
`544
`
`Pawin etal2
`
`Recall questionnaire
`
`246
`
`Jones-Caballero
`et al.7
`
`Single question
`
`2221
`
`Rapp et al.8
`
`Single question
`
`Baker etal.9
`
`Questionnaire
`
`Marazzi etal]°
`
`Patient diary cards
`
`Cunliffe er a/.11
`
`Patient diaries
`
`McEvoy et al.12
`
`No. of appointments kept
`during study period
`
`Zaghloul etal]3
`
`Pill counts, weighing
`of topical medications
`
`Cook-Bolden~4
`
`Self-report and number
`of medication refills
`
`Balkrishnan et alls Number of medication
`refills
`Electronic MEMS caps
`
`Yentzer et al.16
`
`479
`
`2545
`
`188
`
`246
`
`144
`
`403
`
`1979
`
`11
`
`76% adherent "at least some of the
`time" (score of 3 or above on 5 point
`scale)
`47% of subjects reported applying
`medication daily; 45% applied it
`almost daily
`100% adherence reported in 55% of
`subjects using
`isotretinoin/erythromycin gel once
`daily versus 44% of subjects using
`benzoyl peroxide/erythromycin gel
`twice daily
`Mean adherence rate among patients
`using clindamycin/zinc gel once daily,
`clindamycin/zinc gel twice daily, and
`clindamycin gel twice daily: 98%,
`92%, and 92%, respectively
`28% kept all four appointments; 10% Characteristics of subjects most likely to
`kept three appointments; 18%
`keep appointments: Caucasian,
`attended only the initial consultation
`receiving isotretinoin, non-Medicaid
`appointment
`insurance, reported their acne to be
`worse than their parent’s acne
`Level of adherence has a direct linear
`relationship with a patient’s quality of
`life
`Adapalene only and add-on study arms Medication adherence decreases over
`adherence was 88.3% and 87% at
`time; patients may overestimate their
`12 weeks, respectively. Objective
`own medication adherence
`adherence measured by prescription
`refills was 80.3% and 80.4%,
`respectively, at 12 weeks
`~5 million Average number of annual medication
`refills for acne per patient is 2.07
`82% adherent on day one; 45% at
`6 weeks
`
`152 of 287 subjects (53%) returned for
`24% rated as 100% adherent to
`follow-up; those who did not
`therapy; 49% rated as 75% 99%
`complete study may have lower
`adherent to therapy; 26% rated as
`adherence rates
`<75% adherent to therapy,
`94.5%, 93.5%, 94.5% at weeks 3, 6, Nonadherent subjects could be
`and 12, respectively, for patients
`removed from the study at
`using 0.04% tretinoin gel. 94.7%,
`investigator’s discretion
`96.5%, 94.6% respectively for
`patients using 0.1% tretinoin gel
`Topicals: 54% had good adherence;
`46% had poor adherence. Combined
`oral and topicals: 81% had good
`adherence to one or both; 59% had
`poor adherence. Oral isotretinoin
`only: 96% had good adherence
`57% reported medication adherence as Causes of nonadherence: most
`"every day" and 38% as "almost
`commonly "forgetting," "lack of
`every day"
`time," and treatment being too
`boring
`Sex, ethnicity, global health status, and
`acne severity are signif cant predictors
`of adherence; trait anger is not
`Phase 4, open-label study
`
`Self-administered questionnaire was
`found to have a sensitivity of 0.47 and
`a specificity of 0.89 for detecting
`adherence
`
`Adherence improved with once daily
`treatment compared to twice daily
`therapy
`
`Efficacy and tolerability were equivalent
`among all treatment arms; once daily
`dosing may improve adherence
`
`Mean adherence reported as
`64.7 _+ 24%
`
`Patients refilling acne medications more
`often had better overall health status
`Adherence to treatment decreases
`among adolescents as time since the
`last office visit increases
`
`A total of 13 studies addressing acne adherence were selected for review. Studies are arranged by method of measuring adherence;
`methods ranged from single or multiquestion surveys to electronic monitoring systems, n = number of subjects, MEMS = Medication
`Event Monitoring System.
`
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`individuals with mild to moderate facial acne who were
`dissatisfied with their current ache treatment. The
`addition of the pump allowed a more precise amount
`of medication to be dispensed with each application,
`Additionally, subjects were allowed to use up to two
`other nonretinoid acne therapies concurrently. Compli
`ance was assessed at weeks 3, 6, and 12 by subject
`responses to verbal questioning and grouped as: high
`compliancc, 75-100% of doscs takcn; modcratc compli-
`ance, 50-74% of doses taken: intermittent compliance,
`2549% of doses taken; and low compliance, less than
`24% of doses taken. Noncompliant subjects could be
`removed from the study at the investigator’s discretion,
`Compliance was measured as 94.5%, 93.5%, and 94.5%
`for individuals using the 0.04% gel at weeks 3, 6, aud
`12, respectively. For individuals using the 0.1% gel,
`94.7%, 96.5%, and 94.6% of subjects were considered to
`be highly compliant at weeks 3, 6, and 12, respectively,
`Pawin et al.6 created a tool designed to assess
`adherence to topical and oral medication usage in an
`outpatient office setting. They measured adherence by
`providing a self-administered questionnaire to 246
`subjects returning for follow-up for ache treatment to
`determine their recall of the treatment prescribed. A
`subject who correctly named his or her treatment and
`answered the questions in a way that suggested use of
`medications as directed by a dermatologist was consid-
`ered to have good adherence. If the subject was unable
`to describe his or her drug regimen or answered
`questions in a way that suggested he or she had not
`been using them as directed, the patient was considered
`to be poorly adherent. Of subjects using only topical
`medications, 54% had good adherence and 46% had
`poor adherence. Among those using a combination of
`oral and topical medications, 81% were considered to
`have good adherence to either the topical or oral aspect
`of their medication regimen while 59% were considered
`poorly adherent to one or both aspects of their treatment
`regimens. Ninety-six percent of subjects using only oral
`isotretinoin for their ache were considered to have good
`adherence to therapy.
`Jones-Caballero et al.7 reported an analysis of a
`previously published observational, prospective, multi-
`center study of one oral and one topical acne medication
`used twice daily. There were 2221 subjects who
`participated in two once visits, one at the beginning
`and one at the end of the 12-week study. Adherence was
`measured subjectively by asking subjects to rate adher-
`ence as daily, almost daily, sometimes, or rarely. Daily or
`almost daily use was considered adherence and some-
`times or rarely was considered nonadherence; overall
`96.2% of subjects reported daily or almost daily use.
`
`Medication adherence among acile patients ¯ R Lott et al.
`
`Adherent subjects were slightly older and had less severe
`ache than nonadherent subjects at the end of the study.
`Despite having objectively more severe acne than
`adherent males and females and nonadherent females,
`these subjects viewed their acne as less severe, and
`believed it had less impact on their emotional state and
`functioning. Nonadherent women were affected emo-
`tionally and functionally much more than adherent
`womcn. Nonadhcrcnt womcn fclt thcir acnc improvcd to
`a lesser extent than women who were adherent or
`mostly adherent. Sixty-five percent of patients listed
`"forgetting" as their main reason for nonadherence to
`treatment. Other reasons cited included "lack of time,"
`being bored, and less commonly medication side effects.
`Males, younger patients, and unemployed patients had
`poorer adherence overall.
`Rapp et al.s assessed anger, global quality of life, skin-
`related quality of life, satisfaction, and adherence in 479
`subjects with acne. Trait anger was measured with six
`items describing angry mood: subjects were asked to rate
`how often they experienced each mood, and the average
`rating was calculated to determine a mean trait anger
`score. Adherence was measured using a single question
`which asked the patient how often she had been
`adherent in the last week. Poor adherence was associ-
`ated with male gender, nonwhite ethnicity, and poor
`overall health. More severe acne was also related to
`poorer adherence. A subject’s level of anger was not
`significantly related to adherence although there was a
`trend towards poorer adherence among individuals with
`high trait anger.
`Baker et al.9 reported a Phase IV multicenter non-
`comparative study with 2545 subjects participating in a
`12-week opendabel trial examining the efficacy and
`tolerability of once daily application of adapalene gel
`0.1%. Adherence was assessed at the end of the study by
`a questionnaire. Overall 92% of the subjects reported
`themselves as always or almost always adherent, with
`the remainder of subjects reporting their medication
`adherence as sometimes or seldom.
`A 12-week multicenter study of 188 patients with
`ache conducted by Marrazi et al.1° found that those
`applying isotretinoin/erythromycin gels once a day had
`a better compliance rate than patients applying benzoyl
`peroxide/erythromycin gel twice a day. Subjects in each
`group were given verbal and written instructions on
`how to apply the study medication, including storage of
`the benzoyl peroxide/erythromycin medication in a
`refrigerator (but not the isotretinoin/erythromycin
`product). Subjects returned for follow-up visits 2, 4, 8,
`and 12 weeks into the study. There was no statistically
`significant difference in the efficacy of the two
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`Medication adherence among acne patients ° R Lott et al.
`
`acne therapy via medication weight for topical medi-
`medications at 12 weeks as rated by subjects and by the
`investigators. Adherence to the study regimen was
`cations and pill count for oral medications. The effects
`on adherence of patient’s age, sex, isotretinoin vs. other
`measured by patient diary cards filled out daily by
`medication use, and quality of life measured by the
`participating subjects. Between 8 and 12 weeks, 55% of
`Dermatology Life Quality Index (DLQI) on adherence
`patients using isotretinoin/erythromycin gel and 44% of
`were assessed. The majority of subjects involved in this
`patients using benzoyl peroxide/erythromycin gel
`study were taking isotretinoin during the study: 19%
`were 100% compliant, while 2% of patients using
`used topical and oral medications other than isotretin-
`isotretinoin/erythromycin gel and 13% of patients using
`oin. Nonadhcrcnt subjccts wcrc morc likcly to bc
`bcnzoyl pcroxidc/crythromycin gcl wcrc lcss than 50%
`young, single, male, unemployed, and to have person-
`compliant,
`Cunliffe et al.11 reported on the adherence among 246
`ally paid for their medications. A distinct and signifi-
`cant negative correlation was found between
`subjects in a Phase III clinical trial assessing a new
`medication adherence and quality of lilt. Adherence
`cfindamycitVzinc product lbr the treatment of mild to
`among subjects using topical and oral medications
`moderate acne. Study subjects received topical clinda-
`myciuizinc gel daily, clindamyciLb/zinc gel twice daily,
`other than isotrelinoin was 35.2% while adherence
`among isotretinoin subjects was 71.4%. The main
`or clh~damycin lotion twice daily for 16 weeks. Adher-
`reasons for missing treatment were frustration, forget-
`ence was recorded by patient diaries. Mean reported
`fulness, and being too busy. Medication adherence was
`adherence rates were 98%, 92%, and 92%, respectively,
`assessed during an interview in which each subject was
`for the three treatment groups,
`asked to assess how much medication he or she had
`Other methods used to measure medication adherence
`used during the study.
`include appointment records, pharmacy refill records,
`The MORE (Measuring Acne Outcomes in a Real-
`and electronic adherence monitoring systems. McEvoy
`et al.12 used appointment keeping as a measure of World Experience)trial14 examined the efficacy, tolera-
`adherence to treatment. Pre- and posttreatment ques-
`bifity, patient satislaction, and adherence of 1979 acne
`tionnaires assessing subjects’ beliefs about acne treat-
`patients in two treatment arms: those using only
`adapalene 0.1% gel for their acne treatment, and those
`ment and adherence behaviors also were administered,
`A total of 144 patients participated in the study, and 97
`adding adapalene 0.1% gel to their current acne
`treatment regimen. Among the adapalene only and
`returned the post-study questionnaire. Subjects were
`scheduled for a follow-up visit with a nurse 1 week after
`add-on study arms, self-reported medication adherence
`the initial visit: all other appointments were scheduled
`was 94.6% and 94.2%, respectively, at 6 weeks and
`with a doctor every 4 6 weeks after the initial visit for a
`88.3% and 87%, respectively, at 12 weeks. Objective
`total of one nurse visit and four doctor visits. Eighteen
`measurement of adherence based on number of pre-
`percent of subjects did not return for any follow-up
`scriptions filled was 94% of the adapalene only and
`appointments, 13% returned only for the nurse visit, and
`92.8% of the add-on groups at 6 weeks and 80.3% and
`28% kept all four doctor appointments. The remainder of
`80.4%, respectively, at 12 weeks.
`A cross-sectional study by Balkrishnan et al.~5 that
`the subjects kept two or three visits, or dropped out of
`treatment and thenreturnedlaterinthe study. Subjects
`examined the charts of 5.6 million acne patients
`who were most likely to keep appointments were
`reported a positive correlation between patient medico-
`Caucasian, subjects with insurance other than Medicaid,
`tion adherence, measured by pharmacy refills of acne
`women whose ache did not worsen with menses, and
`medications, and better health status.
`Yentzer et al.16 in a small study of 11 teenagers
`individuals who believed their acne to be worse than
`their parents’ acne. Of the 65 subjects who did not keep
`returning for follow-up, found after 6 weeks of therapy
`all the appointments and returned poststudy question-
`with once daily benzoyl peroxide a drop in adherence
`naires, 24 reported that they had kept all appointments,
`from 82% on the first day of treatment to 45% on the
`Age, sex, or acne severity did not correlate with
`final day of the study. This study measured the adher-
`individual likelihood of keeping follow-up appointments,
`ence of study subjects without their knowledge until the
`Reasons given for failure to follow-up included not
`end of the study and so attempted to replicate the
`enough time to keep appointments, improvement of
`conditions found in a nonresearch setting. Adherence
`acne, financial reasons, and giving up because of no
`was measured via the Medication Event Monitoring
`System (MEMS®, AARDEX Corp., Fremont, CA, USA),
`observed improvement.
`Zaghloul et aI.1~ measured acne patient compliance
`which records the date and time when the cap on the
`in 403 subjects on oral isotretinoin or conventional
`medication tube is removed.
`
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`Discussion
`
`Topical medications are commonly used to treat
`chronic skin diseases. Topical application allows the
`use of potent medications while limiting the risk of
`systemic side effects.17 Unfortunately, topical medica-
`tion use is complicated and time consuming compared
`to the use of oral medications. The disparity between
`oral and topical medication adherence is demonstrated
`in the study conducted by Pawin et al.6 and may have
`contributed to the large differences of adherence
`observed by Jones-Caballero et al.7 in the "other
`medication" group, although the number of topical
`medication users and oral antibiotic users in this group
`was not reported. Although there is sonic conflicting
`data on whether adherence to oral medications is more
`or less than adherence to topical medications, one
`study of oral prednisone and topical tacrolimus for
`hand dermatitis found better adherence to the oral
`treatment using objective electronic monitors,xs’19
`Patients may be more adherent to oral therapies due
`to perceived better efficacy compared to topical medi-
`cations. Identifying risk factors for nonadherence may
`help identify patients at risk lbr nonadherence and thus
`for treatment failure. Although there was some dis-
`agreement between the studies reviewed, generally
`patients with a better quality of life were shown to be
`more adherent to therapy.4’s’13 This is somewhat
`counterintuitive as it seems more likely that individuals
`more distressed by their disease would better adhere to
`medical therapies. However, this is the opposite of the
`observed trend as acne patients with a decreased
`quality of life tend to have worse adherence behavior,
`consistent with findings in patients with other derma-
`tologic conditions,x3’19 This trend may be due to an
`increased psychiatric morbidity among populations
`with very poor adherence.7’19 In some cases successful
`treatment of ache may result in improvement in
`symptoms of anxiety and depression.2°
`While quality of life is perhaps the best studied factor
`related to adherence behavior, other characteristics that
`may be associated with nonadherence include being
`male, young, single, unemployed, on Medicaid, in poor
`health, a minority, or having more severe disease. One
`might conclude that these traits could be helpful in
`identifying individuals at a particularly high risk for
`nnnadberence and treatment failure who may need
`closer treatment supervision, motivational interviewing,
`or other techniques to enhance adherence. However,
`poor adherence is common across the acne population
`and the value of these factors for identifying at risk
`individuals is uncertain,
`
`Medication adherence among acne patients ¯ R Lott et al.
`
`Minimizing medication side effects is commonly men-
`tioned as a way to increase medication adherence.2x 23
`Of the studies reviewed, only Tan et al. and Jones-
`Caballero et al. mentioned medication adverse effects as a
`major cause of nonadherence. Zaghloul et al.13 and
`Pawin et aL6 found that patient adherence to oral
`isotretinoin is superior compared to adherence to either
`topical medications alone or a combination of oral and
`topical acnc mcdications. Oral isotrctinoin is known to
`have far more numerous and severe side effects than
`topical medications. The relationship between side effects
`and adherence may be complex; for example, the
`presence of side effects could help remind patients to
`take their medication. Also, patients may be willing to
`tolerate adverse effects if they believe the drug will
`improve their condition, while they may be less tolerant
`of side effects caused by drugs perceived to be less
`effective. Educating patients about potential side effects
`of newly prescribed medications may improve adher-
`ence, as patients will not be surprised by a side effect and
`discontinue the medication abruptly. Expected and
`benign side effects may also be used to reinforce to
`patients that a medication is "working"; for example,
`dryness experienced by acne patients using topical
`retinoid medications.
`Forgetting to take medications was a conmmn reason
`for poor adherence in all three studies questioning
`patients on nonadherent behavior.<7’13 Providing pa-
`tients with strategies to remember to take medications
`and emphasizing the importance of using the medication
`as prescribed could help improve treatment success
`rates. For example, a topical medication could be taped
`to a tube of toothpaste, so that palients are reminded to
`use the medication when they brush their teeth. Many
`other reminder systems exist, but the usefulness of these
`tools has not been proven in controlled studies.
`Other strategies that may improve adherence include
`selecting medications that are as easy to use and more
`frequent follow-up.16 Choosing drugs with simple dosing
`regimens may increase a patient’s level of compliance
`with one medication above that of another medication
`requiring the patient to use it more often or to store it in
`inconvenient areas such a refrigerator? Adherence may
`also decrease as the length of time since the patient’s
`office visit increases.~6 Decreasing the period of time
`between visits can help decrease nonadherent behavior.
`Medication adherence is a complex human behavior.
`Adherence to medical treatment is overestimated by
`subjective lbrms of measurement, and topical medication
`adherence is difficult to measure due to the added need
`to measure not only how often a patient takes a dose of
`medication but also how much medication is used per
`
`© 2010 Wiley Periodicals, Inc. ¯ Journal of Cosmetic Dermatology, 9, 160-166 ’165
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`Medication adherence among acne patients ° R Lott et al.
`
`dose.17 Future studies are needed to better understand
`medication adherence behavior and to develop and test
`strategies to improve medication adherence in patients
`
`with acne.
`
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