Tolerability of and Adherence to Topical Treatments in Atopic Dermatitis: A Narrative Review

Abstract

Atopic dermatitis (AD) is a common, chronic inflammatory skin disease that oftentimes requires complex therapy. Poor adherence is a major barrier to AD treatment success. An interspecialty, virtual roundtable panel was held, through which clinical dermatologists, allergists, and behavioral and social psychologists discussed AD management and adherence. Relevant literature was reviewed, and the content of this article was organized based on the roundtable discussion. Current guidelines for AD treatment include maintenance and acute therapy for mild-to-severe AD. Therapy is often complex and requires significant patient involvement, which may contribute to poor treatment adherence. Behavioral and social psychology strategies that may help improve adherence include scheduling timely follow-up appointments, using a clearly written eczema action plan (EAP), reducing perceived treatment burden, utilizing anchoring techniques, sharing anecdotes, and rewarding children using positive reinforcement and stickers. There are multiple practical ways by which providers can improve both the management and treatment adherence of patients with AD.

Keywords: Adherence; Atopic dermatitis; Behavior; Corticosteroid; Eczema; Management; Patient; Social psychology; Tolerability; Treatment.

Fig. 1

Diagnosis and assessment of AD. To aid in the diagnosis of AD, the American Academy of Dermatology (AAD) published various features of AD and categorized them as required features needed for an AD diagnosis, important features, and associated features [2]

Fig. 2

Comparing AD severity measurement tools. There are various tools that help providers assess AD disease severity. ¹SCORing Atopic Dermatitis; ²Eczema Area and Severity Index; ³Validated Investigator Global Assessment Scale for Atopic Dermatitis

Fig. 3

Categorizing treatment regimens for AD. Managing treatment regimens for AD can be effectively organized based on severity (clear or nonlesional, mild, moderate, and severe), and further categorized by maintenance (daily regimen for clear skin) treatments and acute (flare-up) treatments in patient-friendly language [20]

Fig. 4

Step-up treatment for worsening AD. Organization of guidelines depicts when it may be appropriate to change treatment regimens or how to step up therapy if AD worsens [20]. Treatment adherence should be adequately assessed before initiating new therapy or introducing systemic treatment

Fig. 5

Average rate of adherence versus time after starting topical treatment. Adherence to topical treatment is poor, and average rates of adherence decline as time passes after the initial appointment and start of treatment. Adherence tends to increase just before a scheduled follow-up appointment (*), but then declines again. More frequent follow-ups may be beneficial in helping to improve adherence to therapy in AD [9]

Fig. 6

Adherence intervention pyramid. The groundwork for helping to improve patient treatment adherence starts with establishing a trusting physician–patient relationship and scheduling more frequent follow-up appointments. These follow-ups and more frequent interactions with the patient will not only help to deepen the physician–patient relationship but also improve patient accountability. Another step to improving treatment adherence is to provide clear, written instruction for patients in the form of an EAP. Psychological techniques can also be employed, including the use of anchoring, providing anecdotes, and using rewards and praise [10]

Fig. 7

Generic treatment plan. An example of a generic EAP, which provides written instruction for a patient’s treatment regimen to clarify complex directions and organize products and techniques used in typical, multistep AD therapy [26]

Fig. 8

Pseudotailored treatment plan. An example of a pseudotailored EAP, which provides the experience of customization without actually providing individualized content. The treatment plan is perceived as personalized by the patient. Treatment options are circled among decoy options [26]

Fig. 9

Effect of anchoring on patient treatment willingness. Patients were split into two groups and asked about their willingness to inject a subcutaneous medication indicated once monthly. The first group was not anchored, and was only asked about their willingness to inject once monthly. The second group was anchored by first being asked how willing they were to inject daily. After being asked about once daily injections, the anchor group was then asked how willing they were to inject once monthly. The willingness was scored on a scale of 1–10, with 1 being not at all willing, and 10 being the most willing. Average willingness to adhere to treatment was almost four times higher in patients who were anchored than those who were not [27]