PracticeUpdate Dermatology February 2019

EDITOR’S PICKS 8

A Smartphone Application Supporting Patients With Psoriasis Improves Adherence to Topical Treatment The British Journal of Dermatology Take-home message • This randomized controlled trial evaluated the efficacy of a smartphone application (app) for improving treatment adherence in patients with psoriasis. In all, 122 patients completed the study. Each patient was given a medication canister containing calcipo- triol/betamethasone dipropionate cutaneous foam equipped with a chip which recorded the date and time of each application. Patients were instructed to apply the medication once daily. Patients in the intervention group were also given an app which sent daily reminders to their phone to apply their medication. At the end of 4 weeks, 65% of patients in the intervention group were compliant with the daily regimen (use of medication on greater than 80% of days) vs 38% of patients in the non-intervention group. • Patient adherence and psoriasis disease severity can be positively impacted using a smartphone app for daily reminder. Caitlyn T. Reed MD COMMENT By Robert T. Brodell MD, FAAD W hen I read this randomized study involving use of a smartphone app to remind patients to adhere to their topical treatment for psoriasis in a treatment and con-

longer one is on a drug, the less often the patient uses the drug.” Therefore, in this study, I would have expected that at longer time intervals (Weeks 8 and 24) there would have been MORE significant variance in the use of the topical product reflected in greater improvement and more favorable quality of life in the intervention group. This study showed a significant improvement only in week 4! Also, by my reading of this study, the adherence measures were only performed for the first 4 weeks of the trial. I believe that patients may become “bored” with the app and begin to ignore it over longer periods of time. Assuming that this is correct, we may need a more engaging, effective app…. and, another study could be done to demonstrate a scalable approach to overcoming patient adherence problems with adherence measured over a 24-week time frame. An alterna- tive explanation: the medication they chose to test may work so well, that missing more applications in the control group makes no difference in the eventual outcome based upon physician global assessment and quality of life measures. I have asked Steve Feldman to respond to this commentary! initial adherence, the app didn’t cause patients to develop a habit of using their treatment. Developing approaches – whether technological or psychosocial – that lead patients to develop solid medication use habits could be a profound way to improve the long-term outcomes of topical treatment for a wide range of skin diseases. I remember the tag line, “Better living through chemistry.” It may be that “Better living through psychology” describes an even more productive way of improving our patients’ outcomes.

trol group, I thought immediately of Steve Feldman. When I saw that memory caps on the foam canisters were used to judge adherence along with a secondary measure (weight of canisters brought in during visits) and that physician global assessment and quality of life measures were used in the study, I KNEW he must have a hand in this even though the study was performed at the University of South Denmark in Odense. Kudos are in order for the continued efforts of dermatologists from around the world that have been inspired by Dr. Feldman to perform research on the problem of adherence in dermatology that is experienced by ALL of our patients. There are findings in this study that did not match my hypotheses regarding patient adherence. I believe that tachyphylaxis (failure of a drug after prolonged use) is not primarily a pharmacologic phenomenon. In the setting of a topical product, it is not “the longer one uses a drug the less well it works” but, rather, “the By Steven R. Feldman MD, PhD S vendsen et al find that patients with psoriasis are not highly adherent to their topical treatment and that a reminder app can help increase their use of treatment. Their study, done in a Danish population who were sufficiently clever to use an English app and bothered enough by their disease to make regular visits to the dermatology office, shows that even well- educated patients with bothersome disease don’t use their topical medication. This study also shows that a simple, scalable app can help improve, but not altogether solve, the problem of poor adherence. In this study, the reminder app was only used for the first month. At 1 month, adherence and outcomes were better in patients who received the reminders. Although adherence was only measured for that month, only smaller differences – not statistically significant ones – remained in treatment outcomes at 8 and 12 weeks, suggesting that, although the app helped improve

Dr. Feldman is a Professor of Dermatology, Pathology & Public Health Sciences at Wake Forest University School of Medicine in Winston-Salem, North Carolina.

PRACTICEUPDATE DERMATOLOGY