Christie L. Carroll

Better medication adherence results in greater improvement in severity of psoriasis

Background  Patients are commonly nonadherent to medication regimens. In dermatology, there has been little study of the effect of nonadherence on outcomes.

Electronic monitoring of medication adherence in skin disease: Results of a pilot study

BACKGROUND Traditional medication adherence monitoring for topical medication use in dermatology relies heavily on measures of self-reporting and ointment tube weight, which are susceptible to various biases. METHODS We first assessed the feasibility of using medication electronic monitoring system caps with cream, ointment, and gel formulations. We then performed a pilot study using 10 patients given a diagnosis of psoriasis with a weekly follow-up visit. Topical salicylic acid 6% was supplied to patients in medication jars with caps that recorded the opening and closing of the bottles, without patient knowledge. RESULTS Medication electronic monitoring system cap monitors accurately recorded the opening and closing of bottles of topical agents. Patients overreported adherence in patient logs, and there was greater detection of missed doses using electronic monitors than self-reporting through patient log (relative risk = 6.2, 95% confidence interval: 1.13, 34.09). CONCLUSION Electronic monitoring shows promise as a more accurate form of measuring treatment adherence to topical medication regimens.

Adherence in dermatology: A review of the last 20 years

Background: Adherence has been studied in many areas of medicine; however, there are few published articles pertaining to adherence and dermatology. Objective: The purpose of this review is to summarize the current literature on medical adherence as it specifically applies to dermatology. Methods: We conducted a PUBMED search between the years of 1985 and 2005 using the following terms: 1‐[adherence AND dermatology] and 2‐[dermatology AND treatment]. The search was limited to articles in English and human subjects. Results: The literature search yielded 57 articles. Seventeen of these articles met the inclusion criteria and were reviewed in order to define, measure, quantify, validate, and understand adherence in dermatology. Conclusions: Adherence to topical therapy among dermatology patients is difficult to measure reliably, hence the few articles available on this topic. A small number of studies using new electronic monitoring technology have shown that dermatology patients have low adherence rates to treatment regimens. There are socioeconomic, cognitive, and psychological factors that contribute to non‐adherence among patients. Improving patient knowledge and the doctor–patient relationship are ways to improve patient adherence.

Disease severity and associated family impact in childhood atopic dermatitis

Aim: To examine the association between childhood atopic dermatitis (AD) severity and family impact at baseline and after an intervention by a physician specialist, using validated measures of both severity and family impact. Methods: Cross sectional self administered survey of parent–caregivers of 49 randomly selected children with AD; 35 parents were available for follow up. Family impact was measured using a modified AD Family Impact Scale completed by the parent–caregiver. The child’s disease severity was measured using both the investigator’s assessment via the Eczema Area and Severity Index (EASI) and the caregiver’s assessment via the recently validated Self Assessment Eczema Area and Severity Index (SA-EASI). Results: The parent–caregiver’s assessment of severity of the child was the most significant correlate of the family impact of the child’s AD (p = 0.65 at baseline and p = 0.38 at follow up). In multivariate regression models, the parent–caregiver’s estimate of severity remained the single strongest predictor of family impact before and after receipt of dermatologist care, as well as the difference in impact between pre and post-dermatologist care. Conclusions: There is evidence to support the ability of parent–caregivers of children with AD to accurately determine severity of their child’s AD; perceived severity is the driver of the family impact of this condition. Treatment of a child by a physician specialist is associated with reductions in both perceived severity, as well as family impact of this condition.

Pruritus in adult dermatomyositis

Dermatomyositis has a significant clinical component of pruritus that has not yet been studied. Pruritus can significantly affect the life of patients. The aim of the present work was to study the degree of pruritus experienced by patients. A four‐question survey was sent to patients with documented dermatomyositis. The survey used a 100‐mm Visual Analogue Scale (VAS) to describe current, worst and daily pruritus, and the effect this has on daily activities. Twenty‐six subjects returned completed questionnaires: four had no pruritus; the majority had a significant amount with means above 50 on the VAS. A mean of 44.6 was found for the effect on daily life. Further studies should be performed to examine the prevalence and severity of pruritus in this population and its effect on their quality of life. Clinicians must be aware of the significant pruritus and provide adequate therapy to improve quality of life.

Tacrolimus ointment: the treatment of atopic dermatitis and other inflammatory cutaneous disease

Topical tacrolimus (FK506, Protopic™) has been developed and marketed for the treatment of atopic dermatitis (AD). Tacrolimus works as an inhibitor of calcineurin, which creates a downregulation of the inflammatory cascade. Numerous trials have shown the efficacy and safety of tacrolimus in treating AD in both adults and children. Additionally, comparison data with other medications commonly used for AD, such as topical steroids and pimecrolimus, show improved efficacy of tacrolimus. A comprehensive review of the off-label uses of tacrolimus in other dermatoses, including psoriasis, lichen planus and seborrhoeic dermatitis, is provided. The efficacy of tacrolimus in treating these diseases is based on Phase IV clinical trials and on case reports or series in the literature. Overall, tacrolimus has proven to be a safe and useful topical therapy for many inflammatory dermatological conditions, with AD being the principal indication.

Open label trial of alefacept in palmoplantar pustular psoriasis.

Background: Palmoplantar pustular psoriasis (PPP) is difficult to treat. We assessed the effectiveness of alefacept in PPP and the safety of a 30 mg/week dose. Methods: Fifteen individuals with PPP were started on 15 mg/week intramuscularly (IM) alefacept. Efficacy was measured by the PPP severity instrument (PSI). Treatment was continued for 16 weeks, and the alefacept dose was increased to 30 mg/week IM at week 9 if the PSI did not decrease by at least 25%. Other outcomes included physicians global assessment (PGA), reported adverse events and CD4+ T‐lymphocyte counts. Clinical response was observed for 12 weeks after the last injection. Results: The severity of PPP improved in both the PSI and the PGA (p<0.0001 and p = 0.0009, respectively). Much of the improvement occurred after 10 weeks of therapy. Nail severity scores improved (p = 0.0003). CD4+ counts decreased, but all remained>250 cells/mm3. There were no severe adverse effects or discontinuations due to adverse events. Conclusions: Alefacept in doses up to 30 mg/week was well tolerated in patients with PPP and appeared to have some efficacy. The use of concomitant therapy, the lack of a comparator, and the small sample size are limitations of the study.

A comparative study of clinical characteristics, work-up, treatment, and association to malignancy in dermatomyositis between two tertiary skin centers in the USA and Singapore

Background  To date, no study has compared the clinical characteristics, malignancy associations, and treatment of dermatomyositis in predominantly Caucasian vs. Asian populations.

Cutaneous blood flow in dermatomyositis and its association with disease severity.

Background: Several studies using nailfold capillary microscopes have demonstrated capillary changes in patients with dermatomyositis (DM); however, no previous study has examined cutaneous blood flow in this disease.

A Randomized, Double-Blind, Vehicle-Controlled, Right/Left Comparative Study of the Efficacy of Acitretin with and without the Co-Administration of 0.1% Tacrolimus Topical Ointment in the Treatment of Moderate to Severe Psoriasis

Background Topical tacrolimus is effective as monotherapy for inverse psoriasis. Its use in combination with other systemic agents may be an effective treatment for psoriasis in less sensitive areas. Objective To determine if topical tacrolimus in combination with oral acitretin is more effective than oral acitretin and vehicle ointment. Methods All patients received oral acitretin; subjects were randomized to apply topical tacrolimus to one side of their body and vehicle to the other. Results Topical tacrolimus was more effective than vehicle ointment as early as week 4. There were no serious adverse events thought to be due to drug or dose changes during the study. Limitations Due to the short time horizon of the study, it may not be appropriate to generalize the results to longer treatment periods. Conclusions Topical tacrolimus is an effective psoriasis treatment and was well-tolerated when combined with systemic acitretin in the treatment of psoriasis.