Kathryn L. Anderson

Interventions to Increase Treatment Adherence in Pediatric Atopic Dermatitis: A Systematic Review.

Poor adherence to treatment is a major factor limiting treatment outcomes in patients with atopic dermatitis. The purpose of our systematic review is to identify techniques that have been tested to increase treatment adherence in atopic dermatitis. A MEDLINE search was performed for clinical trials focusing on interventions used to increase adherence in atopic dermatitis. Four articles were retrieved. References of these studies were analyzed yielding three more trials. The seven results were evaluated by comparing the intervention used to improve adherence, how adherence was assessed, and the outcome of the intervention tested. Different approaches to increase adherence such as written eczema action plans, educational workshops, extra office visits, and use of an atopic dermatitis educator were evaluated. All interventions increased adherence rates or decreased severity in patients, except for two. The MEDLINE search yielded limited results due to a lack of studies conducted specifically for atopic dermatitis and adherence was measured using different methods making the studies difficult to compare. Interventions including patient education, eczema action plans, and a quick return for a follow-up visit improve adherence, but based on the lack of clinical trials, developing new techniques to improve adherence could be as valuable as developing new treatments.

Frequency of Primary Nonadherence to Acne Treatment

IMPORTANCE Treatment outcomes depend on adherence to the prescribed regimen. Primary nonadherence refers to not obtaining and starting to take a prescribed medication. The frequency of primary nonadherence to acne treatment has not been well characterized. The complexity of multidrug acne regimens may add to this problem but, to our knowledge, has not been explored. OBJECTIVES To estimate acne treatment primary nonadherence rates and to determine the relationship between primary nonadherence and the number of acne treatments prescribed. DESIGN, SETTING, AND PARTICIPANTS A review of medical records from an outpatient university dermatology clinic identified patients with an acne diagnosis at a dermatology visit in the past 3 months who were prescribed 1, 2, or 3 or more treatments. Patients were excluded if they were not English speakers, were not prescribed treatment for their acne, or did not have an active telephone number. Using randomized lists, these patients were queried via telephone regarding which acne treatments they obtained. The results were analyzed using Fisher exact tests and multivariable logistic regression. For patients who were prescribed 1, 2, or 3 or more treatments, 47, 48, and 48 eligible patients were contacted, respectively. MAIN OUTCOMES AND MEASURES The primary study outcomes were the overall rate of primary nonadherence and the rate for each treatment-number subgroup. Secondary outcomes included the association of sex, age, medication type, and electronic prescription status with primary nonadherence. RESULTS Overall, 27% of patients did not fill all their prescriptions. Of patients who were given 1, 2, or 3 or more treatments, 9%, 40%, and 31%, respectively, did not fill all their prescriptions. There was no statistically significant difference by sex or age for primary nonadherence in any of the 3 treatment-number groups. Based on multivariable analyses, being prescribed a topical retinoid (odds ratio, 2.9; 95% CI, 1.0-8.0) or an over-the-counter product (odds ratio, 3.6; 95% CI, 1.1-12.3) was associated with primary nonadherence. Based on univariate analysis, there was less primary nonadherence with electronic prescriptions compared with paper prescriptions (P < .001). CONCLUSIONS AND RELEVANCE Primary adherence to an acne treatment regimen is better when only 1 treatment is prescribed. Some patients may not complete acne treatment because 1 or more of their medications were never obtained.

A guide to prescribing home phototherapy for patients with psoriasis: The appropriate patient, the type of unit, the treatment regimen, and the potential obstacles

BACKGROUND Ultraviolet B phototherapy is underused because of costs and inconvenience. Home phototherapy may alleviate these issues, but training is spotty, and many physicians are not comfortable prescribing home phototherapy. OBJECTIVE The purpose of this review is to provide a practical guide for recognizing appropriate patients, prescribing, and dealing with potential obstacles for home phototherapy treatment. METHODS Current guidelines for treatment of psoriasis were used to describe an appropriate patient for home phototherapy. Current literature and resources from phototherapy providers were reviewed to determine appropriate type of light, unit, treatment regimen, and how to navigate the insurance claim process. RESULTS Treatment schedules vary based on skin type. Home phototherapy companies provide various units suited for individual situations. Assistance can be used from suppliers to facilitate the process of obtaining a home phototherapy unit and navigating obstacles. LIMITATIONS Phototherapy treatment varies on an individual basis, so this review serves only as a guide. CONCLUSION Home phototherapy is a suitable treatment for many patients for whom office-based phototherapy is not accessible. Home phototherapy companies simplify the process by providing assistance for prescribing home light units.

A Review of the Use of Tanning Beds as a Dermatological Treatment

IntroductionIn-office phototherapy is an effective treatment for many dermatologic conditions, however, many patients are unable to adhere to the rigorous travel and time commitments sometimes needed. Tanning bed facilities are nearly ubiquitous in modern society and could represent a more convenient means to obtain ultraviolet (UV) exposure when office phototherapy is not feasible. The purpose of this study was to review available evidence on the use of tanning facilities as a treatment for dermatologic conditions.MethodsPubMed was searched on February 2015 for “tanning beds” and “phototherapy”, and with some dermatologic conditions sensitive to UV light, including “psoriasis”, “mycosis fungoides”, “acne”, “atopic dermatitis” and “eczema”. From there, further articles were found using the reference sections of the initial papers. A similar methodology was used with the Google Scholar search engine. Only articles in English and prospective studies were included in this review.ResultsWe found studies validating the use of tanning facilities for psoriasis treatment. Use as a treatment option for atopic dermatitis, mycosis fungoides, acne, scleroderma, vitiligo, and pruritus, as well as other UV sensitive dermatoses, may also be beneficial. This study is limited by the lack of double-blind, placebo-controlled trials, long-term follow-up studies, and meta-analyses for tanning facility use in dermatologic phototherapy, and by the lack of standardization of both tanning facilities and exposure dosing.ConclusionUnsupervised sun exposure is a standard recommendation for some patients to obtain phototherapy. Selected use of commercial tanning beds in the treatment of dermatologic conditions may be another useful and effective treatment for those patients with an inability to access office-based or home-based phototherapy.

Epidemiology, Diagnosis, and Treatment of Scabies in a Dermatology Office

Background: Scabies is a neglected skin disease, and little is known about current incidence and treatment patterns in the United States. The purpose of this study was to examine demographic data, treatment types, success of treatment, and misdiagnosis rate of scabies in an outpatient dermatology clinic. Methods: A retrospective chart review of patients diagnosed with scabies within the past 5 years was performed. Results: A total of 459 charts were identified, with 428 meeting inclusion criteria. Demographic data, diagnostic method, treatment choice, misdiagnosis rate, treatment failure, and itching after scabies are also reported. Children were the largest age group diagnosed with scabies, at 38%. Males (54%) were diagnosed with scabies more than females. The majority of diagnoses were made by visualizing ova, feces, or mites on light microscopy (58%). At the time of diagnosis, 45% of patients had been misdiagnosed by another provider. Topical permethrin was the most common treatment used (69%), followed by a combination of topical permethrin and oral ivermectin (23%), oral ivermectin (7%), and other treatments (1%). Conclusion: Our findings suggest that more accurate and faster diagnostic methods are needed to limit unnecessary treatment and expedite appropriate therapy for scabies.

Reasons for Treatment Changes in Patients With Moderate to Severe Psoriasis

Background: Psoriasis treatment involves multiple treatment arms. Treatment choice depends on many factors and may change, due to the chronicity of psoriasis. Objective: The purpose of our study is to explore reasons for treatment changes in patients with moderate to severe psoriasis. Methods: Ten charts of patients with moderate to severe psoriasis were reviewed. The medication changes and reasons for change were extracted. A “treatment change” was defined as switching between medication classes, adding or removing a medication class, or switching medications within the oral or biologic medication class. Results: Seventy-seven treatment changes were identified. On average, 1 treatment change occurred per year of follow-up. The most common reason for treatment change was inadequate disease control. Conclusions: Inadequate disease control with current therapy is the most common reason a physician changes treatment for moderate to severe psoriasis. More efficacious treatments or ways to improve efficacy may help improve the long-term outcomes of psoriasis.

Training for prescribing in-office and home phototherapy.

One reason phototherapy use is lacking in the United States may be inadequate phototherapy education during dermatology training. The purpose of this study was to estimate the level of dermatology resident training with prescribing phototherapy and to see whether inadequate education may be contributing to the underuse of phototherapy in the United States.