It doesn't work if you don't take it

February 1, 2007

National report - Steve Feldman, M.D., Ph.D., began a lecture about scalp psoriasis a few years ago by relating to his audience.

"I said that scalp psoriasis is so frustrating," he says. "I told them that it is really frustrating for dermatologists, too, because we like to see our patients get better, and scalp psoriasis never gets better."

The audience nodded.

Dr. Feldman, a dermatologist and professor of dermatology, pathology and public health sciences at Wake Forest University School of Medicine, Winston-Salem, N.C., describes the moment as cathartic.

The audience seemed relieved that they no longer had to live their lie.

'Memory' cap tells tales

Dr. Feldman speaks from experience - and from science.

He and colleagues did a study on 30 psoriasis patients (J Am Acad Dermatol. 2004 Aug;51(2):212-216), looking at the efficacy of Protopic (tacrolimus, Astellas) in combination with 6 percent salicylic acid gel for plaque psoriasis.

All study subjects were told to use the salicylic acid twice daily.

To measure compliance, the researchers used a special cap, the Medication Event Monitoring System (MEMS) by Aardex, on the salicylic acid bottles.

"When you screw on the MEMS cap it pushes on a little plunger that sends a signal to the computer chip in the cap and records the day and time when the bottle was opened or closed," Dr. Feldman says.

Subjects were told their use of the medication would be monitored and were asked to fill out a daily medication diary. They were not told the caps were recording their compliance. Researchers merely asked that subjects bring in their medicine at the one-, two-, four-and eight-week follow-ups, and said the medicine would be weighed.

The key finding was not whether the Protopic and salicylic combination worked (it did, to a degree); rather, it was that droves of patients were not compliant.

"On the first day of the study, the patients used their medicine just the way they were supposed to. Four days later, their compliance dropped by 40 percent," Dr. Feldman says. "After that, it looked like compliance was dropping by about 20 percent every five weeks - yet they were telling us that they were using the medication as directed."

Once dermatologists realize that treatment resistance may be due to poor compliance, he tells Dermatology Times, "then they can start trying to change people's compliance."

Too much lag time

The problem, according to Dr. Feldman, is that dermatologists traditionally tell patients to take a medication and come back in eight weeks.

That's too long a time - without some kind of follow-up - to expect patients to continue often burdensome treatments, he says.

During appointments, Dr. Feldman says, he tries try to appear empathetic. He asks patients a few questions about the condition, listens intently, and does an exam that includes palpation of the lesions (even if he has already settled on the diagnosis and treatment). He then chooses the vehicle that will be easiest for the patient to endure. Sometimes, it's a medicine that the patient has already tried, unsuccessfully.