Steven R. Feldman, M.D., a dermatologist at Wake Forest University and a member of NPF’s medical board, rattles off three reasons why treatments, especially topicals, often fail if you have psoriatic disease.
“One, poor compliance; two, poor compliance; and three, poor compliance,” Feldman says.
Poor compliance is one of the biggest challenges in treating a chronic disease like psoriasis or psoriatic arthritis. Caring for psoriatic disease can be complicated. A promising treatment has no promise if you don’t use it – or don’t use it correctly.
“The behavior of taking medicine is very complex behavior,” Feldman says. “I think every dimension of human psychology affects it.”
Stopping a drug, administering it incorrectly or reducing the dosage without a physician’s advice can results in flare-ups or cause the medicine to stop working, says Farah K. Malick, M.D., a dermatologist at the Michigan Dermatology Center in Troy, Michigan. And increasing the dosage without a doctor’s guidance can result in serious consequences – even death.
There are many reasons why people with psoriasis and psoriatic arthritis have trouble following a treatment plan. Here are some of the most common reasons, with some ideas on how to overcome them.
The Treatment Is Messy/Time-Consuming/Uncomfortable
Compliance is more difficult with topical medications than with oral medications, Malick says. Topical ointments can be greasy, leave stains on clothing and take more time and effort to apply than just swallowing a pill. Applying a topical can take anywhere from minutes to an hour if you have to wait for your skin to absorb the lotion before you get dressed.
Fortunately, today you can choose from sprays, foams, gels, creams or lotions for topicals – treatments that may be less objectionable.
Fear of Side Effects
Some patients hold misconceptions about risk. People hear the word “steroid” – a common ingredient in topical creams and ointments – and picture balding men and beefy women, Feldman says. But the steroids used in most creams are forms of cortisone, the same hormone the human body naturally creates.
It’s also common for people to be wary of systemic drugs, especially biologics. Feldman urges people to weigh the real risk of a side effect against the potential for relief from psoriasis or psoriatic arthritis.
Dermatologist Andrew Blauvelt, M.D., the president and investigator of Oregon Medical Research Center in Portland, Oregon, agrees with Feldman. He says that the current generation of biologics, instead of targeting broad swathes of the immune system, specifically target psoriatic inflammation, making them more effective and safer at the same time.
“There is a tremendous benefit-to-risk ratio” with biologics, Blauvelt says. “Patients are more at risk of harm due to untreated psoriasis than any harm that may occur with using a current generation biologic.”
Dosing Instructions Are Confusing and Easy to Forget
It’s human nature to forget the details, which is why Feldman writes down dosage instructions for his patients. “If you don’t give it in writing, it’s almost as if you didn’t tell the person,” he says. If you can’t remember whether you should take a drug once a week or daily for a week, don’t guess.
Taking too much can result in serious consequences. Taking too little could trigger a flare or reduce the drug’s effectiveness. Contact your doctor’s office and get the correct information.
The Treatment Is Too Expensive
It may be tempting to cut back or stop taking a medication when costs go up or when your insurance status changes, but don’t. If you can’t afford medication or if you don’t have insurance, contact the drug company for assistance, Feldman says. Those who don’t qualify for help should work with their doctor to find a less expensive treatment. You can also contact the NPF Patient Navigation Center, which may find creative solutions to help pay for treatment.
Ultimately, Malick says, the best treatment is the one the patient prefers to use.
Can Your Phone Help?
A November 2018 study published in the British Journal of Dermatology, “Testing an adherence-improving app for patients with psoriasis,” suggests exactly that. A smartphone app that provided daily reminders about topical treatment improved use of the medication in the four‑week period of the study. Patients saw a short-term reduction in the severity of their psoriasis (long-term was not measured). The authors (one of whom was Feldman) concluded that apps have the potential to improve psoriasis patients’ use of topical medications.
(Editor’s note: Additional reporting for this story by Steve Bieler and Louisa Cockbill.)