Current psoriasis treatments in an Italian population and their association with socio-demographical and clinical features

Transcription

1 DOI: /j x JEADV ORIGINAL ARTICLE Current psoriasis treatments in an Italian population and their association with socio-demographical and clinical features E. Altobelli,, * C. Marziliano, M.C. Fargnoli, R. Petrocelli, M. Maccarone, S. Chimenti, K. Peris Department of Internal Medicine and Public Health, University of L Aquila, L Aquila, Italy Department of Dermatology, University of L Aquila, L Aquila, Italy Italian Association of Psoriatic Patients (ADIPSO), Rome, Italy Department of Dermatology, University of Rome Tor Vergata, Rome, Italy *Correspondence: E. Altobelli. emma.altobelli@cc.univaq.it; emmaalto@tin.it Abstract Background healthcare professionals. Objective Patient adherence is a key element for therapeutic success and represents a major concern for all Aim of our study was to assess the frequency of use of treatments currently available for psoriasis and its association with specific socio-demographical and clinical variables. Methods The study population consisted of 1689 patients, aged years. Information concerning sociodemographical variables, clinical features and the type of current treatment was collected. Items on patients satisfaction of current treatments and of dermatologist-patient relationship were also included. The chi-squared test was used to estimate the association between the categorical variables, whereas Wilcoxon and Kruskal Wallis tests were applied to the interval and ordinal variables. The Cochran Mantel Haenszel chi-squared trend test was used to evaluate the degree of satisfaction related to dermatologist patient relationship. Results Of the 1689 psoriatic patients, 54.1% did not use any treatments and 45.9% used at least one treatment. The use of drugs was significantly associated exclusively to severity of disease and affected body surface area. Systemic therapies, both traditional treatments and biological agents, were mainly used in patients with disease duration >10 years and disease severity. Treatment adherence was significantly associated to the degree of patient s satisfaction of his her relationship with the dermatologist. Alternative treatment such as over the counter medications and acupuncture were used by 33% of patients. Conclusion The majority of psoriatic patients do not use any treatments. However, treatment adherence significantly increases when dermatologists clarify the treatment schedule, inform patients and meet the patients needs. Received: 2 March 2011; Accepted: 7 July 2011 Conflict of interest The authors declare that they have no competing interest. Introduction Psoriasis is a chronic, immune-mediated disease known to have a profound psychosocial impact on the patient s quality of life (QoL). Indeed, disability caused by psoriasis is comparable to that observed in major systemic diseases such as hypertension, diabetes and cancer. 1,2 Patient compliance is a key element for therapeutic success and represents a major concern for all healthcare professionals. The importance of the impact of psoriasis on the patients QoL, and its role on patients compliance have been extensively assessed in clinical trials investigating efficacy and safety of the recently introduced biological agents. 3 5 However, little is known about patients adherence to and satisfaction of traditional and topical therapies. 6 8 The term adherence is preferred to compliance to define the extent to which a person s behaviour taking medication, following a diet, executing lifestyle changes or a combination of these corresponds with agreed recommendations from a health care provider. 9 Primary non-adherence, i.e. patients not buying or not taking the prescribed drugs, is extraordinarily frequent in patients with chronic diseases and, particularly, in patients with psoriasis In addition, Krueger et al. 16 reported that more than 50% of the non-adherent psoriasis patients were not satisfied with their treatments. The lack of adherence was due, in 40% of patients, to their frustration of the ineffectiveness of

2 2 Altobelli et al. treatment, and in 32% of these cases to their feeling that therapies were not aggressive enough. 16 Concerning socio-demographical features that might influence patients adherence to treatment, conflicting results have been reported so far. With regard to gender, some authors showed that women are significantly more adherent to treatment than men, 6,17 whereas others did not identify any significant differences. 15 Being employed and married as well as being aged >59 years have been related to increased adherence. 6,15,17 Topical therapy showed the poorest rate of adherence in one study, 17 but this finding was not confirmed in another study. 18 Long-treatment duration was a further important feature associated with reduced adherence. 18,19 Finally, Richards et al. 20 emphasized that treatment adherence is affected by patients perceptions as well as by doctor-patient relationship. The knowledge of factors predictive of treatment adherence could enable dermatologists to target their efforts to increase patients adherence in patients at high risk for non-adherence. Aim of this study was to assess the distribution of frequency of use of treatments currently available for psoriasis and its association with socio-demographical and clinical variables in a large Italian population of psoriatic patients. Patients and methods Study population From 1 January 2008 to 31 December 2008, 1813 patients with psoriasis including both new and followed-up patients, attending outpatient Dermatology Clinics in Northern, Central and Southern Italy were invited to participate in this study. The estimate of sample size was performed using the following parameters: sample error E = 0.023, the event occurrence proportion P = 0.5 (in the case of maximum variability), probability 1)a = Approximately 7% of the patients refused to be interviewed. Informed consent was obtained from all patients and from parents of patients younger than 18 years. Data collection A standardized questionnaire was used for data collection and explained by trained personnel to psoriatic patients when they underwent routine visits at Dermatologic Clinics. The questionnaire included socio-demographical variables (gender, age, education, marital status, occupational status), clinical variant of psoriasis (plaque, others, i.e. guttate, localized pustular, generalized pustular, erythrodermic, inverse), age at onset of psoriasis (defined as age at diagnosis by a dermatologist), disease duration, affected body sites (A = genital areas; B = knees and elbows; C = trunk, scalp, upper and lower extremities; D = palms and soles) and body surface area (BSA) (A = psoriasis covering one patient s palm, B = psoriasis plaques covered by two palms; C = scattered psoriasis plaques corresponding to three to ten palms, D = psoriasis covering >10 palms). The type of current topical (corticosteroids, tazarotene, vitamin D derivatives, coal tar) and systemic treatment (cyclosporine, methotrexate, azathioprine, fumarates, biologics) as well as alternative treatments (over the counter medications, sun-exposure and others including dietary approach, relaxation techniques, acupuncture, herbs, tunning beds and baths with salt, oatmeal) were evaluated. Items on patients satisfaction of symptoms control by current treatments and patients satisfaction concerning dermatologist patient relationship were also included. The dermatologist patient relationship was evaluated through three questions (1. How much does your dermatologist meet your needs?, 2. How much does your dermatologist provide you sufficient information about your disease and related treatment options? and 3. How positive is your overall opinion of your dermatologist?), scored on a 11-point scale (0 3: low degree of satisfaction; 4 7: moderate, and 8 10: high). Patients completed the questionnaire singularly and autonomously. Patients who used any treatments were defined as treatment users, and those who did not use any treatments were defined as non-users. Statistical analysis The chi-squared test was used to estimate the association between the categorical variables under study. The Cochran Mantel Haenszel chi-squared trend test was used to evaluate degree of satisfaction related to dermatologist patient relationship. Wilcoxon and Kruskal Wallis tests were applied to the interval and ordinal variables. A value of P < 0.05 was considered statistically significant. SAS version (SAS Institute, Cary, NC, USA) was used to perform all statistical analyses. Results The study population consisted of 1689 patients, aged years, who were consecutively enrolled into the study: 959 patients were men with an average age of 48.6 years [standard deviation (SD) 15.0] and 730 were women with an average age of 47.4 years (SD: 15.5). Over 70% of patients were married, had a high level of education with high school or university degree and were affected with plaque type psoriasis. A total of 775 of 1689 patients (45.9%) used at least one treatment, whereas 914 (54.1%) did not use any treatments. The results of the association between clinical and sociodemographical features and treatment users and non-users are summarized in Table 1. A statistically significant difference between treatment users and non-users was detected for BSA (P < ). In all patients with psoriasis involving up to ten palms (groups A C), the percentage of non-users was higher than that observed in treatment users. More specifically, 39.9% of nonusers had scattered psoriasis plaques covering 3 10 patients palms, whereas 32.6% of users had widespread disease. No significant differences between users and non-users were found for socio-demographical characteristics such as gender,

3 Current frequency of treatments in Italian psoriatic patients 3 Table 1 Clinical and socio-demographical features of treatment users and non-users Users Non-users P Gender (total no. of responders = 1689) Male 440 (45.9) 519 (45.9) 0.99 Female 335 (54.1) 395 (54.1) Age-group (total no. of responders = 1689) <20 19 (2.4) 19 (2.1) (28.5) 270 (29.5) (45.2) 397 (43.4) (24.1) 228 (25.0) Education (total no. of responders = 1689) No education 15 (1.9) 14 (1.5) 0.05 Primary school 107 (13.8) 98 (10.7) Junior high school 231 (29.8) 261 (28.6) High school 323 (41.7) 418 (45.7) University 99 (12.8) 123 (13.5) Marital status (total no. of responders = 1588) Married 517 (70.3) 597 (70.1) 0.91 Divorced 193 (26.2) 223 (26.1) Never married 26 (3.5) 32 (3.8) Occupational status (total no. of responders = 1390) Manual worker 120 (18.7) 137 (18.3) 0.56 Office worker 178 (27.8) 234 (31.2) Professional 128 (20.0) 138 (18.4) Unemployed 38 (5.9) 39 (5.2) House-worker 131 (20.4) 145 (19.4) Other 46 (7.2) 56 (7.5) Type of psoriasis (total no. of responders = 1443) Plaque 531 (78.0) 547 (43.6) 0.06 Others* 159 (23.0) 206 (27.4) Age at onset of disease (total no. of responders = 1689) < (30.7) 269 (29.4) (43.7) 401 (43.9) > (25.6) 244 (26.7) Disease duration (years) (total no. of responders = 1689) < (31.0) 261 (28.6) (33.4) 340 (37.2) > (35.6) 313 (34.2) Body sites (total no. of responders = 814) A 18 (4.2) 12 (3.1) 0.38 B 109 (25.7) 125 (32.1) C 69 (16.3) 51 (13.0) D 228 (53.8) 202 (51.8) Body surface area (total no. of responders = 1599) A 75 (10.1) 116 (13.5) < B 176 (23.8) 228 (26.5) C 248 (33.5) 317 (39.9) D 241 (32.6) 198 (23.1) *Pustular, Erythrodermic, Inverse or Guttate psoriasis. A = Genital area; B = Knees and Elbows; C = Trunk, scalp and extremities; D = Palms and soles. A = psoriasis involving one patient s palm; B = psoriasis with plaques covering 2 3 palms; C = scattered plaques that could be covered by three to 10 palms; D = plaque psoriasis corresponding to more than 10 palms. age-group, education, marital status, occupational status, type of psoriasis, age at disease onset, disease duration and body site. To further evaluate differences of socio-demographical and clinical characteristics between users and non-users, we classified users (no. 775) into four groups based on the type of treatment: topicals (no. 296), biologics (no. 286), cyclosporine (no. 97) and methotrexate (no. 96) (Table 2). Treatment with fumarate and azathioprine were not included as they were used in a very small percentage (0.5%) of patients (4 775) and azathioprine in 0.4% (3 775). Disease duration had a significant influence on type of treatment (P < ): a disease duration >20 years was associated with an increased use of biologics (47.2%) whereas a disease duration between 10 and 20 years was significantly related to cyclosporine (41.2%), and a disease duration <10 years with topical treatments (37.5%) (Table 2). Topical treatments were used by all patients groups independent of the affected BSA and their use was infrequent (12%) in patients with localized disease. Systemic therapies such as cyclosporine, MTX and biologics were more commonly used in patients with scattered or disseminated lesions involving >3 palms (Table 2). Regarding patients satisfaction of current treatment on symptoms control, we found that 66.6% of patients were satisfied and very satisfied with the current treatment with biologics as were 50% of patients with traditional treatments, i.e. cyclosporine and MTX (P < ) (Table 2). No differences were detected among the four categories of users for gender, agegroup, type of psoriasis and body sites (Table 2). We also analysed the relation between use of alternative treatments and patients clinical and socio-demographical characteristics (Table 3). A total of 557 of 1689 patients (33.0%) used alternative treatments, which were divided into three groups: over the counter medications, sun-exposure and others. We found that all type of alternative treatments were mostly used by married patients (P = 0.03) and office workers (P = 0.04). In addition, a lower percentage of patients who were unemployed used alternative treatments compared with the workers. Notably, most patients with plaque type psoriasis used alternative treatments, mainly sun-exposure, compared with patients affected by other types of psoriasis (P = 0.006) (Table 3). 36.2% of patients with psoriasis involving 3 10 palms used sun-exposure, 34% of patients with psoriasis covering 2 3 palms preferred over the counter medications and 32.8% with scattered or disseminated lesions involving >3 palms used other alternative treatments (P = 0.04). 48.3% of patients using over the counter medications were sufficiently satisfied of symptoms control, but a very low percentage (<10%) was very satisfied and 31.9% of patients using sun-exposure were satisfied (Table 3). Finally, treatment use was directly related to the patients satisfaction of the dermatologist-patient relationship, patients information about the disease and available treatments, and the patients positive opinion of the dermatologist (P < for all three questions) (Table 4).

4 4 Altobelli et al. Table 2 Differences in treatment use based on characteristics of psoriatic patients Topics Gender (total no. of responders = 775) Biologics Cyclosporine Metotrexate M 164 (55.4) 168 (58.7) 52 (53.6) 56 (58.3) 0.76 F 132 (44.6) 118 (41.3) 45 (46.4) 40 (41.7) Age-group (years) (total no. of responders = 775) <20 8 (2.7) 6 (2.1) 4 (4.1) 1 (1.0) (28.3) 68 (23.8) 37 (38.1) 30 (31.2) (41.6) 146 (51.0) 39 (40.2) 42 (43.8) (27.4) 66 (23.1) 17 (17.5) 23 (24.0) Type of psoriasis (total no. of responders = 531) Plaque 207 (78.1) 202 (79.2) 64 (72.7) 58 (70.7) 0.30 Other* 58 (21.9) 53 (20.8) 24 (27.3) 24 (29.3) Disease duration (years) (total no. of responders = 775) < (37.5) 73 (25.5) 30 (30.9) 26 (27.1) < (36.5) 78 (27.3) 40 (41.2) 33 (34.4) >20 77 (26.0) 135 (47.2) 27 (27.9) 37 (38.5) Body sites (total no. of responders = 424) A 11 (7.4) 2 (1.2) 3 (5.4) 2 (3.6) 0.12 B 36 (24.3) 37 (22.3) 15 (27.3) 21 (38.2) C 25 (16.9) 30 (18.1) 7 (12.7) 7 (12.7) D 76 (51.4) 97 (58.4) 30 (54.6) 25 (45.5) Body Surface Area (total no. of responders = 740) A 34 (12.0) 28 (10.2) 8 (8.5) 5 (5.6) B 81 (28.6) 54 (19.8) 22 (23.4) 19 (21.1) C 98 (34.7) 80 (29.3) 35 (37.2) 35 (38.9) D 70 (24.7) 111 (40.7) 29 (30.9) 31 (34.4) Satisfaction of current treatment in symptom control (total no. of responders = 755) Unsatisfied 20 (7.0) 7 (2.5) 9 (9.6) 5 (5.3) < Poorly satisfied 49 (17.1) 24 (8.5) 15 (16.0) 8 (8.5) Sufficiently satisfied 107 (37.4) 63 (22.4) 25 (26.6) 33 (35.1) Satisfied 77 (26.9) 83 (29.6) 29 (30.8) 24 (25.5) Very satisfied 33 (11.5) 104 (37.0) 16 (17.0) 24 (25.6) *Pustular, Erythrodermic, Inverse or Guttate psoriasis. A = Genital area; B = Knees and Elbows; C = Trunk, scalp and extremities; D = Palms and soles. A = psoriasis involving one patient s palm; B = psoriasis with plaques covering 2 3 palms; C = scattered plaques that could be covered by three to 10 palms; D = plaque psoriasis corresponding to more than 10 palms. P Discussion In this study, we showed that 54.1% of the patients affected with psoriasis do not use any type of treatment and only 45.9% adhere to topical, systemic or alternative therapies. Our results are in line with previous reports that found that up to 50% of patients with psoriasis do not comply with the suggested treatment regimen. 10,11 In addition, a recent study on primary adherence, that is redemption of an initial prescription, demonstrated that about 30% of patients with psoriasis do not redeem their first prescription for a previously untried medication. 15 Adherence tends to increase around doctor visits (so-called white coat effect ) in combination with more severe disease, and declines between clinic visits. 20,21 Altogether these findings are worrisome and highlight the importance of the non-adherence issue in patients with psoriasis. The lack of adherence also implies worsening of patients QoL, increased morbidity and increased healthcare costs for further visits, laboratory examinations and prescriptions. Therefore, patients adherence to treatment should always be considered when a complex or time-consuming medication regimen is prescribed and when no response or loss of efficacy occurs during treatment. Indeed, non-adherence to a given therapy may be due either to unintentional reasons as misunderstand directions or forgetting or intentional motivations such as perceived inefficacy of the treatment or fear of side-effects. 6,20 A variety of tools are currently available to monitor patients adherence including self-report, pill counts, pharmacy records as well as more sophisticated electronic monitoring caps or electronically monitored patient diaries or even a National register as the one recently established in Denmark in

5 Current frequency of treatments in Italian psoriatic patients 5 Table 3 Use of alternative treatments and clinical and socio-demographical characteristics of psoriatic patients Gender (total no. of responders = 557) Over the counter medications Sun-exposure Others M 58 (59.8) 136 (52.5) 121 (60.2) 0.20 F 39 (42.8) 123 (47.5) 80 (39.8) Age-group (years) (total no. of responders = 557) <20 6 (6.2) 7 (2.7) 4 (2.0) (22.7) 80 (30.9) 68 (33.8) (49.4) 107 (41.3) 86 (42.8) (21.7) 65 (25.1) 43 (21.4) Education (total no. of responders = 557) No education 1 (1.0) 4 (1.5) 4 (2.0) 0.31 Primary school 11 (11.3) 31 (12.0) 10 (5.0) Junior high school 28 (28.9) 79 (30.5) 65 (32.3) High school 41 (42.3) 114 (44.0) 93 (46.3) University 16 (16.5) 31 (12.0) 29 (14.4) Marital status (total no. of responders = 520) Married 72 (79.1) 170 (70.5) 120 (63.8) 0.03 Separated 19 (20.9) 67 (27.8) 64 (34.1) Never married 0 (0.0) 4 (1.7) 4 (2.1) Occupational status (total no. of responders = 454) Manual worker 16 (20.3) 25 (11.9) 40 (24.4) 0.04 Office worker 26 (32.9) 69 (32.7) 41 (25.0) Professional 15 (19.0) 37 (17.5) 35 (21.3) Unemployed 5 (6.3) 15 (7.1) 12 (7.3) House-worker 14 (17.7) 53 (25.1) 26 (15.9) Other 3 (3.8) 12 (5.7) 10 (6.1) Type of psoriasis (total no. of responders = 372) Plaque 57 (65.5) 178 (82.4) 137 (74.9) Other* 30 (34.5) 38 (17.6) 46 (25.1) Disease duration (years) (total no. of responders = 557) <10 29 (29.9) 68 (26.2) 60 (29.9) (37.1) 89 (34.4) 82 (40.8) >20 32 (33.0) 102 (39.4) 59 (29.3) Body sites (total no. of responders = 284) A 3 (6.4) 7 (5.3) 4 (3.8) 0.85 B 11 (23.4) 31 (23.7) 28 (26.4) C 7 (14.9) 29 (22.1) 17 (16.0) D 26 (55.3) 64 (48.9) 57 (53.8) Body surface area (total no. of responders = 543) A 17 (18.1) 31 (12.2) 24 (12.3) 0.04 B 32 (34.0) 64 (25.2) 43 (22.1) C 22 (23.4) 92 (36.2) 64 (32.8) D 23 (24.5) 67 (26.4) 64 (32.8) Satisfaction of your current treatment in symptom control (total no. of responders = 540) Unsatisfied 7 (7.7) 18 (7.2) 20 (10.1) 0.04 Poorly satisfied 13 (14.3) 42 (16.7) 24 (12.1) Sufficiently satisfied 44 (48.3) 69 (27.5) 54 (27.3) Satisfied 18 (19.8) 80 (31.9) 57 (28.8) Very satisfied 9 (9.9) 42 (16.7) 43 (21.7) *Pustular, Erythrodermic, Inverse or Guttate psoriasis. A = Genital area; B = Knees and Elbows; C = Trunk, scalp and extremities; D = Palms and soles. Dietary approach or Relaxation techniques or Herbs or Tanning beds or Baths. A = psoriasis involving one patient s palm; B = psoriasis with plaques covering 2 3 palms; C = scattered plaques that could be covered by three to 10 palms; D = plaque psoriasis corresponding to more than 10 palms. P

6 6 Altobelli et al. Table 4 Degree of satisfaction concerning the dermatologist patient relationship Questions Patients Low (0 3) 1. How much does your dermatologist meet your needs? (total no. of responders = 1562) 2. How much does your dermatologist provide you sufficient information about your disease and related treatment options? (total no. of responders = 1552) 3. How positive is your overall opinion of your dermatologist? (total no. of responders = 1529) Moderate (4 7) High (8 10) Chi-squared trend test P Users 53 (42.7) 269 (40.2) 416 (54.1) < Non-users 71 (57.3) 400 (59.8) 353 (45.9) Users 57 (35.6) 272 (42.6) 407 (54.0) < Non-users 103 (64.4) 366 (57.4) 347 (46.0) Users 35 (37.2) 268 (41.6) 429 (54.2) < Non-users 59 (62.8) 376 (58.4) 362 (45.8) which all redemptions of prescriptions are recorded. 22 Most of these measures, however, seem to overestimate the actual use and adherence to treatment in patients with psoriasis. Interestingly, Carroll et al. 6 showed that 45% of patients who were compensated for their medication use and were informed that their medication use was being monitored were non-adherent for the study period. Similarly, 50% of patients with chronic diseases are non-adherent when prescriptions are repeated. 1,23,24 These data emphasize the importance of planning follow-up consultation and the need of interventions for improving adherence. In this regard, other measures should be considered including mailing, calling or visiting the patients. As expected, our results showed that the presence of a more severe disease, with disseminated plaques covering most of the BSA, was associated with a higher use of drugs. No significant differences of socio-demographical and clinical factors such as gender, age, marital and occupational status were found between treatment users and non-users, suggesting that these factors do not contribute to patients adherence to treatment. In our patient population, the type of treatment varied according to disease duration and affected BSA. More specifically, biological agents were significantly more used in patients with severe psoriasis (>10 palms) and long disease duration (>20 years), whereas traditional treatments (i.e. cyclosporine, MTX) were used in patients with BSA psoriasis involving 3 10 palms and >10 palms and years disease duration. This is in line with suggestions of recent guidelines reported by experts on psoriasis 25 and recommendations of the Italian Psocare register ( in which prescriptions of biological agents are allowed only in patients with moderate-to-severe plaque psoriasis who failed or have contraindications to at least two traditional therapies including phototherapy, cyclosporine, MTX and retinoids. Topical treatments were used in patients with both localized and disseminated disease; noteworthy, patients with very limited psoriasis involvement used less frequently topical therapies compared with patients with more diffuse psoriasis. A high percentage of patients (66.6%) were satisfied or very satisfied of symptoms control by biological therapies supporting the numerous evidences of great improvement of patients QoL with these drugs. 3 5 Satisfaction with traditional therapies was reported by 51.1% of patients treated with MTX and 47.8% treated with cyclosporine. Finally, the use of alternative therapies was significantly more frequent in patient with plaque type psoriasis compared with other clinical variants and significantly differed according to the patients occupational status. In particular, unemployed subjects were those with the lowest use of such treatments probably due to economical reasons. In addition, a lower percentage of professionals used alternative treatments compared with office workers indicating a possible different lifestyle and time availability to dedicate to treatments such as sun-exposure or baths. Notably, only 10% of patients were highly satisfied of the over the counter medications although almost 50% of patients were sufficiently satisfied. In line with previous studies, 7,20,26 we observed that adherence improves with a good doctor patient communication. Our findings suggest that dermatologists who involve patients in the treatment decisions, who gives understandable instructions on treatment schedule and shows interest in the patients needs and concerns may help to improve patients adherence to treatment. In addition, we believe that encouraging patients to ask questions and to express their concerns may help them in coping with their disease. References 1 Rapp SR, Feldman SR, Exum ML et al. Psoriasis causes as much disability as other major medical diseases. J Am Acad Dermatol 1999; 41: De Arruda LHF, De Moraes APF. The impact of psoriasis on quality of life. Br J Dermatol 2001; 144: Reich K, Sinclair R, Roberts G, Griffiths CE, Tabberer M, Barker J. Comparative effects of biological therapies on the severity of skin symptoms and health related quality of life in patients with plaque-type psoriasis: a meta-analysis. Curr Med Res Opin 2008; 24: Schmitt J, Wozel G. Targeted treatment of psoriasis with adalimumab: a critical appraisal based on a systematic review of the literature. Biologics 2009; 3: Scanlon JV, Exter BP, Steinberg M, Jarvis CI. Ustekinumab: treatment of adult moderate to severe chronic palque psoriasis. Ann Pharmacother 2009; 43: Carroll CL, Feldamn SR, Camacho FT, Manuel JC, Balkrishnan R. Adherence to topical therapy decreases during the course of an 8-week psoriasis clinical trial: commonly used methods of measuring adherence to topical therapy overestimate actual use. J Am Acad Dermatol 2004; 51:

7 Current frequency of treatments in Italian psoriatic patients 7 7 Katugampola RP, Hongbo Y, Finlay AY. Clinical management decisions are related to the impact of psoriasis on patient-rated quality of life. Br J Dermatol 2005; 152: Feldman SR. Approaching psoriasis differently: patient-physician relationship, patient education and choosing the right topical vehicle. J Drugs Dermatol 2010; 9: World Health Organization. Adherence to Long-Term Therapies, Evidence for Action. World Health Organization, Geneva, Richards HL, Fortune DG, O Sullivan TM, Main CJ, Griffiths CE. Psoriasis patients compliance with medication. J Am Acad Dermatol 1999; 41: Renzi C, Picardi A, Abeni D et al. Association of dissatisfaction with care and psychiatric morbidity with poor treatment compliance. Arch Dermatol 2002; 138: Kjellgren KI, Ring L, Lindblad AK, Maroti M, Serup J. To follow dermatological regimens-patients and providers views. Acta Derm Venereol 2004; 84: Serup J, Lindblad AK, Maroti M et al. To follow or not to follow dermatological treatment a review of the literature. Acta Derm Venereol 2006; 86: Feldman SR, Horn EJ, Balkrishnan R et al. Psoriasis: improving adherence to topical therapy. J Am Acad Dermatol 2008; 59: Storm A, Andersen SE, Benfeldt E, Serup J. One in 3 prescriptions are never redeemed: primary nonadherence in an outpatient clinic. J Am Acad Dermatol 2008; 59: Krueger G, Koo J, Lebwohl M, Menter A, Stern RS, Rolstad T. The impact of psoriasis on quality life: results of a 1998 National Psoriasis Foundation patient membership survey. Arch Dermatol 2001; 137: Zaghloul SS, Goodfield MJD. Objective assessment of compliance with psoriasis treatment. Arch Dermatol 2004; 140: Van de Kerkhof PC, de Hoop D, de Korte J, Cobelens SA, Kuipers MV. Patients compliance and disease management in the treatment of psoriasis in the Netherlands. Dermatology 2000; 200: Ley P. Compliance among patients. In Baum A, Newman S, Weinman J, West R, Mcmanus C eds. Cambridge Handbook of Psychology, Health and Medicine. Cambridge University Press, Cambridge, 1997: Richards HL, Fortune DG, Griffiths CEM. Adherence to treatment in patients with psoriasis. J Eur Acad Dermatol Venereol 2006; 20: Cramer JA, Scheyer RD, Mattson RH. Compliance declines between clinic visits. Arch Intern Med 1990; 150: Danish National Electronic Pharmacy Register. Available from: URL: 23 Hugtenburg JG, Blom AT, Kisoensingh SU. Initial phase of chronic medication use: patient s reasons for discontinuation. Br J Clin Pharmacol 2006; 61: Andersson K, Melander A, Svensson C, Lind O, Nilsson JL. Repeat prescriptions: refill adherence in relation to patient and prescriber characteristics, reimbursement level and type of medication. Eur J Public Health 2005; 15: Pathirana D, Ormerod AD, Saiag P et al. European S3 guidelines on the systemic treatments of psoriasis vulgaris. J Eur Acad Dermatol Venereol 2009; 23:1 70. Erratum in: J Eur Acad Dermatol Venereol 2010; 24: Bewley A, Page B. Maximizing patient adherence for optimal outcomes in psoriasis. J Eur Acad Dermatol Venereol 2011; 25: 9 14.