How can physicians improve medication adherence and outcomes in dermatological conditions?

INTRODUCTION: Medication non-adherence is a major contributor to suboptimal disease treatment across medical specialties and is a particular hurdle with topicals. While adherence is a patient behavior affected by many socioeconomic and health system factors, physicians can play an important role in encouraging good adherence. AREAS COVERED: We discuss methods for measuring adherence, including ethics of such research, provide select examples of dermatology-specific adherence studies, and conclude with physician-focused practices to improve patients' adherence. Articles were selected from a PubMed search spanning 2003 to 10 December 2023, using the following terms: 'dermatology,' 'medication,' 'treatment,' 'adherence,' 'compliance,' and 'intervention.' EXPERT OPINION: Poor adherence to treatment is a major cause of poor treatment outcomes. As the goal of medical care is to achieve successful treatment outcomes, encouraging good adherence may be as much a foundation of care as making the right diagnosis and prescribing the right treatment. Taking a doctor-centric perspective on reasons for non-adherence may be more productive than simply finding fault with the patient. Establishing trust and accountability is a foundation for good adherence; after establishing the provider-patient relationship, physicians can improve adherence by incorporating behavioral and counseling strategies, communicating through technology, and advocating for distribution of validated educational information.

Cytokine-Mediated Molecular Pathophysiology of Hidradenitis Suppurativa: A Narrative Review.

Background: Hidradenitis suppurativa (HS) is a chronic inflammatory condition of the skin that mainly affects the apocrine gland-rich intertriginous areas. The disease manifests as painful nodules, abscesses, and pus-filled tunnels, which can severely impact patient's quality of life. While diagnosis is clinical, successful treatment options for this condition are limited. There has been an increase in research and clinical trials focusing on biomarkers and cytokines for clinical use. Understanding the potential biomarkers and cytokines implicated in HS pathogenesis may allow efficacious and safe treatment options. Summary: A literature review was conducted on nine biomarkers and cytokines. IL-1, IL-10, IL-17, IL-23, TNF-α, YKL-40, G-CSF, NOD2, and the complement system were identified due to their potential clinical utilization and pathophysiological involvement in HS. Key Messages: With further research expanding our understanding of the pathophysiology of HS and the roles these cytokines and biomarkers play, there is potential for utilization as diagnostic markers or development of antagonists against these specific agents for HS management.

Evaluation of ruxolitinib cream 1.5% as an at-home therapy for repigmentation in non-segmental vitiligo.

INTRODUCTION: Vitiligo is a chronic, autoimmune condition characterized by skin depigmentation caused by inflammatory-mediated melanocyte degradation. Treatment of vitiligo is challenging due to the chronic nature of the condition. Ruxolitinib cream 1.5% was recently approved by the Food and Drug Administration (FDA) as a Janus kinase 1 and 2 inhibitor for use in nonsegmental vitiligo for those 12 years and older. AREAS COVERED: The purpose of this review is to describe the role of ruxolitinib in treating nonsegmental vitiligo.We searched PubMed using search terms nonsegmental vitiligo, jak inhibitor, and ruxolitinib. Clinicaltrials.gov was used to identify clinical trial data including efficacy, pharmacodynamics, pharmacokinetics, safety, and tolerability. EXPERT OPINION: In both phase II and phase III (TRuE-V1 and TRuE-V2) trials, ruxolitinib cream 1.5% improved repigmentation with minimal adverse effects. Topical ruxolitinib is a much needed new vitiligo treatment option.  Real life efficacy may not match that seen in clinical trials if the hurdle of poor adherence to topical treatment is not surmounted.

Validity of facial skin analysis pore detection: A comparative analysis.

BACKGROUND: Reliable, objective measures to assess facial characteristics would aid in the assessment of many dermatological treatments. Previous work utilized an iOS application-based artificial intelligence (AI) tool compared to the "gold standard" computer-based and a physician assessment on five skin metrics (British Journal of Dermatology, 2013, 169, 474). The AI tool had superior agreement for all skin metrics except pores and subsequently underwent an algorithm update for its pore detection system. AIMS: This comparative analysis assessed the performance of the updated AI tool's pore scores across all Fitzpatrick skin phototypes to determine whether the AI tool more accurately represents a dermatologist's assessment of pores. PATIENTS/METHODS: Frontal facing photographs in uniform lighting conditions were taken of each participant. Percentile scores were generated by each of the four self-learning models of the updated AI tool. The pore percentile scores generated by the original and updated AI tool were used to rate "worse" pores among participant pairs. These ratings were compared to pore assessments performed by a "gold-standard" device and a board-certified dermatologist. RESULTS: Compared to the original pore detection tool and the computer-based program, models A and D had the highest concordance with the physician's pore assessments for Fitzpatrick skin phototypes III-IV and V-VI, respectively. CONCLUSIONS: The AI tool's pores detection update was successful in its ability to accurately detect pores on all Fitzpatrick skin types, improving on the performance of the AI prior to the update. Responsibly developed AI tools that can accurately and reliably detect skin metrics across diverse Fitzpatrick skin types can facilitate dermatologic evaluation, individualize treatment, and determine treatment response.

Spesolimab: A Review of the First IL-36 Blocker Approved for Generalized Pustular Psoriasis.

OBJECTIVE: This article reviews clinical trial data that assesses the safety, efficacy, and clinical application of spesolimab, an interleukin-36 (IL-36) blocker, for the treatment of generalized pustular psoriasis (GPP). DATA SOURCES: A review of the literature was conducted using the search terms: "spesolimab," "BI 655130," and "spevigo" in MEDLINE (PubMed) and Clinicaltrials.gov from January 1, 1950 to October 31, 2023. STUDY SELECTION AND DATA EXTRACTION: Relevant articles in English relating to the pharmacodynamics, pharmacokinetics, efficacy, and safety of spesolimab were included. DATA SYNTHESIS: In one phase 2 clinical trial evaluating single dose IV spesolimab for GPP flares at day 8, 54% of patients receiving spesolimab had a GPP physician global assessment (GPPGA) pustulation subscore of 0, and 43% had a GPPGA total score of 0 compared with 6% and 11% for the placebo group, respectively. Another phase 2 clinical trial assessing subcutaneous spesolimab found 23% of patients in low-dose, 29% in medium-dose, and 10% of high-dose spesolimab had flares by week 48 compared with 52% of the placebo group. Hazard ratios for time to GPP flare compared with placebo were 0.16 (P = 0.0005), 0.35 (P = 0.0057), and 0.47 (P = 0.027) for the spesolimab groups, respectively. Infection rates were similar across treatment and placebo groups, and severe adverse events such as drug reactions with eosinophilia and systemic symptom (DRESS), cholelithiasis, and breast cancer occurred with spesolimab. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE IN COMPARISON TO EXISTING DRUGS: Spesolimab is a first-in-class IL-36 monoclonal antibody receptor antagonist approved for the treatment of acute GPP flares. It is a safe and effective therapeutic agent in preventing future GPP flares, with no current comparator trials with other GPP agents. CONCLUSION: Spesolimab is a safe and effective treatment for acute GPP flares in adults. Future clinical trials can establish safety and efficacy compared with other agents.

Qualitative investigation of disease course, characteristics and lived experience of generalized pustular psoriasis.

BACKGROUND: Generalized pustular psoriasis (GPP) is a relapsing-remitting chronic disease characterized by painful pustules with systemic symptoms that negatively impacts quality of life. The psychosocial and economic burden of this rare condition is not well characterized. OBJECTIVES: To qualitatively characterize the cumulative burden of generalized pustular psoriasis on patients' quality of life and psychosocial wellbeing. METHODS: A retrospective chart review of patients with generalized pustular psoriasis was performed to collect demographic information, followed by prospective semi-structured clinical interviews. Interview transcripts were analyzed using thematic analysis. RESULTS: Three major themes were revealed: (1) Burden of having a chronic disease with an unpredictable course, (2) an inability to fulfill societal roles results in a loss of identity, and (3) a physician-patient relationship grounded in trust and transparency can be invaluable in helping patients endure chronic disease. CONCLUSION: GPP has a negative impact on patients' quality of life and psychosocial wellbeing. Impairments in daily function and mental health primarily affects patients during flares and influences behavior during periods of quiescence. A strong patient-physician relationship may help mitigate the impact of GPP.

Patient preferences for treatment attributes in moderate-to-severe atopic dermatitis: a discrete choice experiment.

Purpose: Evidence on treatment preferences of patients with moderate-to-severe atopic dermatitis (AD) in the United States (US) is limited and an assessment of treatment preferences in this group is warranted.Materials and methods: An online discrete choice experiment survey was conducted (June 2023) among US adults with self-reported moderate-to-severe AD or experience with systemic therapy who had inadequate response to topical treatments. Preference weights estimated from conditional logistic regression models were used to calculate willingness to trade off and attributes' relative importance (RI).Results: Participants (N = 300; mean age: 45 years; 70% females; 52% systemic therapy experienced) preferred treatments with higher efficacy, lower risk of adverse events (AEs), and less frequent blood tests (p < .05). Treatment attributes, from high to low RI, were itch control (38%), risk of cancer (23%), risk of respiratory infections (18%), risk of heart problems (11%), sustained improvement in skin appearance (5%), blood test frequency (3%), and frequency and mode of administration (2%); together, AE attributes accounted for more than half of the RI.Conclusions: Participants preferred AD treatments that maximize itch control while minimizing AE risks, whereas mode of administration had little impact on preferences. Understanding patients' preferences may help improve shared decision-making, potentially leading to enhanced patient satisfaction with treatment, increased engagement, and better clinical outcomes.

Comparative analysis of persistence and remission with guselkumab versus secukinumab and ixekizumab in the United States.

Purpose: Real-world data comparing long-term performance of interleukin (IL)-23 and IL-17 inhibitors in psoriasis are limited. This study compared treatment persistence and remission among patients initiating guselkumab versus IL-17 inhibitors.Methods: Adults with psoriasis initiating guselkumab, secukinumab, or ixekizumab treatment (index date) were identified from Merative™ MarketScan® Research Databases (01/01/2016-10/31/2021). Persistence was defined as no index biologic supply gaps of twice the labeled maintenance dosing interval. Remission was defined using an exploratory approach as index biologic discontinuation for ≥6 months without psoriasis-related inpatient admissions and treatments.Results: There were 3516 and 6066 patients in the guselkumab versus secukinumab comparison, and 3805 and 4674 patients in guselkumab versus ixekizumab comparison. At 18 months, the guselkumab cohort demonstrated about twice the persistence rate as secukinumab (hazard ratio [HR] = 2.15; p < 0.001) and ixekizumab cohorts (HR = 1.77; p < 0.001). At 6 months after index biologic discontinuation, the guselkumab cohort was 31% and 40% more likely to achieve remission than secukinumab (rate ratio [RR] = 1.31; p < 0.001) and ixekizumab cohorts (RR = 1.40; p < 0.001).Conclusions: Guselkumab was associated with greater persistence and likelihood of remission than IL-17 inhibitors, indicating greater disease control and modification potential.