Ensure Patient Adherence in Pediatric Atopic Dermatitis Cases

Treatment adherence in pediatric patients with atopic dermatitis (AD) patients is key to seeing clearer skin in most cases. Steve Feldman, MD, PhD, professor at Wake Forest University School of Medicine in Winston-Salem, North Carolina, is presenting adherence strategies on an panel alongside AD treatment experts Peter Lio, MD, Medical Dermatology Associates of Chicago, and Amy Paller, MD, Northwestern University Feinberg School of Medicine, on July 14 from 11:15-11:45 am during the 2023 Society for Pediatric Dermatology Meeting in Asheville, North Carolina.

In an interview with Dermatology Times®, Feldman shared his experiences and takeaways from memorable AD cases, communication tips for adherence, and his book titled Practical Ways to Improve Patient Adherence.

Dermatology Times: What approach do you take to ensure pediatric patient adherence?

Feldman: The general approach that physicians take to get anybody to use their medicines is almost ridiculous. Let me just illustrate this with the parable of the piano teacher. So, my kids took piano lessons. The teacher gave them some sheet music to practice and told them, "We're gonna have a lesson once a week. I want you to practice this every day. And I'll see you at the recital in eight to 12 weeks." Now in the recital, my kid sounded pretty good, not great. But they said a pretty good because they were practicing some every week.

Well, what would happen if a new piano teacher said, "Well, this is a very inefficient system that you've got going on." The reason people sound good is because they're practicing every day, not because of the weekly lesson. So I will give them the sheet music, tell them to practice every day, won't have weekly lessons with them and just seeing them back at the end of 8 to 12 weeks. Well, now everybody knows that recital with sound X group, because nobody's going to practice without the accountability created by the weekly lessons.

If you look at studies of treatments for pediatric atopic dermatitis, they bring patients back weeks 1, 2, 4, 6, and 8. Well, that's like, the standard approach to teaching people piano. Those visits create accountability. The normal approach to practicing medicine is worse than that second piano teacher I described, the normal approach to getting people to use their medicines would be like a piano teacher saying, "Here's the prescription for some sheet music, take it to the sheet music store, I have no idea what it's going to cost or whether your insurance company's gonna pay for it, but I want you to fill the prescription. I want you to practice this sheet music every day. If you do, there's a chance you may get diarrhea, rash, possibly serious infection. I'll see you with the risk, we're not gonna weaken this. I'll just see you at the recital in 2 or 3 months. And if the recital doesn't sound good, I'll give you a second maybe a third musical instrument to practice at the same time."

You know, with that understanding of the importance of accountability, you realize that no, the normal things we try to do to get people to take their medicines just aren't going to work. You know, I mean, if the piano teacher doesn't have weekly lesson, so that recital sounded terrible. I need to do it, the doctors do to get people to use their medicine.

I'm going to give people written instructions. I'm going to educate them about their treatment and their disease. I'll reduce their worries about side effects, I'll make sure that the treatment doesn't cost too much. And it's simple. Without accountability, it doesn't work. So, the first thing I would say is you want patients to use the medicine. First thing you've got to do is establish a foundation where the patient thinks you care about them. I know we care about our patients, but now what matters is the patient realizes we care deeply about them so that they'll trust us and want to please a second way to hold them accountable have to have a visit after a week. If you're not gonna have a visit after a week, well, you have find some other way to create accountability.

I do it by giving my cell phone to people I tell them I'll see you back in a week no wait, gosh, then you'll have to miss school or work has to pay another copay. Let me give you my cell phone number you call me let me know how this medicines work and call me in one week. You don't have to call you can text me whatever you young people like to do, but I need to hear from you in 1 week. That sense of accountability will force them to use the medicine and then they'll see that the medicine works. Now, on top of that foundation, yes, you can educate people. You can give them written instructions. You can keep the treatment simple. You can give them a reminder system you can you know, sways them as far as side effects are concerned. I think those are all secondary to the foundation, which has been rotten in large part that is making people trust us and hold them accountable.

Dermatology Times: Tell us about notable atopic dermatitis cases in your experience that others can learn from.

Feldman: I've got 2, and these were both of these were published in case reports. One was a child I was the attending supervising the console resident. A young child admitted to the pediatric ward for, I don't know what, but also had horrible AD and would scream whenever the nurses tried to put the triamcinolone ointment on the child and you know, it was just horrible every time. We switch triamcinolone ointment to fluocinolone oil in peanut oil, which goes on much easier. And in 2 days, I'm not even sure it was 2 days it might have been 1 day, the kid's skin was dramatically better with just the low to mid potency topical steroid in a vehicle that was easy to go on and didn't irritate.
The other 1 patient: The mother of this child that she had adopted from Asia, the kid was like 2-years old, had unrelenting eczema, and I was ready to use all my standard approach. We're going to put the triamcinolone on your child, just do it for twice a day for the next 3 days and mom's like, "You're not listening to me. I'm a nurse, I've been putting triamcinolone ointment on that on a child every day. For the last 2 years. It did not work." I'm like, alright, we'll do clobetasol for 3 days. And then we'll go back to the triamcinolone. Today's Thursday, you call me Sunday."
She sends me an email the next day Friday saying, "You were right. I didn't get the clobetasol. So I just put the triamcinolone you prescribed on the child and she's already dramatically better." That was it for 1 day. And she said, "You know, the other doctors would be giving me these small tubes. You gave me this big bucket I hadn't been using enough. She's already better.
By the way, there was another mom who brought a child to see me who had failed previous treatment from another dermatologist for the eczema, and the kids skin was dry as could be. I asked mom what she's bathing the child with and she said, "Ivory soap."
I said, "Well Ivory soap... is that what the previous dermatologist recommended?" And she said yes--the previous dermatologist recommended either Dove or Ivory. Now. To me, Dove is one of the most mild soaps you could use. And Ivory, I consider one of the most harsh things you can use. I am quite confident that the previous dermatologist told the mom to use Dove not Ivory. But you know people don't remember anything we tell them. So, I think you do need to put in writing anything you want patients to remember. So on top of creating that foundation of trust and accountability, written instructions are probably not a bad idea.

Dermatology Times: How does a change in routine, such as going back to school, affect adherence?

Feldman: I have never tested what happens with school. Recently, colleagues and I took some patients and gave them topicals to use with computer chips in the cap from since all health I've been working with them. They will record when people open and close the container. These caps actually will record how much medicine the patient uses. And we did this before the Christmas holidays, over the Christmas holidays, and after to see if people use their medicines well and then if a change in their life, causes them to break habits and lose efficacy over time, which which we appear to have found not surprisingly so. I would think during school people's lives are regimented and it's easier for them to establish a habit but to change from one period to another period, like from summer to school, I would think would throw everything off.

Dermatology Times: How can clinicians learn more about techniques and communication strategies to improve patient adherence?

Feldman: My book on how to get people to use their medicines is about to come out. It should be out in another month or 2. There is already one version out just all those years of experience, all those sneaky tricks that you could do to get people to use their medicines. Practical ways to improve patients' adherence. Yeah, you're gonna want to read a copy! And the it's co-authored by Daniel Lewis, who's I think at the University of Pennsylvania still or just finished there. The second edition out and available on Amazon, and the third edition is about the plumb out from Taylor and Francis and...new and improved with all the with all the all the latest tricks.