Table of Content

Archive

Winter 2015, Vol. 23 No. 4

Hong Kong J. Dermatol. Venereol. (2015) 23, 161-174


Original Article

Adherence to topical corticosteroids and moisturisers in adults with endogenous eczema in Singapore

新加坡的內源性濕疹成年患者在外用皮質類固醇和潤膚霜的使用依從性

RK Huynh, HH Wong 黃宏惠, DCW Aw 胡政偉, MPHS Toh 卓漢森

Abstract

The mainstays of treatment in endogenous eczema (EE) are topical corticosteroids (TCS) and moisturisers. This study aimed to survey the factors correlating with adherence to treatment for EE outpatients. Forty-nine-item cross-sectional interviews with 110 adult EE outpatients from the dermatology clinic at the National University Hospital, Singapore revealed that improving adherence in the non-geriatric population can be further explored; steroid phobia affects adherence to TCS; lifestyle and personal preferences affect adherence to moisturisers. Patient education on the safe and correct use of TCS and the development of moisturisers with more comfortable texture and ease of application should be considered.

外用類固醇和潤膚霜都是內源性濕疹的主要治療,本研究的目的是調查門診中的內源性濕疹成年患者在這兩種治療的使用依從性之相關聯因素。在新加坡國立大學醫院皮膚科門診內,有110名內源性濕疹成年患者完成了有49個項目的橫斷面採訪。結果揭示非老年人口群組的使用依從性有待改進,可進一步探討。另外,對類固醇的不當恐懼影響着外用類固醇的使用依從性,而生活方式和個人喜好則影響着潤膚霜的使用依從性,固教育患者安全和正確使用外用類固醇及研發質感舒服並應用方便的潤膚霜是重要的考慮範疇。

Keywords: Adult, eczema, medication adherence, Singapore

關鍵詞: 成年人、濕疹、藥物依從性、新加坡

Introduction

Endogenous eczema (EE) is a chronic skin condition that may be endogenous and not related to external stimuli.1 Subsets include atopic eczema (AE), xerotic eczema, hand and foot eczema. EE as a whole presents a significant disease burden in Singapore, where 67% of all eczema cases seen at a tertiary dermatological referral centre were endogenous in nature.2 Also, the prevalence of EE in Singapore increased from 31% to 67% between 1973 and 1990.2

The principles of care for EE are similar to AE and typically involve a topical corticosteroid (TCS) and moisturiser. Long-term therapeutic aims include prompt management of acute exacerbations, maintenance of remission by pro-active measures, and monitoring of adherence to therapy. TCS is used for rapid resolution of AE during acute flares and might also be used in conjunction with moisturisers for long-term maintenance to prevent recurrent flares.3,4 Other treatments such as topical calcineurin inhibitors, oral antihistamines, phototherapy and oral immunosuppressants may be indicated or given together with the usual treatments when required.3,4

There are few studies on EE, and there is no published data on adherence to topical therapy in EE. Research is lacking in studying non-adherence in dermatology.5 A 20-year review on adherence in dermatology concluded that difficulty in measuring adherence to topical therapy among dermatology patients led to the paucity of such publications.6 The available studies generally showed low adherence rates to treatment5-9 and demonstrated a link between poor adherence to topical treatment and poor treatment outcomes,10-12 highlighting the importance of this issue.13-15

In patients with AE, fear of TCS is being increasingly recognised,16,17 and has been demonstrated to be linked with poor compliance to TCS therapy.16 Many authors concluded that patient and parental education can lead to improved compliance and clinical outcomes for treating paediatric AE.13,18-20 Studies have sought to characterise barriers to adherence in paediatric AE patients by surveying their caregivers, some of which include concerns about the time-consuming nature of applying topical treatments, cost and safety of the prescribed medications.21,22 Our study focuses on adherence and factors affecting adherence to treatment in adult patients with EE to address the paucity of data in this area.

Materials and methods

Study design
This was a cross-sectional study whereby information on the severity and nature of eczema was obtained followed by an interviewer-administered questionnaire in either the English or Chinese language.

There were two trained interviewers and all questionnaires were checked for completeness.

Study population
One hundred and twenty-four consecutive adults aged 21 years old and over with pre-existing EE were recruited over the course of seven weeks in 2012 from the dermatology clinic of the National University Hospital. The institutional Ethics Committee approved the study (ref. no. 2012/00102, National Healthcare Group Domain Specific Review Board). A verbal informed consent was obtained from all participants, as the study was of minimal risk and involved no recording of identifiable information.

The study excluded patients with a) seborrhoeic eczema because it usually does not require long-term therapy; and b) venous eczema because it is attributable to chronic venous insufficiency, a potentially reversible cause.

There were 14 non-responders of which 10 declined participation in the survey and four were unable to communicate adequately.

Study instruments
The attending dermatologists specified the nature of eczema and graded its severity using the Investigator's Global Assessment (IGA) scale during the consultation.

Investigator's Global Assessment grades the disease from clear, almost clear, mild, moderate, severe to very severe disease on a scale of 0 to 5.23

The 10-item Dermatology Life Quality Index (DLQI) developed and validated by Finlay and Khan was used to assess quality of life (QoL).24 The DLQI score is calculated by summing the scores of its 10 questions. The maximum score is 30 and the minimum is 0. The scores represent the effect of the skin disease, in this study EE, on the QoL. A score of 0-1 indicates that there is no effect at all on the patient's life, 2-5 a small effect, 6-10 a moderate effect, 11-20 a very large effect and 21-30 an extremely large effect. It can be analysed under six different domains, namely symptoms and feelings, daily activities, leisure, work and school, personal relationships, and treatment.

Twenty-one items on demographics and medical details were obtained from the patients (Appendix 1).

Data analysis
Data was processed using Microsoft Excel XL and Predictive Analytics Software version 18. The Pearson's chi-squared test was used to compare proportional data. A probability (p) <0.05 was considered statistically significant.

Results

The questionnaires of 110 participants were analysed.

Characteristics of study population (Table 1)
There was a slight male predominance (58.2%), mainly Chinese (86.4%), and the median age was 56 (range of 21-79).

The majority of the patients had non-specific EE (37.3%) and AE (36.4%); followed by xerotic eczema (20.0%), and then palmoplantar eczema (4.5%), dyshidrotic eczema (0.9%), and prurigo nodularis (0.9%). At the point of the survey, most patients had mild eczema (44.5%). Almost all patients were using TCS (98.2%) and moisturiser (90.9%).

Table 1 Characteristics of outpatients with EE (n=110)
Variable No. (%)
Gender
Male 64 (58.2)
Female 46 (41.8)
Age group
Median (range) 55.50 (21-79)
21-29 22 (20.0)
30-39 10 (9.1)
40-49 14 (12.7)
50-59 19 (17.3)
60-69 19 (17.3)
70-79 26 (23.6)
Ethnic group
Chinese 95 (86.4)
Malay 6 (5.5)
Indian 5 (4.5)
Others 4 (3.6)
Type of endogenous eczema
Non-specific endogenous 41 (37.3)
Atopic 40 (36.4)
Xerotic 22 (20.0)
Palmoplantar 5 (4.5)
Dyshidrotic 1 (0.9)
Prurigo nodularis 1 (0.9)
Severity of eczema (IGA)
Clear (0) 8 (7.3)
Almost clear (1) 17 (15.5)
Mild (2) 49 (44.5)
Moderate (3) 27 (24.5)
Severe (4) 9 (8.2)
Application of TCS  
Yes 108 (98.2)
Application of moisturiser
Yes 100 (90.9)
EE, Endogenous Eczema; TCS, Topical Corticosteroid; IGA, Investigators' Global Assessment

Adherence and barriers to adherence
Adherence and barriers to adherence to TCS (n=108) (Table 2).

More than half of the patients (54.6%) stopped applying TCS upon subjective improvement of their skin, while 43.5% even forgot to apply TCS. Carelessness was defined as not applying the cream over all lesional areas or laziness to apply TCS. This was identified in 30.6% of participants, most of whom were careless once a week/month (87.9%).

The most commonly cited barriers to adherence were concerns about side-effects of TCS (36.1%), and not finding it useful in managing eczema (27.8%).

Adherence and barriers to adherence to moisturiser (n=100) (Table 2).

While the ideal frequency of application of moisturiser varies according to patients' preference and skin condition, as well as doctors' knowledge, preference, and clinical experience, we routinely recommend a minimum standard of twice daily application. Using this criterion, slightly more than half of the patients had inadequate application of moisturiser (52.0%). Close to half of the patients even forgot to apply moisturiser (46.0%). One-third of the patients stopped applying moisturiser upon subjective improvement. Less than one-third of the patients applied moisturiser infrequently
(24.0%), usually using it once a week/month (79.2%). Most patients (88.0%) used moisturiser after a shower and at bedtime when it was most convenient.

The most commonly cited barriers to adherence were feeling of discomfort on the skin (27.0%), not finding it useful in managing eczema (23.0%) and cost deterring them from using it (23.0%).

Table 2 Adherence and barriers to adherence to TCS and moisturiser
  TCS
n=108
Moisturiser
n=100
No. (%) No. (%)
Variable
Adherence
Forget
Yes 47 (43.5) 46 (46.0)
No 61 (56.5) 54 (54.0)
Careless
Yes, every time 5 (4.6) 5 (5.0)
Yes, once a week 12 (11.1) 6 (6.0)
Yes, once a month 16 (14.8) 13 (13.0)
No 75 (69.4) 76 (76.0)
Stop
Yes 59 (54.6) 33 (33.0)
No 49 (45.4) 67 (67.0)
Frequency of application
Inadequate NA 52 (52.0)
Adequate   48 (48.0)
Time of application    
Undesirable NA 12 (12.0)
Desirable   88 (88.0)
Barriers to adherence
It is uncomfortable on your skin
Neutral/disagree/strongly disagree 81 (75.0) 73 (73.0)
Agree/strongly agree 27 (25.0) 27 (27.0)
The cost deters you from using it
Neutral/disagree/strongly disagree 87 (80.6) 77 (77.0)
Agree/strongly agree 21 (19.4) 23 (23.0)
Too much time is required to it
Neutral/disagree/strongly disagree 83 (76.9) 78 (78.0)
Agree/strongly agree 25 (23.1) 22 (22.0)
You do not find the it useful in managing eczema
Neutral/disagree/strongly disagree 78 (72.2) 77 (77.0)
Agree/strongly agree 30 (27.8) 23 (23.0)
Concerns about the side effects decreases your desire to use them
Neutral/disagree/strongly disagree 69 (63.9) NA
Agree/strongly agree 39 (36.1)  
TCS, Topical Corticosteroid

Factors affecting adherence (Table 3 and Table 4)
The non-geriatric population was more likely to forget to use TCS (52.1% vs. 25.7%, p=0.010) and more likely to have inadequate application of moisturiser (59.1% vs. 38.2%, p=0.048). Despite not reaching statistical significance, the non-geriatric population was less adherent for all other items measuring adherence. Those with xerotic eczema were more likely to have adequate application of moisturiser (20.0% vs. 60.0%, p=0.001). Those without chronic medical problems were more likely to forget to use TCS (56.5% vs. 33.9%, p=0.019).

The proportion of those who stopped applying TCS upon subjective improvement was higher in those with educational qualifications of secondary school or above (64.1% vs. 32.0%, p=0.010), those who were familiar with TCS (63.8% vs. 38.5%, p=0.011) and those who were concerned about its side effects (74.4% vs. 43.5%, p=0.002).

The proportion of those who stopped applying moisturiser upon subjective improvement was higher in males (43.1% vs. 19.0%, p=0.012), those who complained of discomfort from TCS (55.6% vs. 24.7%, p=0.014) and those who felt that it was too time-consuming (54.5% vs. 26.9%, p=0.015).

No statistically significant relationship was noticed between severity of EE, concurrent skin condition(s), family history of EE, previous consultation with other doctors, paying status, number of consultations and adherence to TCS or moisturiser.

Table 3 Relationship between adherence to TCS and other variables
  Use of TCS (n=108)
  Forget
No. (%)
n=47
(43.5%)
p-value Careless
No. (%)
n=33
(30.6%)
p-value Stop
No. (%)
n=59
(54.6%)
p-value
Variable
Demographics
Gender
Males 28 (43.8) 0.953 20 (31.3) 0.850 32 (50.0) 0.244
Females 19 (43.2)   13 (29.5)   27 (61.4)  
Age group
Non-geriatric 38 (52.1) 0.010 25 (34.2) 0.229 41 (56.2) 0.644
Geriatric 9 (25.7)   8 (22.9)   18 (51.4)  
Retirement status
Non-retiree 36 (48.6) 0.113 25 (33.8) 0.282 43 (58.1) 0.284
Retiree 11 (32.4)   8 (23.5)   16 (47.1)  
Educational attainment
Primary or none 10 (40.0) 0.686 6 (24.0) 0.417 8 (32.0) 0.010
Secondary
and above
37 (44.6)   27 (32.5)   51 (61.4)  
Ethnic group
Chinese 41 (44.1) 0.767 29 (31.2) 0.725 52 (55.9) 0.504
Malay/Indian/Others 6 (40.0)   4 (26.7)   7 (46.7)  
Main language spoken
English 25 (49.0) 0.275 18 (35.3) 0.312 32 (62.7) 0.109
Chinese/Malay/Tamil 22 (38.6)   15 (26.3)   27 (47.4)  
Medical details
Other skin condition
Yes 9 (42.9) 0.946 7 (33.3) 0.758 10 (47.6) 0.472
No 38 (43.7)   26 (29.9)   49 (56.3)  
Chronic medical problem(s)
No 26 (56.5) 0.019 14 (30.4) 0.981 30 (65.2) 0.057
Yes 21 (33.9)   19 (30.6)   29 (46.8)  
Severity of EE
Clear 2 (28.6) 0.647 2 (28.6) 0.993 6 (85.7) 0.170
Almost clear and mild 30 (46.2)   20 (30.8)   36 (55.4)  
Moderate and severe 15 (41.7)   11 (30.6)   17 (47.2)  
Nature of EE
Xerotic 7 (31.8) 0.215 4 (18.2) 0.158 9 (40.9) 0.147
Non-Xerotic 40 (46.5)   29 (33.7)   50 (58.1)  
Family history of EE
Yes 12 (38.7) 0.522 13 (41.9) 0.103 15 (48.4) 0.408
No 35 (45.5)   20 (26.0)   44 (57.1)  
Health utilisation
Consulted other doctors
Yes 27 (42.9) 0.870 22 (34.9) 0.244 34 (54.0) 0.870
No 20 (44.4)   11 (24.4)   25 (55.6)  
Paying status
Private 12 (50.0) 0.468 6 (25.0) 0.503 16 (66.7) 0.179
Subsidised 35 (41.7)   27 (32.1)   43 (51.2)  
Number of consultations
Less than or equals to 5 19 (39.6) 0.461 17 (35.4) 0.327 27 (56.3) 0.762
More than 5 28 (46.7)   16 (26.7)   32 (53.3)  
Knowledge of TCS
Understand what is a topical steroid
No 19 (48.7) 0.413 8 (20.5) 0.088 15 (38.5) 0.011
Yes 28 (40.6)   25 (36.2)   44 (63.8)  
TCS is used for inflammation of the skin
N/D/SD 22 (46.8) 0.545 13 (27.7) 0.566 22 (46.5) 0.152
A/SA 25 (41.0)   20 (32.8)   37 (60.7)  
Barriers to adherence
It is uncomfortable on your skin
N/D/SD 31 (38.3) 0.057 24 (29.6) 0.717 41 (50.6) 0.147
A/SA 16 (59.3)   9 (33.3)   18 (66.7)  
The cost of the TCS deters you from using it
N/D/SD 37 (42.5) 0.673 24 (27.6) 0.173 48 (55.2) 0.818
A/SA 10 (47.6)   9 (42.9)   11 (52.4)  
Too much time is required to apply the TCS prescribed
N/D/SD 34 (41.0) 0.329 23 (27.7) 0.242 45 (54.2) 0.875
A/SA 13 (52.0)   10 (40.0)   14 (56.0)  
You do not find the TCS useful in managing eczema
N/D/SD 30 (38.5) 0.087 20 (25.6) 0.074 45 (57.7) 0.303
A/SA 17 (56.7)   13 (43.3)   14 (46.7)  
Side-effects of TCS deters you from using them
N/D/SD 30 (43.5) 0.991 17 (24.6) 0.076 30 (43.5) 0.002
A/SA 17 (43.6)   16 (41.0)   29 (74.4)  
You prefer other treatments, such as Traditional Chinese Medicine
N/D/SD 42 (43.8) 0.891 31 (32.3) 0.268 31 (32.3) 0.268
A/SA 5 (41.7)   2 (16.7)   2 (16.7)  
TCS, Topical Corticosteroid; EE, Endogenous Eczema; N/D/SD, Neutral/Disagree/Strongly Disagree; A/SA, Agree/Strongly Agree

Table 4 Relationship between adherence to moisturisers and other variables (n=100)
  Adherence to moisturiser
  Forget
p-value Careless
p-value Stop

p-value
  n=46
(46.0)
  n=24
(24.0%)
  n=33
(33.0%)
 
  No. (%)   No. (%)   No. (%)  
Variable
Demographics
Gender
Females 20 (47.6) 0.782 10 (23.8) 0.970 8 (19.0) 0.012
Males 26 (44.8)   14 (24.1)   25 (43.1)  
Age group
Non-
Geriatric
34 (51.5) 0.123 17 (25.8) 0.566 22 (33.0) 0.921
Geriatric 12 (35.3)   7 (20.6)   11 (32.4)  
Ethnic group
Chinese 6 (40.0) 0.613 2 (13.3) 0.294 3 (20.0) 0.245
Malay/
Indian/
Others
40 (47.1)   22 (25.9)   30 (35.3)  
Main language spoken
English 24 (47.1) 0.828 10 (19.6) 0.294 19 (37.3) 0.356
Chinese/
Malay/
Tamil
22 (44.9)   14 (28.6)   14 (28.6)  
Educational level
Primary
and below
11 (45.8) 0.985 4 (16.7) 0.335 8 (33.3) 0.968
Secondary
and above
35 (46.1)   20 (26.3)   25 (32.9)  
Medical details
Other skin condition
No 38 (47.5) 0.547 18 (22.5) 0.482 27 (33.8) 0.750
Yes 8 (40.0)   6 (30.0)   6 (30.0)  
Other chronic medical problem(s)
No 19 (47.5) 0.806 7 (17.5) 0.214 12 (30.0) 0.602
Yes 27 (45.0)   17 (28.3)   21 (35.0)  
Nature of EE
Xerotic 11 (55.0) 0.367 5 (25.0) 0.907 6 (30.0) 0.750
Non-
Xerotic
35 (43.8)   19 (23.8)   27 (33.8)  
Severity of EE
Clear 4 (50.0) 0.056 2 (25.0) 0.995 3 (37.5) 0.848
Almost clear
and mild
32 (55.2)   14 (24.1)   20 (34.5)  
Moderate
and severe
10 (29.4)   8 (23.5)   10 (29.4)  
Family history of EE
Yes 32 (45.7) 0.930 11 (15.7) 0.003 26 (37.1) 0.178
No 14 (46.7)   13 (43.3)   7 (23.3)  
Health utilisation
Consulted other doctors
Yes 20 (45.5) 0.923 8 (18.2) 0.227 12 (27.3) 0.280
No 26 (46.4)   16 (28.6)   21 (37.5)  
Paying status
Private 12 (50.0) 0.652 4 (16.7) 0.335 6 (25.0) 0.339
Subsidised 34 (44.7)   20 (26.3)   27 (35.5)  
Number of consultations
≤5 20 (47.6) 0.782 13 (31.0) 0.166 16 (38.1) 0.356
>5 26 (44.8)   11 (19.0)   17 (29.3)  
Knowledge of moisturiser
Moisturiser is used for patients with dry skin
N/D/SD 8 (32.0) 0.105 6 (24.0) 1.000 3 (12.0) 0.010
A/SA 38 (50.7)   18 (24.0)   30 (40.0)  
Patients with eczema have dry skin
N/D/SD 11 (50.0) 0.670 5 (22.7) 0.874 7 (31.8) 0.894
A/SA 35 (44.9)   19 (24.4)   26 (23.3)  
Barriers to adherence
Moisturiser is uncomfortable on the skin
N/D/SD 28 (38.4) 0.012 16 (21.9) 0.423 18 (24.7) 0.004
A/SA 18 (66.7)   8 (29.6)   15 (55.6)  
The cost of the moisturiser deters you from using it
N/D/SD 38 (49.4) 0.578 16 (20.8) 0.168 23 (29.9) 0.223
A/SA 8 (34.8)   8 (34.8)   10 (43.5)  
Too much time is required to apply moisturiser
N/D/SD 32 (41.0) 0.060 16 (20.5) 0.124 21 (26.9) 0.015
A/SA 14 (63.6)   8 (36.4)   12 (54.5)  
You do not find the moisturiser useful in managing eczema
N/D/SD 23 (29.9) 0.223 20 (26.0) 0.398 23 (29.9) 0.223
A/SA 10 (43.5)   4 (17.4)   10 (43.5)  
EE, Endogenous Eczema; N/D/SD, Neutral/Disagree/Strongly Disagree; A/SA, Agree/Strongly Agree.

Table 4 (Con't) Relationship between adherence to moisturisers and other variables (n=100)
  Adherence to moisturiser
  Inadequate
application
p-value Undesirable
time of
application
p-value
  n=52
(52.0)
  n=12 (12.0)  
  No. (%)   No. (%)  
Variable
Demographics
Gender
Females 19 (45.2) 0.249 4 (9.5) 0.517
Males 33 (56.9)   8 (13.8)  
Age group
Non-
Geriatric
39 (59.1) 0.048 8 (12.1) 0.959
Geriatric 13 (38.2)   4 (11.8)  
Ethnic group
Chinese 8 (53.3) 0.911 1 (6.7) 0.491
Malay/
Indian/
Others
44 (51.8)   11 (12.9)  
Main language spoken
English 23 (45.1) 0.159 5 (9.8) 0.491
Chinese/
Malay/
Tamil
29 (59.2)   7 (14.3)  
Educational level
Primary
and below
10 (41.7) 0.245 3 (12.5) 0.931
Secondary
and above
42 (55.3)   9 (11.8)  
Medical details
Other skin condition
No 42 (52.5) 0.841 10 (12.5) 0.758
Yes 10 (50.0)   2 (10.0)  
Other chronic medical problem(s)
No 21 (52.5) 0.935 3 (7.5) 0.258
Yes 31 (51.7)   9 (15.0)  
Nature of EE
Xerotic 4 (20.0) 0.001 3 (15.0) 0.644
Non-
Xerotic
48 (60.0)   9 (11.3)  
Severity of EE
Clear 6 (75.0) 0.172 0 (0.0) 0.530
Almost clear
and mild
32 (55.2)   8 (13.8)  
Moderate
and severe
14 (41.2)   4 (11.8)  
Family history of EE
Yes 36 (51.4) 0.861 8 (11.4) 0.788
No 16 (53.3)   4 (13.3)  
Health utilisation
Consulted other doctors
Yes 33 (58.9) 0.118 3 (6.8) 0.158
No 19 (43.2)   9 (16.1)  
Paying status
Private 15 (62.5) 0.238 1 (4.2) 0.176
Subsidised 37 (48.7)   11 (14.5)  
Number of consultations
≤5 23 (54.8) 0.638 6 (14.3) 0.543
>5 29 (50.0)   6 (10.3)  
Knowledge of moisturiser
Moisturiser is used for patients with dry skin
N/D/SD 14 (56.0) 0.644 1 (4.0) 0.155
A/SA 38 (50.7)   11 (14.7)  
Patients with eczema have dry skin
N/D/SD 11 (50.0) 0.832 2 (9.1) 0.634
A/SA 41 (42.6)   10 (12.8)  
Barriers to adherence
Moisturiser is uncomfortable on the skin
N/D/SD 35 (47.9) 0.182 11 (15.1) 0.121
A/SA 17 (63.0)   1 (3.7)  
The cost of the moisturiser deters you from using it
N/D/SD 40 (51.9) 0.985 67 (87.0) 0.578
A/SA 12 (52.2)   21 (91.3)  
Too much time is required to apply moisturiser
N/D/SD 38 (48.7) 0.216 10 (12.8) 0.634
A/SA 14 (63.6)   2 (9.1)  
You do not find the moisturiser useful in managing eczema
N/D/SD 44 (57.1) 0.060 8 (10.4) 0.365
A/SA 8 (34.8)   4 (17.4)  
EE, Endogenous Eczema; N/D/SD, Neutral/Disagree/Strongly Disagree; A/SA, Agree/Strongly Agree.

Adherence, barriers to adherence and QoL (Table 5)
There was no statistical correlation between QoL and adherence, with the exception of those with poor compliance with TCS (9.1% vs. 90.9%, p=0.029).

The proportion of those affected by EE increased in those who complained of skin discomfort from TCS (96.3% vs. 71.6%, p=0.008), those who had decreased compliance due to concerns about side effects of TCS (89.7% vs. 71.0%, p=0.025), and those who found it time-consuming to apply a moisturiser (100.0% vs.71.8%, p=0.005).

Table 5 Relationship between DLQI and adherence and barriers to adherence to TCS and moisturisers in outpatients
  Effect on QoL
  For TCS
n=108
p-value For moisturiser
n=100
p-value
  No effect
at all
n=24
(22.2%)
Small, moderate, large, extremely large
n=84 (77.8%)
  No effect at all
n=22
(22.0%)
Small, moderate, large, extremely large
n=86 (88.0%)
 
  No. (%) No. (%)   No. (%) No. (%) No. (%)
Variable
Adherence
Forget
Yes 7 (14.9) 40 (85.1) 0.108 11 (23.9) 35 (76.1) 0.670
No 17 (27.9) 44 (72.1)   11 (20.4) 43 (79.6)  
Careless
Yes 3 (9.1) 30 (90.9) 0.029 4 (16.7) 20 (83.3) 0.469
No 54 (72.0) 21 (28.0)   18 (23.7) 58 (76.3)  
Stop
Yes 12 (20.3) 47 (79.7) 0.605 6 (18.2) 27 (81.8) 0.518
No 12 (24.5) 37 (75.5)   16 (23.9) 51 (76.1)  
Frequency of application
Adequate NA     13 (27.1) 35 (72.9) 0.238
Inadequate       9 (17.3) 43 (82.7)  
Time of application
Desirable NA     4 (33.3) 8 (66.7) 0.312
Undesirable       18 (20.5) 70 (79.5)  
Barriers to adherence
It is uncomfortable on your skin
N/D/SD 23 (28.4) 58 (71.6) 0.008 19 (26.0) 54 (74.0) 0.110
A/SA 1 (3.7) 26 (96.3)   3 (11.1) 24 (88.9)  
The cost deters you from using it
N/D/SD 22 (25.3) 65 (74.7) 0.119 20 (26.0) 57 (74.0) 0.079
A/SA 2 (9.5) 19 (90.5)   2 (8.7) 21 (91.3)  
Too much time is required to it
N/D/SD 22 (26.5) 61 (73.5) 0.051 22 (28.2) 56 (71.8) 0.005
A/SA 2 (8.0) 23 (92.0)   0 (0.0) 22 (100.0)  
You do not find the it useful in managing eczema
N/D/SD 19 (24.4) 59 (75.6) 0.389 16 (20.8) 61 (79.2) 0.590
A/SA 5 (16.7) 25 (83.3)   6 (26.1) 17 (73.9)  
Concerns about the side effects decreases your desire to use them
N/D/SD 20 (29.0) 49 (71.0) 0.025 NA    
A/SA 4 (10.3) 35 (89.7)        
DLQI, Dermatology Quality Life Index; QoL, Quality of Life; TCS, Topical Corticosteroids; N/D/SD, Neutral/Disagree/Strongly Disagree; A/SA, Agree/Strongly Agree.

Discussion

Achieving adherence in the non-geriatric population
The younger patients (below 55 years) had lower adherence for all variables, to both TCS and moisturisers reaching statistical significance in forgetting to use TCS and inadequate frequency of moisturiser use. A worldwide observational study showed that poor adherence to acne treatment was correlated with young age.25 Our study appears to be the first to demonstrate a similar age-adherence correlation in EE patients.

Patients without co-existing chronic medical problems tended to be younger patients, and these patients demonstrated lower adherence. Conversely, geriatric patients with co-existing chronic medical problems recognised the value of adherence to medical therapy because of their prior medical encounters. Higher adherence was evident with TCS therapy for these patients as well, as those without co-existing chronic medical problem(s) were more likely to forget to apply TCS (p=0.019). This was supported by the finding that there was a higher proportion of the non-geriatric population with no chronic medical illness (19.4% vs. 80.6%, p=0.001).

Higher adherence to moisturisers was also demonstrated in patients with xerotic-type eczema, which is understandable as the primary pathology is overt xerosis. As such, inadequate moisturiser application was significantly increased in patients with non-xerotic eczema (p=0.001). Among the non-geriatric population, the majority had non-xerotic eczema (25.0% vs. 63.6%, p<0.001). Accordingly, in the geriatric population, with co-existing chronic medical problems and xerotic eczema were both more prevalent, but it is unclear if there is any possible relationship.

Patients view moisturiser therapy in a different light from TCS therapy. Unlike with TCS usage, those with chronic medical problems were not more adherent with moisturiser therapy than those without any chronic medical problems (45.0% vs. 47.5%, p=0.806). Instead, males (p=0.012) and those who felt that moisturisers were uncomfortable on the skin (p=0.004) and that moisturiser application was too time-consuming (p=0.025) had a higher chance of stopping moisturisers with subjective improvement. This suggests that those with chronic medical issues perceive TCS as the core component of their treatment regimen while moisturisers are seen as less important. Thus, there is less unidirectional adherence with moisturiser therapy compared to TCS. Lifestyle or personal preferences may have an influence but this may also be a reflection of the fact that TCS typically require a prescription while moisturisers can be bought over-the-counter. Thus, moisturisers may not be perceived as important as TCS in the treatment of EE even though moisturisers form the basis of maintenance treatment. Alternatively, it can be argued that patients who present at the clinic are more likely to be experiencing acute flares, and the application of TCS is more important than the application of moisturisers in the acute stage relative to when the disease process is in remission, when the usage of moisturiser is more important than TCS. Subsequently, adherence to TCS affected QoL, whereas adherence to moisturiser did not affect QoL.

Finally, the discomfort of moisturisers could be attributed to the hot and humid climate of Singapore.

Severity of EE
In contrast to the findings on adherence to topical treatment in acne25 and psoriasis26 patients, we found an absence of correlation between the severity of EE and treatment adherence. This finding reinforces the importance of inculcating and routinely monitoring adherence in all our EE patients regardless of their clinical severity and our pre-conceived notions that it would influence patients' therapeutic adherence.

Steroid phobia
Topical corticosteroids should only be stopped when the acute flare of EE has subsided completely, and not when only improvement is seen. In fact, it has been shown that twice-weekly use of TCS on "hot spots" after visible clearance of eczema prolongs remission. Of the participants, 36.1% were concerned about the side-effects of TCS, 27.8% of the participants felt that TCS was not useful in managing eczema, and more than half of the patients surveyed had stopped TCS after subjective improvement in their skin condition. The knowledge questions revealed that those who were familiar with TCS, were more likely to be aware of TCS side-effects (80.0% vs. 54.3%, p=0.007). Indeed, participants concerned about the side-effects of TCS were more likely to stop using TCS with subjective improvement in skin condition (p=0.002). This could lead to poor symptom control, and eventually lower patient satisfaction. It is well-known that those with steroid phobia tend to be less compliant to TCS.16,17

Furthermore, those of a higher educational level, defined as secondary level of schooling or higher, were more likely to stop using TCS with subjective improvement (p=0.010). This finding is likely because a higher proportion of those with higher educational levels were familiar with TCS (80.0% vs. 54.3%, p=0.007) and were aware of their side effects (92.9% vs. 50.0%, p<0.001). The proportion of those affected by EE increased in patients who were concerned about the side effects of TCS and who were less likely to use them (p=0.025). Conversely, those with lower educational levels were more likely to engage in unidirectional compliance of the physician's directions without exceptions, as opposed to those with higher educational levels, who stopped TCS therapy on their own when they felt that their skin condition had improved. Further exploration can be given to concordance, which is the collaboration between physician and patient in coming to a consensus on treating the condition together, in this group of patients to improve therapy.27

A number of studies have discussed and examined patients who view steroids negatively or are averse to their usage due to knowledge of known TCS side-effects.16,17 Our study confirms the presence of steroid phobia in Singapore. Proper education of our patients regarding the use of TCS is paramount for optimal management of EE, as using too little or early termination of usage of TCS will lead to less than desirable outcomes.

Limitations
This study has several limitations. Firstly, we managed to recruit 110 patients from a single centre with EE who met all inclusion criteria and completed the questionnaires. Although the overall response rate (89%) was high, future research should strive to assess a larger number of patients with EE in a multi-centred setting to improve generalisability.

Next, other factors affecting adherence were not studied, such as the patient-prescriber relationship; healthcare system factors, which includes waiting time, patients' beliefs, attitudes and expectations; smoking and alcohol intake; and social support were not assessed. Fear of TCS also can be further explored.

Last but not least, our study used proxy statements to reflect adherence to TCS and moisturiser. A more quantitative approach, such as the use of diaries and weighing of the creams, would have resulted in more accurate and informative data that could have been better studied for correlation to adherence. Studies have shown that patients with dermatological conditions tend to overestimate their adherence, and traditional methods of using questionnaires, dairies and weighing of creams are not as accurate as electronic measures.28-30

Conclusion

Adherence impacts clinical outcomes for EE. However, given the complexity of the disease and variation in disease severity, effective management of both acute episodes and chronic lesions can be difficult. Some factors, such as patient education and effective communication, have been found to impact clinical outcomes. Our results have shown that age, gender, presence of chronic medical problems, level of education, knowledge, concerns and preferences towards TCS and moisturisers were significantly associated with adherence. An important finding was the lack of correlation between disease severity and adherence.

Finally, factors affecting adherence to TCS and moisturisers are different. This underlines the importance of using different approaches to improve compliance for TCS and moisturiser in the treatment of EE. With regard to adherence to TCS, steroid phobia is significant, whereas adherence to moisturiser is associated with lifestyle and personal preferences. In the management of EE, we need to educate our patients on the safe and proper use of TCS. Although the importance of regularly using moisturisers should be continually emphasised to our patients, it appears that therapeutic moisturisers that are pleasant as well as easy to use need to be developed.

Acknowledgements

Undergraduate research opportunities programme by the National University of Singapore, which funded the printing of the questionnaires. We also thank Professor A. Y. Finlay for permission to use the DLQI.

Appendix 1. Details on 39 items in questionnaire
  • 9 items pertained to Demographics, such as age, gender and occupation.
  • 3 items pertained to health utilisation:
    1. Paying status
    2. History of consulting other doctors
    3. Number of consultations with a dermatologist at National University Hospital
  • 5 items pertained to patient's medical details:
    1. Any chronic medical problem(s) other than eczema
    2. Concurrent skin condition(s)
    3. Family history of eczema
    4. Nature of eczema
    5. Severity of eczema
  • 4 items were on knowledge:
    1. Understand what is a TCS
    2. Whether TCS is used for inflammation of the skin
    3. Whether moisturiser is used for dry skin
    4. Whether patients with eczema had dry skin
  • 3 items were pertained to adherence to TCS:
    1. Whether they ever forget to apply TCS
    2. Whether they are careless with, for example, not applying over the whole skin area with eczema or are too lazy to apply TCS
    3. Whether they stop applying TCS when they think that their skin is better
  • 5 items pertained to adherence to moisturiser:
    1. Whether they ever forget to apply moisturiser
    2. Are careless with, for example, not applying over the whole skin area with eczema or are too lazy to apply moisturiser
    3. Whether they stop applying moisturiser when they think that their skin is better
    4. Frequency of application of moisturiser
    5. Time of application of moisturiser
      Patients who said that they were careless to TCS and moisturiser were asked whether they were always careless, careless once a week, or once a month.
  • 5 items were on barriers to adherence to TCS:
    1. Time required for application
    2. Cost
    3. Whether it felt uncomfortable on the skin
    4. Perception of usefulness of TCS and moisturiser in managing eczema
    5. Whether patients were concerned about the side-effects of TCS
  • 4 items were on barriers to adherence to moisturiser:
    1. Time required for application
    2. Cost
    3. Whether it felt uncomfortable on the skin
    4. Perception of usefulness of moisturiser in managing eczema
  • Additional barriers to treatment included:
    1. Preference for other treatments, such as Traditional Chinese Medicine

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