key: cord-0690298-f1non1n4 authors: Oguz Topal, Ilteris; Kara Polat, Asude; Zindancı, İlkin; Kıvanç Altunay, İlknur; Akbulut, Tuğba Özkök; Arıkan, Eylem Emel; Topaloğlu Demir, Filiz; Sivaz, Onur; Karadağ, Ayşe Serap title: Adherence to systemic therapy in patients with psoriasis during the COVID‐19 pandemic: A multicenter study date: 2021-11-18 journal: J Cosmet Dermatol DOI: 10.1111/jocd.14610 sha: 5d46ec8a896516dd5eeadf6d758bfa38cfac6f35 doc_id: 690298 cord_uid: f1non1n4 BACKGROUND: Adherence to treatment is important in chronic dermatological diseases. There are limited data regarding the adherence to treatment in patients with psoriasis during the COVID‐19 pandemic. AIMS: We aimed to determine the rates of adherence to systemic treatments in patients with psoriasis and to identify the causes of non‐adherence during the COVID‐19 pandemic. METHODS: We conducted a cross‐sectional multicenter study from May 2021 to August 2021. A questionnaire including items regarding sociodemographic characteristics of the patients, disease‐related characteristics, and treatment‐related characteristics were filled out by the physicians. The Psoriasis Area Severity Index (PASI), Hospital Anxiety, and Depression Scale, and the Dermatology Life Quality Index were calculated. The rate of adherence and non‐adherence to treatment and reasons for non‐adherence to treatment were examined. RESULTS: A total of 342 patients with psoriasis were included (182 male/160 female) in the study. The mean age of the patients was 45.9 ± 14.2 years. The average duration of psoriasis was 192 ± 134.7 months. While the rate of adherence to treatment was 57.6%, the rate of non‐adherence to treatment was 42.4%. There were no significant differences with respect to adherence to treatment in comparison with oral and injection‐therapy groups. The most frequent reasons for non‐adherence to treatment were inability to go to the hospital (19.2%), concern about the COVID‐19 infection (16.3%), discontinuation of the treatment by the doctor (13.7%), inability to reach the doctor (7.3%), and inability to have access to the medication (7.3%). CONCLUSION: Adherence to oral and injection therapies was fairly high among our patients with psoriasis during the COVID‐19 pandemic. Psoriasis severity and duration of medication use had a negative impact on adherence to treatment. Psoriasis is a chronic, immune-mediated disease. Long-term therapy in chronic skin disorders such as psoriasis is important regarding effective treatment outcomes, the management of the disease, and a better quality of life. [1] [2] [3] These are achieved with adherence to treatment. Adherence is the extent to which a patient takes medication as prescribed by his/her healthcare professional. 4 Generally to speak, this is often poor in patients with psoriasis,especially in those who are using topical treatment compared those who are using systemic treatment. 5 Recently, adherence to biological agents in psoriatic patients has been evaluated in different studies. 6, 7 However, there are limited data about adherence to systemic therapies during the COVID-19 pandemic. Since it is thought that immunotherapeutics can negatively affect normal immune functioning and increase the risk of infection, with the onset of the COVID-19 outbreak, concern about the status of the patients with chronic dermatological diseases who are receiving immunosuppressant and biological treatment has arisen. 8 After the beginning of the COVID-19 pandemic, interruptions have occurred in the treatment of many chronic diseases. Some patients have discontinued systemic treatments due to several factors such as concern about COVID-19 infection and immunosuppressive effects of the medications, inability to go to hospital and inability to have access to the medication. Some of the physicians have suspended or changed their patients' medication. Thus, due to these factors, adherence to treatment in patients with psoriasis has become a complicated issue. 9 In this study, we aimed to determine the rates of adherence to systemic treatments in patients with psoriasis and to identify the causes of non-adherence to treatment during the COVID-19 pandemic. In this cross-sectional descriptive study, we included patients aged 18 years and above, who were diagnosed with psoriasis and followed up in 8 different dermatology clinics from May 2021 to August 2021. The patients who did not receive systemic therapy and those who did not completely answer the questionnaire were excluded. The questionnaire included items regarding sociodemographic characteristics of the patients (age, gender, marital status, smoking, alcohol use, and concomitant disorders), disease-related characteristics (type of psoriasis, duration of the disease, sites of involvement, the presence of psoriatic arthritis, and previous treatments), treatment-related characteristics (duration of treatment, whether the treatment continues, reasons for discontinuation).If the patient discontinued the treatment whether there was an increase of psoriatic lesions, degree of increase by visual analogue scale [VAS]) was filled out by the physician. The questions included in the questionnaire are shown in Table 1 . Additionally, the Psoriasis Area Severity Index (PASI), Hospital Anxiety and Depression Scale (HADS), and the Dermatology Life Quality Index (DLQI) were calculated. Patients were subdivided into the following two subgroups, according to age: the young adult group <50 years of age and the elderly group >50 years of age. For oral therapy, the patient was evaluated as non-adherent to treatment if he or she reduced the dosage of the medication, stopped treatment completely, or discontinued the medication temporarily for more than 2 weeks. For injection therapy, if the patient did not administer the injection more than one dose, the patient was evaluated as a non-adherent patient. The study was approved by the medical ethics committee of the Clinical Ethics Committee (approval number: 22/04/2021-97). All participants gave written informed consent to participate in the study. SPSS software (ver. 17; SPSS Inc.) was used for statistical analyses. The descriptive analysis was presented in tables as mean (SD) and median (minimum-maximum) for numeric data and frequency (n) and percent (%) for categorical data. The chi-squared test and Fisher's exact test were used to assess associations between categorical variables. The Mann-Whitney U test was used to compare numerical variables. Statistical significance was set at p < 0.05. Psoriasis is a chronic dermatologic condition that has a huge impact on patients' quality of life and requires long-term treatment for disease management. Before the COVID-19 pandemic rates of adherence to treatment ranged from 27% to 92% in psoriasis. However there are limited data about adherence to systemic therapies during the COVID-19 pandemic. This study aimed to determine the rates of adherence to systemic treatments in patients with psoriasis and to identify the causes of non-adherence to treatment during the COVID-19 pandemic A total of 342 patients with psoriasis were enrolled in the study. The rate of adherence to systemic therapy was 57.6%. There were no significant differences between the injection-therapy group and the oral-therapy group with respect to adherence to the treatment. The most frequent reasons for non-adherence to treatment were inability to go to the hospital (19.2%), concern about the COVID-19 infection (16.3%), and discontinuation by the doctor (13.7%). Psoriasis severity and duration of medicine use had a negative effect on adherence to treatment in the present study. (Table 3) . While the rate of adherence to treatment was 57.6% (197 patients), the rate of non-adherence to treatment was 42.4% (145 patients). Main reasons for non-adherence to treatment were inability to go to the hospital (19.2%), concern about the COVID-19 infection Table 4 . The mean VAS score was 3.4 ± 3.5 (0-10). The mean VAS scores were higher in non-adherent patient group than adherent patient group (p < 0.001). There were no significant differences between younger patients (<50 years of age) and older patients (>50 years of age), married and single patients, patients with comorbidities and patients without comorbidities, patients who used concomitant medications, and patients who did not use concomitant medication in terms of adherence (p > 0.05). Also, the rates of adherence showed no significant difference in terms of educational status and monthly income There was no significant relationship between adherence and disease duration with Mann-Whitney U test, but there was a correlation between the duration of taking medication and adherence. The duration of taking medication was longer in the non-adherent patient group when compared to the adherent patient group with Mann-Whitney U test (p < 0.001). When the patients were compared with respect to involvement areas, the rate of adherence in patients who did not have nail, scalp, genital, skin-fold, hand, and facial lesions was higher than patients who had nail, scalp, genital, skin-fold, hand, and facial lesions (Table 5) . We found that the rate of adherence was higher in patients with PASI <10 than patients with PASI ≥10. Also, a higher adherence rate was observed in patients who had DLQI score <10 when compared Regarding adherence, there were no significant differences between patients who had anxiety or depression and patients who did not have anxiety or depression (p > 0.05). The proportions of patients with anxiety were 1.8% in the oral-therapy group and 43.5% in the injection-therapy group. The rates of depression were 37.1% and 51.5%, respectively. The mean anxiety and depression scores were higher in the injectiontherapy group than the oral-therapy group (p = 0.034, p = 0.037) ( Figure 1 ). The rate of adherence was 21.3% in the oral-therapy group, while the rate of adherence was 84% in the injection-therapy group, but there were no significant differences between the two therapy groups with respect to adherence. TA B L E 5 Adherence according to the site of involvement, PASI, DLQI, anxiety, and depression F I G U R E 1 Mean of anxiety and depression scores in oral and injectiontherapy groups the 7 patients who discontinued treatment, 5 (71.4%) were male and 1 (14.2%) patient also had psoriatic arthritis. 199 patients received biological therapy in our study. Among these patients, the rate of non-adherence was 36.1% (73 patients). 18 We did not find an association between gender or comorbidities and adherence. A cross-sectional study among Chinese patients with psoriasis investigated the associations of non-adherence to treatment through a web-based questionnaire during the COVID-19 pandemic. The authors suggested that a total of 634 (68.5%) patients reported non-adherence to treatment, and worst adherence was found among patients receiving systemic and topical treatments compared to biological treatments. 9 Although the rate of adherence was higher in the injection-therapy group (84%) than the oral-therapy group (21.3%) in our patient population, there were no significant differences between the two groups with regard to adherence. We found that the adherence ratio was 63.9% in the biological therapy group while it was 14.3% in the methotrexate therapy group. Adherence rates were fairly high in the biological treatment group similar to the pre-pandemic period. In the biological therapy group, 20 In the current study, the proportions of anxiety were 1.8% in the oral-therapy group and 43.5% in the injection-therapy group. The rates of depression was 37.1% and 51.5%, respectively. The mean anxiety and depression scores were higher in the injection-therapy group than the oral-therapy group (p = 0.034, p = 0.037, respectively), but we did not detect a correlation between anxiety or depression and adherence. The major concern in chronic diseases during the pandemic period was the increase in lesions after withdrawal of treatment. We found that 43.9% of our patients who discontinued treatment had an increase in their lesions. The rate of patients with a severe increase was 14.3%. There was a positive correlation between VAS score and severity of lesions. We did not find any relationship between age, marital status, educational status, monthly income, taking additional medications, having comorbidities, and adherence. Interestingly, the rate of adherence in patients who had involvements such as nails and scalp was not higher than those who did not these involvements, but most of the patients were adherent to treatment independent from these involvements. To our knowledge, this is the first study assessing adherence to all systemic medications in psoriasis during the COVID-19 era. The limitations of the present study are the small number of patients in some groups; hence, analysis of differences was not possible. In addition, the severity of the lesions at the time of discontinuation of the medications could not be evaluated by PASI. In conclusion, adherence to oral and injection therapies was fairly high among our patients with psoriasis during the COVID-19 pandemic, and adherence was not associated with the most demographic factors, anxiety, and depression, however the severity of psoriasis and duration of taking medication had a negative effect on adherence. It is of paramount importance to follow-up the patients with psoriasis by ways such as telephone, e-mail during the pandemic. Using systemic medications regularly and making treatment modifications when necessary are essential measures which should be taken by the physicians. None. Adherence in the treatment of psoriasis: a systematic review Objective assessment of compliance with psoriasis treatment Better medication adherence results in greater improvement in severity of psoriasis Adherence to topical treatment in psoriasis: a systematic literature review Non-adherence and measures to improve adherence in the topical treatment of psoriasis Medication adherence and persistence in patients with rheumatoid arthritis, psoriasis, and psoriatic arthritis: a systematic literature review Adherence to topical therapies for the treatment of psoriasis: surveys of physicians and patients COVID-19 and immunosuppressive therapy in dermatology Nonadherence to treatment and patientreported outcomes of psoriasis during the COVID-19 epidemic: a web-based survey Adherence and resource use among psoriasis patients treated with biologics Biologic therapy adherence, discontinuation, switching, and restarting among patients with psoriasis in the US Medicare population Patient adherence to biologic agents in psoriasis Adherence of self-administered subcutaneous methotrexate in patients with chronic plaque-type psoriasis Real-world health outcomes in adults with moderate-to-severe psoriasis in the United States: a population study using electronic health records to examine patient-perceived treatment effectiveness, medication use, and healthcare resource utilization Immunosuppressive drugs for patients with psoriasis during the COVID-19 pandemic era. A review Cutaneous manifestations and considerations in COVID-19 pandemic: a systematic review Patients with specific skin disorders who are affected by COVID-19: What do experiences say about management strategies? A systematic review Rate of patient-driven biologic treatment discontinuation during the COVID-19 pandemic in 2 academic hospital clinics at the University of Toronto Surveillance of psoriatic patients on biologic treatment during the COVID-19 pandemic: a single-center experience Compliance, safety concerns and anxiety in patients treated with biologics for psoriasis during the COVID-19 pandemic national lockdown: a multicenter study in the Czech Republic Treatment adherence in psoriatic patients during COVID-19 pandemic: real-world data from a tertiary hospital in Greece How to cite this article: Oguz Topal I Adherence to systemic therapy in patients with psoriasis during the COVID-19 pandemic: A multicenter study