Abstract
According to current estimates, medication non-adherence has resulted in over $100 billion in
avoidable medical expenses and at least 100,000 avoidable fatalities. With over 50% of patients
stopping topical therapy within the first year, adherence is especially bad for dermatological
diseases. Among the most approachable medical experts, chemists have the power to
significantly reduce pharmaceutical non-adherence through better access to treatment,
medication therapy management, and patient education. The purpose of this review was to
ascertain how chemists have enhanced medication adherence in dermatology and to talk about
ways to get more involved. In order to assess clinical research published within the last 20 years
that have assessed the function of chemists and their influence on adherence to dermatological
products, a thorough review of the medical literature using the PubMed database was carried out.
“Pharmacists’ role in dermatologic medication adherence,” “pharmacist-led interventions in
dermatology,” “pharmacist medication adherence dermatology,” and “pharmacist intervention
dermatology” are some of the search terms that may be found in PubMed. Eighteen pertinent
studies in all were found. By expanding access to pharmaceuticals, offering medication
counselling programs, and providing treatment monitoring services, chemists enhanced
dermatological medication adherence. Nonetheless, chemists’ reluctance to offer corticosteroid
over-the-counter medications may be influenced by corticophobia. Pharmacists are easily
available medical professionals who may help increase adherence to dermatological medicine.
Pharmacists’ understanding of dermatological products may be improved by future advanced
training in dermatology drugs.
Keywords: Pharmacists, Medication Adherence, Dermatology.
Introduction
Adherence refers to a patient’s participation in health-related behaviors, such as taking prescribed
drugs, going to follow-up visits, and altering their lifestyle (1,2). Poor communication or
education, medical comorbidities, medication interactions, regimen length, and complexity are
among factors that can hinder adherence [1,3–10]. Non-adherence is particularly common in
dermatology, which includes a wide range of systemic and topical treatments for various skin
disorders [1,11–13].
Application time, excessive or insufficient application, an unpleasant smell, discomfort, poor
aesthetic qualities, and dirty, sticky, or oily vehicles are all obstacles to adherence [1, 2, 6, 12,
14–17]. Lesions frequently have inadequate coverage [1]. Long-term adherence is significantly
worse than short-term adherence [2,11,12,18]. Psoriasis comorbidities, such as depression (10–
62%) and cardiovascular disease, might result in polypharmacy and complicated regimens,
which have a poor correlation with adherence [14].
Access to prescriptions, cost, and health literacy are some of the factors that affect medication
non-adherence, which is the degree to which patients take their medications as directed [1].
About 50% of patients with chronic illnesses were found to not adhere to their treatment plans,
which is thought to have contributed to at least 100,000 avoidable deaths and more than $100
billion in avoidable medical expenses per year in the US [2]. Poor treatment outcomes, such as
an increase in all-cause hospitalisations and all-cause death for a variety of illnesses, are also
linked to non-adherence to prescribed medicine [3-5].
On the other hand, a 21% lower risk of death is linked to effective drug adherence [3]. A
multimodal strategy helps patients overcome obstacles to medication adherence and achieve
better clinical outcomes, given the significance that appropriate medication usage plays in
improving patient outcomes and lowering health care costs [6]. Despite the development of
numerous health interventions, treatment adherence is still difficult to achieve.
In both high- and low-income nations, dermatological disorders are a major contributor to the
global illness burden [7,8]. The United States also has a high frequency of dermatological
diseases; in 2013, around 85 million Americans visited a doctor for at least one cutaneous illness,
resulting in direct medical expenses of more than $75 billion [9]. With more than 50% of
patients stopping topical medication during the first year, adherence to topical treatment
regimens for psoriasis is appalling. In cases of vitiligo, acne, hair growth problems, and
persistent dermatitis, medication adherence is comparatively low [10].
Since the majority of dermatoses are chronic, following treatment plans is likely to improve
public health outcomes, including the course of the illness (from psoriasis to psoriatic arthritis, or
from acne to scarring), as well as lower health care costs. Dermatological drug adherence is
particularly difficult because popular dermatology medications come in multiple dosage forms;
also, treatments are multimodal, with a significant fraction including a mix of topical, oral, and
parenteral agents. A significant percentage of recommended drugs are topical, and adherence to
these drugs is very low [9,11]. Forgetfulness, discomfort, and worries about side effects are
common causes of poor topical medicine adherence, which has resulted in early discontinuation
[12].
Treatment duration, treatment efficacy, patient health literacy, treatment regimen complexity,
drug administration routes, and accessibility of care are additional factors influencing medication
adherence in dermatology [13, 14]. Various reminder methods, appropriate medication use, and
educational interventions are strategies for increasing adherence [14].
Drug adherence in illness management is enhanced by patient-specific elements such a
supportive setting, knowledge of appropriate drug administration, and customised medicationtaking practices [15]. Through interprofessional teamwork, a truly interdisciplinary strategy
utilising a variety of health-care resources may improve drug adherence.
Through patient education and other means, chemists, who are among the most approachable
medical professionals, can enhance medication adherence [16]. By analysing prescription
regimens, tracking medication use, assessing efficacy, and creating patient care plans, registered
chemists (RPhs) are legally allowed to coordinate drug therapy management [17]. Pharmacists
also conduct motivational interviews and medication counselling, remind patients to pick up
their prescriptions, arrange refills and assist with prior authorisations (PAs) [18, 19].
Health insurance companies employ PAs, an utilisation management method, to pay for
prescription drugs that need previous doctor’s clearance. Medication therapy management
(MTM) chemists offer patient-centered care based on a personalised evaluation of the patient’s
whole health profile, as opposed to merely distributing prescription drugs. Medication
reconciliation, drug interactions, lab test monitoring, drug utilisation review, and medication
counselling are among the MTM services provided by a chemist [20].
Involving chemists in medical care can save money. Ambulatory care pharmacist-led services
have reduced hospital admissions, avoided ED visits, and saved about $650,000 in medical
expenses annually [21, 22]. By navigating insurance coverage of pharmaceuticals and using
manufacturer’s patient support programs to obtain discounts for medications, they not only
improve medication access but also help patients ensure the affordability of medications.
Patients’ health outcomes increase and medication utilisation is improved when community
chemists and patients have productive interactions [23]. The function of pharmacists in
dermatology has not been evaluated, despite the fact that pharmacist-led interventions have
affected drug adherence in other medical specialities. The purpose of this review was to ascertain
how chemists have enhanced medication adherence in the dermatology sector and to talk about
ways to get more involved.
Research Methods
Using PubMed, a thorough literature search was conducted to find studies assessing the
pharmacist’s function and influence on dermatological product adherence. “Pharmacists’ role in
dermatological medication adherence,” “pharmacist-led interventions in dermatology,”
“pharmacist medication adherence dermatology,” and “pharmacist intervention dermatology”
were among the PubMed search phrases used.
Only publications of randomised clinical trials, observational studies, case reports, case series,
and literature reviews that were released during the previous 15 years were included in the
authors’ search. For a chemist to be included in this review, they must have led or participated in
an intervention with a patient. A measure of a medication adherence-related endpoint, either as a
primary or secondary research endpoint, must have been included in eligible studies. As long as
the chemist’s intervention was for a dermatology-related issue, there were no restrictions on the
kind of intervention that may be used with any patient population.
The study name, study type, sample size, intervention or RPh role, primary endpoint of the study
outcomes, and major study conclusion or conclusions were among the parameters of interest
included (Tables 1 and 2). The kind of chemist intervention and its effectiveness in improving
medication adherence were important outcomes of interest.
Table 1: An overview of a few clinical studies evaluating chemist treatments for topical and/or
oral therapy
Study
Penick et al. 24
Kamei et al. 25
Salamzadeh
et al 26
Hu et al. 27
Hecht et al.28
Study type, sample size
Retrospective chart
review, 21 preintervention patients,
27 post- intervention
patients
Retrospective survey
analysis, 1739 patients
Prospective survey, 200
patients
Quality improvement
project, 431 patients
Retrospective analysis,
677 pharmacy PA
requests
66 office requests
Castaneda
et al.29
Observational prospective
study, 63 children
Ubhi et al 30 Retrospective
observational study,
506 prescriptions
Konuru et al. 31 Prospective observational
study, 148 cases
Nguyen et al. 32
Albright et al. 33
Tucker34
Masago et al. 35
Retrospective cohort
pilot study, Preintervention 880
prescriptions,
Post-intervention 941
prescriptions
Retrospective chart
review, 68 patients
Prospective
questionnaire,
observational study.
870 pharmacists
Prospective questionnaire
observational study,
51 patients
Intervention/RPh role
Embedded PGY2 in
dermatology clinic
Impact of
communication
with pharmacist on
adherence
Validated
questionnaire
(ECOB)
administered to
evaluate adherence
to topical/oral
therapies
Clinical dashboard for
TNF-a inhibitor
therapy
Community-based
specialty pharmacy
PA filling
Development of
extemporaneous
formulation and
counseling to
parents
Antibiotic prescribed.
duration of
treatment,
indication and route
of administration
Assessed reasons
for drug related
problems
Multistep order
transmittal
pharmacy service
Centralized specialty
medication
management
service by clinical
pharmacists
Dermatology related
medication use
reviews (MUR) and
confidence
Multimodal rash
management team
Primary endpoints
Time to initiation
of medications.
adherence, adverse
events, prescription
output
EQ-5D-5L and WPAI
scores, adherence
scores, factors
influencingadherence
Treatment adherence,
possible associated
factors
Safety and adherence
monitoring
Time to first PA decision.
time to PA approval
and time to first
medication fill
Adherence, medication
therapy problems
Proper prescription
indication and
duration across
providers
Reason for drug-related
problems
Re-prescribing rate.
reasons for
re-prescribing
Recruitment/retention
of patients, follow-up
appointments.
interventions
Percent undertaken a
dermatology MUR,
confidence level of
dermatology MURs
Rate of toxicity using
TKIs, QOL scores
Results of interest
Time to initiation: 13.5 days post-intervention vs.
21.3 days pre-intervention (p=0.41)
Adherence: 93.14% post-intervention, 99.21% preintervention (p=0.22)
AEs: 7.4% post-intervention and 15% pre-intervention
Prescription volume: Increased 28.87%
Median EQ-5D-5L and WPAI score was lower in AD
than controls (p<0.005)
Adherence scores: higher with greater Health literacy
and with those satisfied with communication with
provider
Survey: Patients place greater importance on
communication with physicians (74.4%) than
pharmacists (57.5%)
Physicians provide more information to patients
(70.0%) than pharmacists do (57.7%)
Overall adherence: 15%
Factors associated with medication adherence: Food
exacerbations and severity of disease (p=0.03)
Total safety flags: 304
Breakdown of safety flags: 9% overdue lab tests, 27%
overdue refills. 6% ED visits. etc
Mean time to PA decisions: 1.9 days pharmacy vs.
20.9 days dermatology office (p<0.001)
Mean time to PA approval 1.9 days pharmacy vs.
14.7 days for providers (p<0.001)
Mean time to first fill: 6.6 days pharmacy vs. 16.2 days
for providers office (p<0.001)
Mean time from approval to fill: 3.5 days pharmacy vs.
Total medication problems: 49
Type of medication error: 18.4% had inadequate dose,
16.3% were non-adherent to treatment, 14.3% had AEs
Pharmacist interventions: Counseling on adherence
(20%), detection of AEs (11.4%) and adjustment of
dose (22.9%)
Indications and duration of therapy: Documented in
36.8% and 91.9% of prescriptions, respectively
Dermatology prescriptions: 34.3% had an indication
and 100% had duration
Adherence to antibiotic guidelines was 98%
Types of drug-related problems: Nonadherence
(50.9%), AEs (38.4%)
Cause of drug-related problem: Patient related
(47.16%), patient caretaker (17%), with pharmacist
and patient (4.4%)
Skin diseases: 6.3% of ADRs and 6.3% of
non-adherence
Re-prescribing rate: decreased from 12.73% (preintervention) to 9.56% in the post-intervention group
(p=0.03)
Reasons for re-prescribing: Modifying destination
pharmacy decreased from 6.25% to 0.64% (postintervention group) (p<0.01). Re-prescribing due to
errors increased from 0.68% to 1.70% (p=0.05) and
re-prescribing due to patient preferences increased
0.91% to 2.55% (p=0.01)
Enrolled in service: 79.4%, and 95.5% had follow-up
Clinical interventions: 161 total: patient education
(17.4%), technique corrections (7.5%) administrative
assistance (33.5%), medication regimen changes
(6.8%)
MUR experience: 44% of pharmacists conducteda dermatology MUR.
Mean confidence rating: 3.5 (SD 1.0)
Number of patients with high-grade skin toxicities:
Decreased post intervention
Total DLQI QOL scores: Increased post-intervention
Study conclusion(s)
Pharmacist involvement in
dermatology care reduced time to
medication initiation and increased
prescription volume
Higher patient health literacy and
satisfaction with communication
with the PCP may improve
adherence
Medication adherence in acne vulgaris
was low, ECOB questionnaires may
guide adherence
Pharmacist led clinical dashboard
programs should be used in
conjunction with collaborative
practice programs
Pharmacies can improve medication
access by expediting the
prescription filling process
Pharmacist medication counseling
increases adherenceand lowers
AEs
Dermatology prescriptions specified
duration but often lacked
indication
Non-adherence was the drug-related
problem causing the highest rate
of hospitalization
Pharmacist led multistep order
transmittal programs reduced represcribing burden
Centralized medication management
services using pharmacists
contributed to safe and effective
medication use
Pharmacists routinely undertake
dermatology MURs with
confidence
Pharmacists improve drug safety in
rash management teams
Table 2: An overview of a few clinical studies assessing pharmacist interventions for topical
treatment
Research Results
94 distinct studies were found using a PubMed literature search. Eighteen researches were
considered in this analysis after studies that did not address dermatological medications or
conditions assess an aspect of adherence, or feature a direct pharmacist-led intervention were
excluded. Retrospective chart analyses and prospective questionnaire observational studies made
up the majority of the included research. The influence of the chemist on enhancing medication
adherence and important adherence outcomes was measured by the search results (Tables 1 and
2).
Medication adherence was enhanced by a number of pharmacist-led initiatives. Compared to the
pre-intervention group (which lacked a pharmacy resident), pharmacists demonstrated
proficiency in reducing adverse event rates, increasing prescription productivity, and improving
time to commencement of drugs (13.5 vs. 21.3 days) through a pharmacist-resident-led service
[24].
Furthermore, compared to dermatology office-based clinics, the pharmacy was more effective at
handling PA requests and enhancing medication access, reducing the mean time to first fill (6.6
vs. 16.2 days for providers office) and the mean time to PA decisions from 20.9 to 1.9 days
(p<0.001) [28].
Pharmacies were better prepared to deal with insurance PAs for quicker access to
pharmaceuticals, even if there was no difference in the meantime from approval to fill time in
pharmacies by provider office-led PA fillings. Furthermore, pharmacy-led, multistep order
transmittal systems had significantly lower re-prescribing rates (0.64%) than those that did not
(6.25%) as a result of needing to change destination pharmacies (p<0.01) [32].
Additionally, re-prescribing rates were much lower in these transmittal pharmacy services
(9.56% vs. 12.73%, p = 0.03). Initiatives spearheaded by chemists also assisted in identifying
areas where provider prescribing might be improved. For example, 34.3% of antibiotics
prescribed by dermatologists did not include the indication, although 100% did mention the
duration [30].
The impact of medication counselling and better patient education on appropriate drug use,
especially with topical treatments, is another component of proper medication adherence.
Compared to the control groups that did not view the video, patients who watched a pharmacistadministered instruction video on topical drug usage improved their medication use (p < 0.001)
[37].
The effectiveness of counselling for cares of children with atopic dermatitis was evaluated in a
related intervention. When compared to the scores prior to the counselling session, the
knowledge score and confidence level regarding managing their child’s symptoms were
improved (p<0.001) (38). Every week, chemists used computerized scales to weigh the drug
container in order to evaluate treatment adherence for topical medications [36].
Prospective questionnaire-style surveys revealed that chemists had advised patients about the
application site, frequency, and side effects; however, fewer respondents mentioned counselling
regarding the use of supplemental brochures or using small amounts of medications to prevent
side effects for topical therapies [39]. Pharmacists have been able to improve topical medication
education by teaching patients proper medication application skills and offering administrative
support for patient medication access through pharmacist-included medication management
services [33].
Corticophobia may make pharmacist topical therapy drug adherence campaigns more difficult.
Pharmacists reported greater levels of corticophobia than dermatologists (p0.001), and they were
more likely than general practitioners (GPs) to advise patients to consider alternatives to
corticosteroids first (p=0.039) (40,41).
Furthermore, fewer than half of chemists (44%) had performed a medication use review (MUR)
in dermatology and were only moderately confident in their ability to do so [42]. The chemist
was occasionally accountable for a drug-related issue (4.4%), but this was far less frequently
than the patient (47.16%) or carer (17%) [31]. When it comes to drug adherence and treatment
monitoring for systemic pharmacological therapies, chemists may be quite important.
Questionnaires administered by chemists to evaluate topical and oral therapy
Similarly, pharmacist-led clinical dashboard projects include medication safety and adherence
monitoring. These pharmacist-led initiatives assisted in identifying patients who were past due
for laboratory testing (9%) or refills (27% using TNF-et inhibitors) [27].
Tyrosine kinase inhibitor medication-related high-grade skin toxicities were less common when
chemists participated in treatment monitoring programs [35]. Pharmacist-led interventions also
frequently included pharmacist counselling on dose modifications and adherence to topical and
systemic treatments [29].
Despite the fact that pharmacists are easier to reach than doctors, patients valued communication
with doctors more than they did with pharmacists, and they said doctors gave them more
information than pharmacists [25].
By addressing prior authorization requests, managing medication administration, and
guaranteeing medication appropriateness, chemists increase patient access to prescription drugs
[24, 28, 29]. Pharmacists addressed any remaining questions and provided patients with effective
advice regarding pharmaceutical use and side effects [29, 33, 37, 38, 39]. Additionally, they
enhance drug adherence by conducting MURs, identifying patients who are past due for a refill,
and monitoring treatment using surveys [26, 33, 42].
Pharmacists’ preconceptions about certain drugs, such corticosteroids, may affect care even
though they assist in making sure patients receive the appropriate dosage. Pharmacists had
greater rates of corticophobia than other medical professionals, which affect how they counsel
patients about their medications [40, 41]. Pharmacists continue to improve patient clinical
outcomes in spite of these provider biases.
Dermatological conditions are common, and many patients seek pharmacist advice on skin
condition management routinely, with many pharmacists making at least one dermatological
recommendation per day [42]. Not only do pharmacists assist patients in educating them on
taking their medications, but they also recommend over-the-counter (OTC) medications for
common conditions, including acne, tinea, mild eczematous dermatitis, and xerosis [43, 44].
Patients also place a greater importance on communication with physicians than pharmacists,
which may contribute to a lack of communication between the pharmacist and patient [25]. By
taking a more active role in educating patients about their skin disease, pharmacists may close
such pharmacist-patient communication gaps.
Pharmacists’ reluctance to recommend over-the-counter corticosteroids may be influenced by
corticophobia. The high prevalence of corticophobia among chemists may be partly attributed to
a lack of information about the exact safety risk profile of topical corticosteroid treatment.
Pharmacists may be reluctant to offer over-the-counter corticosteroids due to the serious side
effects of high potency and chronic topical corticosteroid use, such as skin infections, folliculitis,
and skin irritation.
Additionally, rather than suggesting a topical over-the-counter corticosteroid, chemists may
direct the patient to a doctor for a more comprehensive evaluation of their health due to these
possible risks and probable overuse of corticosteroids. It is possible to reduce unfavourable
attitudes and worries about topical corticosteroid use by educating providers.
Pharmacists are now better equipped to advise patients and make more sensible
recommendations thanks to initiatives to educate them about the use of topical corticosteroids
[45]. Through patient education, it may be possible to increase patient adherence by reiterating
medication counselling points and drug information and motivating chemists to actively
participate in patients’ skin condition management.
Dermatology does not currently have any advanced certifications, despite the fact that there are
over ten distinct pharmaceutical board subspeciality licenses [46]. This could limit chemists’
access to further training in dermatological-related domains and have an impact on their
understanding of dermatology drugs.
Costs related to adverse drug reactions and adverse drug events are also decreased by the
chemist’s influence on prescription errors, improper prescribing, and adverse event prevention.
Preventable adverse medication responses cost $2000–$2500 per individual and account for
6.5% of admissions, with a median bed stay of 8 days [47, 48]. Medication mistakes are
decreased through prescriber education, pharmacist cooperation, and pharmacist-led medication
reconciliation [49]. Through pharmacist-led training activities, which successfully lower
medication mistake rates, pharmacists also enhance the education of other healthcare
professionals [50, 51].
Improving patient outcomes and communication can be achieved by combining the pharmacistphysician connection. Multifaceted issues like medication adherence and collaboration may be
best addressed by raising awareness of and emphasizing the value of inter-professional
collaboration.
Since many patients find that administering topical medications is more challenging than taking
oral medications, topical therapy medication adherence rates are lower than systemic therapy
[52]. Furthermore, a patient’s topical treatment may be complicated by corticophobia, or anxiety
when using corticosteroids, which may also impair the percentage of topical medication
adherence [53].
Poor drug adherence rates are also caused by other variables, including topical therapy costs,
medication features and side effects (such as skin irritation), application complexity, frequency
and duration, and other factors [54]. By offering counselling programs and seeing cost-cutting
options, chemists can increase topical drug adherence [36, 37, 39, 44]. Future educational
initiatives will assist pharmacists in reducing corticophobia in patients as well, given the high
prevalence of corticophobia among pharmacists.
To measure and standardise drug adherence, more objective criteria are required. Recently,
dermatology patients have begun using the Morisky Medication Adherence Scale-8, which was
created to assess medication adherence for a variety of conditions, such as diabetes and
hypertension [53].
This survey gathers information on demographics, drug type (topical or oral), adherence rates,
adverse events, and hospital visits. According to the adherence scale’s preliminary findings,
adherence to topical and oral medications is correlated with age, the frequency of
hospitalisations, individual experiences with the efficacy of drugs, and general treatment
satisfaction. According to one study, adherence to topical formulations is lower than that of
systemic drugs [53].
Future treatment monitoring and adherence assessments will be more accurate if a standardized
medication adherence assessment method is developed. These measures can be used to monitor
improvements in dermatological treatment rates over time and evaluate the effects of chemist
and other provider-led initiatives. Factors influencing topical adherence may also be evaluated
by other instruments, such as the Patient Preference Questionnaire and the Topical Therapy
Adherence Questionnaire [54]. To determine the efficacy of these instruments and compare
studies of such questionnaire-based metrics, more research evaluating validated adherence
assessment metrics across a range of dermatological illnesses is required.
This study has certain drawbacks. A PubMed search was used to find pharmacist-led
interventions in the treatment of dermatological conditions for this review. Many of the research
found were prospective surveys or retrospective chart reviews with few interventional studies
and no clinical trials, despite the fact that the search yielded helpful information about the role of
the chemist in dermatological patient care.
Some of these interventions—such as clinical dashboards, electronic balances, and pharmacy
residents—have not undergone extensive evaluation and might not be financially viable in all
healthcare facilities.
Furthermore, few studies assessing the role of chemists in lowering healthcare costs in
dermatology-specific domains were found. This reduces the risks associated with the cost-benefit
analysis of adding a specialist to a patient’s regular dermatological care.
Conclusion
Pharmacists are vital, approachable medical professionals who can greatly enhance patients with
dermatological disorders’ adherence to their prescription regimens. They guarantee patient
education, facilitate pharmaceutical availability, and oversee treatment therapy. They
aggressively recommend over-the-counter medications and frequently respond to enquiries from
patients about managing their conditions.
Although chemists are well-equipped to improve dermatological treatment, future educational
initiatives can be implemented to eliminate corticophobia, guarantee proper medication
education, and boost trust in dermatological medication monitoring. Pharmacists’ expertise and
confidence in managing dermatological conditions may be further enhanced by future advanced
certification training in dermatology, such as that offered by the Board of Pharmacy Specialists.
MTM Pharmacist and Teamwork Practice When possible, agreement programs can minimize
pharmaceutical errors and enhance patient dermatological outcomes. Pharmacists can
significantly reduce medication non-adherence and medical expenses associated with patients’
dermatological care.
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DOI: 10.65709/001014