Original Paper Dermatology 2014;229:136–140 DOI: 10.1159/000362809
Received: October 22, 2013 Accepted after revision: April 10, 2014 Published online: July 8, 2014
Acne Smart Club: An Educational Program for Patients with Acne Gabriella Fabbrocini Rosanna Izzo Marianna Donnarumma Claudio Marasca Giuseppe Monfrecola Section of Dermatology, Department of Clinical Medicine and Surgery, University Federico II, Naples, Italy
Abstract Objective: To evaluate adherence to therapy in acne patients using mobile phones and Short Message Service (SMS) to communicate. Methods: 160 patients were randomly assigned to two groups: the SMS group received 2 text messages twice a day for a period of 12 weeks; the control group did not receive any messages. Before and after 12 weeks, the following evaluations were performed in all patients: digital photographs, the Global Acne Grading System, the Dermatology Life Quality Index, the Cardiff Acne Disability Index, the doctor-patient relationship evaluated through the Patient-Doctor Depth-of-Relationship Scale, and the adherence to treatment evaluated by asking patients how many days a week they had followed the therapy. For statistical analysis we used Student’s t test. Results: The SMS group had a better improvement of all parameters compared to the control group. Conclusion: Adherence and compliance are higher for patients who are included in a strategy of control. © 2014 S. Karger AG, Basel
© 2014 S. Karger AG, Basel 1018–8665/14/2292–0136$39.50/0 E-Mail [email protected] www.karger.com/drm
Introduction
Acne is a common skin disease affecting 70–80% of adolescents; it persists into the 20s and 30s in around 64 and 43% of individuals, respectively, with a considerable psychological and social impact [1, 2]. As acne is a chronic condition and its treatment lasts several years, the patient’s adherence to the therapeutic program represents a key point [3]. Several studies, in fact, suggest that adherence to acne medications is often poor; factors with an impact on adherence included satisfaction with treatment and the experience of side effects [4]. There is no unique validated score to measure adherence worldwide and some strategies can be very helpful to implement it. According to data from the literature, patients with chronic diseases who receive text messages to remind them of their therapy have significantly higher adherence to therapy compared with subjects not opting to receive medication-specific text messages [5]. Since acne affects mostly teenagers who often use mobile phones and Short Message Service (SMS), we evaluated adherence to the therapeutic program of acne patients to whom mobile phone text messages were delivered during the 12 weeks of treatment. Prof. Gabriella Fabbrocini, MD Section of Dermatology, Department of Clinical Medicine and Surgery University Federico II of Naples Via Pansini 5, IT–80131 Naples (Italy) E-Mail gafabbro @ unina.it
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Key Words Acne · Acne Smart Club · Educational program · Mobile phone · Short Message Service · Adherence · Compliance
Table 1. Text messages sent to acne patients
160 patients with mild, moderate or severe acne were enrolled in this randomized, controlled, physician-blinded prospective pilot study at our outpatient specific service for acne in the month of December 2012. The inclusion criteria were the following: (1) age between 14 and 28 years; (2) current systemic and topical treatment; (3) a Global Acne Grading System (GAGS) score of 1–39; (4) having a mobile phone able to receive text messages and the ability to use it; (5) severe psychological discomfort observed using the Cardiff Acne Disability Index (CADI) questionnaire, with a value of >7. Patients were randomly allocated in a 1: 1 ratio to the SMS or control group; randomization was done by a computer-generated random number list to group assignment which was stored electronically. The dermatologists were blinded to SMS or control group assignment until the end of the study. A group of young collaborators, who performed the randomization and had no contact with the enrolled patients, were also responsible for sending the text messages to the patients. Initially, 200 patients were recruited randomly. 20 patients refused to take part in the study, and another 20 patients, for other reasons, were considered not eligible for the study; 6 patients in the SMS group and 9 patients in the control group were lost to follow-up (fig. 1). All patients who participated in our study were matched for similar level of education; all patients of both groups had a mobile phone. Patients were randomly assigned to one of the two groups. In the SMS group, the patients received 2 text messages twice a day for a period of 12 weeks; in the control group, the patients did not receive any messages. All patients gave informed consent before taking part in the study. We used a simple and familiar language in our text messages, considering the frequently asked questions about acne medications (administration, side effects, daily dose) (table 1). The text messages were reminder messages, identical for all patients and not created or chosen for individual patients; the text messages were sent in the same order for all subjects, in a predefined sequence defined by our collaborators: 2 text messages a day, one in the morning and one in the evening, for a sequence of 11 days, after which the messages were sent in the same sequence. Before starting the study and after 12 weeks, the following evaluations were performed in all patients: digital photographs, the GAGS [6], the Dermatology Life Quality Index (DLQI) [7], the CADI [8], the doctor-patient relationship evaluated through the Patient-Doctor Depth-of-Relationship Scale (PDDRS) [9] (a patient self-completed questionnaire designed to measure patient-doctor relational depth), and the adherence to treatment, evaluated by asking patients how many days a week they had followed the therapy. This medication adherence was assessed asking patients to complete a 7-day recall calendar, marking the days during the last week when they had been adherent to the treatment [10]. Finally we asked, through a questionnaire, whether patients were satisfied and whether they considered our SMS service useful (choosing between ‘very much satisfied’, ‘somewhat satisfied’, ‘not much satisfied’ and ‘not at all satisfied’). Pre- and post-treatment scores were compared using Student’s t test.
Morning
Evening
Remember to apply your creams and cleanser
Remember to use your products in the evening
Follow well and daily our therapeutic indications to obtain your goal!
If you have itch, you can apply a lenitive cream
Avoid excessive sun exposure if you are applying retinoid or after peeling
Remove your makeup and cleanse your skin well
Remember to use sunscreen before going out
If you are on isotretinoin regimen, remember to always use contraceptive pill
If you have redness, don’t worry: this is an effect of therapy
In the first days you will see few improvements, but don’t worry and continue therapy!
If the redness is source of anxiety, contact us
Continue your therapy, don’t give up!
Remember to not abuse topical retinoids, you may have excessive dryness
Remember to apply the topical antibiotic only on the pustules
Apply only oil-free makeup to avoid worsening your acne
Remember to inform your dermatologist in case of pregnancy
Before doing esthetic treatment on your face, consult your dermatologist
Avoid sunlamps
If you are on isotretinoin therapy, remember to perform blood analysis monthly (GOT, GPT, total and HDL cholesterol)
Avoid touching and scratching the lesions, you may worsen your acne and more easily create an infection
In case of side effects, consult your dermatologist
If you have excessive dryness of the lips, remember to apply the hydrating products prescribed by your dermatologist
Evaluation of Adherence to Therapy in Acne Patients Using Mobile Phones
Dermatology 2014;229:136–140 DOI: 10.1159/000362809
Results
The baseline characteristics of the SMS group and the control group are reported in table 2. Our study showed that adherence to treatment in the SMS group increased from 4.10 to 6.6 days/week; on the contrary, in the control group, there was no significant increase in this parameter at the end of treatment (from 4.3 to 4.9 days/week) (p < 0.0001) (fig. 2a). The average GAGS score at T0 was 25.3 ± 8.9 for the SMS group and 24.7 ± 7.6 for the control group. After 137
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Patients and Methods
Enrollment
Patients potentially eligible (n = 200) Refused (n = 20) Other reason (n = 20)
Control group
Allocated to intervention (n = 80)
Allocated to intervention (n = 80)
Follow-up
SMS group
Lost to follow-up (n = 6)
Lost to follow-up (n = 9)
Analysis
Allocation
Randomized (n = 160)
Analyzed (n = 74)
Analyzed (n = 71)
8
30 25
6
20
4
10
2
a
Fig. 2. Adherence to treatment evaluated by asking patients how many days a week they had followed the therapy (a), GAGS (b), DLQI (c), CADI (d) and PDDRS (e).
5 T0 T1 Adherence to treatment at T0 and T1
b
10
10
8
8
6
6
4
4
2
2
0
c
T0 T1 DLQI at T0 and T1
12 weeks of treatment the SMS group had a significant improvement, with a reduction in GAGS score (the average GAGS score at T1 was 8.7 ± 3.6), while there was no significant variation in the control group (the average GAGS score at T1 was 16.2 ± 5.6) (p < 0.0001) (fig. 2b). Our results showed that patients’ compliance in the SMS group was higher; this was confirmed by the DLQI and CADI tests, showing a statistical improvement in SMS patients’ quality of life compared to the control group. The DLQI score in patients changed from 9.2 ± 138
0
Dermatology 2014;229:136–140 DOI: 10.1159/000362809
0
d
T0 T1 GAGS at T0 and T1
T0 T1 CADI at T0 and T1
35 30 25 20 15 10 5 0
e
T0 T1 PDDRS at T0 and T1
2.2 at T0 to 5.4 ± 1.8 at T1, while in the control group it moved from 9.5 ± 1.8 at T0 to 8.0 ± 1.4 at T1 (p < 0.0001) (fig. 2c). The CADI score decreased from 8.6 ± 1.3 at T0 to 2.0 ± 0.8 at T1 in the SMS group and from 7.8 ± 1.2 at T0 to 5.1 ± 0.8 at T1 in the control group (p < 0.0001) (fig. 2d). Finally, all these data led to an improvement in PDDRS (including 8 items with a score ranging from 0 to 32) from 15 at T0 to 29 at T1 in the SMS group and from 11 at T0 to 18 at T1 in the control group (fig. 2e). Fabbrocini/Izzo/Donnarumma/Marasca/ Monfrecola
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0
SMS group Control group
15
Color version available online
Fig. 1. CONSORT diagram.
Male Female Mean age, years Education High school University GAGS Mild acne (GAGS 1 – 18) Moderate acne (GAGS 19 – 30) Severe acne (GAGS 31 – 38) DLQI CADI PDDRS Adherence to treatment
SMS group
Control group
35 45 19.5
38 42 18.5
44 36 25.3 ± 8.9 24 36 20 9.2 ± 2.2 8.6 ± 1.3 15 4.1
44 36 24.7 ± 7.6 23 38 19 9.5 ± 1.8 7.8 ± 1.2 12 4.3
From our questionnaire evaluating the satisfaction with the text message service, the data showed that 65% of patients was very much satisfied, 30% was quite satisfied, 4% was not much satisfied and only 1% not at all satisfied.
Discussion
Acne is a disease that can have negative consequences on the patients’ psyche, which can cause depression and loss of self-esteem with important effects on their social life [11–15]. Since acne is a chronic disease, it typically requires prolonged treatment. Clinical experience and recent published data suggest that adherence is the main critical aspect for the therapy’s success [16]; non-adherence to treatment, in fact, is a well-known challenge associated with poor health outcomes and increased utilization of healthcare resources. Miyachi et al. [4] reported that in Japanese acne patients there was an overall rate of poor adherence in 76% of subjects; adherence to topical medication was poor in 52% of patients treated with only one topical product, and among those taking combination therapies, adherence to the topical portion of therapy was poor in 49% of subjects. Feldman et al. [17] observed that frequent outpatient visits seem to improve adherence to therapy. Despite various more or less complex behavioral and educational strategies that have been suggested to improve patient medication adherence, such as cognitive-educational inEvaluation of Adherence to Therapy in Acne Patients Using Mobile Phones
terventions, behavioral-counseling interventions or interventions based on electronically monitored adherence feedback, monitored feedback cell phone text messages can represent a new and innovative modality to improve adherence to therapy [5]. Several studies demonstrated higher compliance to therapy in patients followed up with text messages in several diseases such as chronic cardiovascular disease, pulmonary disease and psoriasis [18– 20], but not in acne. Our study suggests that these findings can be useful also for acne treatment. Our study showed that patients who received text messages had higher adherence to therapy. The GAGS score confirmed that patients in the SMS group had better results. It is well known that acne can affect patients’ quality of life: the DLQI and CADI showed that patients in the SMS group had a better quality of life than controls. It is important to note that the text messages can improve the relationship between the doctor and the patient, and the patients are very much satisfied with this service. Our study showed some limitations, such as the nonvalidated self-reported measurement of treatment adherence and the small sample size. There is no unique validated score to measure adherence, and most studies in dermatology are based on self-reported measures. These simple self-reported measures are commonly used in clinical practice for their advantage of being quick and easy to use. Our study showed some adherence improvement using the SMS strategy. Even if the sample size is not too large, it could be representative of those young individuals who would be most likely to want to integrate text messages into the delivery of their healthcare. The majority of the participants was under the age of 30 and they were recruited following worldwide validated procedures. Our data show that text messages can be a high statistical significance strategy to improve the satisfaction with and adherence to therapy, probably because the study was performed in a population of young people, who more frequently use mobile phones and make large use of text messages. According to our data, this experimental setup based on text message service is inexpensive and easy to use, and it could be a good strategy to encourage young patient to adhere to therapy.
Disclosure Statement The authors have no conflict of interest.
Dermatology 2014;229:136–140 DOI: 10.1159/000362809
139
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Table 2. Baseline characteristics of the SMS and the control group (standard deviation given for GAGS, DLQI and CADI)
References
140
9 Ridd MJ, Lewis G, Peters TJ, Salisbury C: Patient-doctor depth-of-relationship scale: development and validation. Ann Fam Med 2011;9:538–545. 10 Pena-Robichaux V, Kvedar JC, Watson AJ: Text messages as a reminder aid and educational tool in adults and adolescent with atopic dermatitis: a pilot study. Dermatol Res Pract 2010;2010:894258. 11 Motley RJ, Finlay AY: Practical use of a disability index in the routine management of acne. Clin Exp Dermatol 1992;17:1–3. 12 Girman CJ, Hartmaier S, Thiboutot D, Johnson J, Barber B, DeMuro-Mercon C, Waldstreicher J: Evaluating health-related quality of life in patients with facial acne: development of a self-administered questionnaire for clinical trials. Qual Life Res 1996;5:481–490. 13 Gupta M, Johnson AM, Gupta A: The development of an acne quality of life scale: reliability, validity, and relation to subjective acne severity in mild to moderate acne vulgaris. Acta Derm Venereol 1998;78:451–456. 14 Tan J, Fung KY, Khan S: Condensation and validation of a 4-item index of the Acne-QoL. Qual Life Res 2006;15:1203–1210.
Dermatology 2014;229:136–140 DOI: 10.1159/000362809
15 Jankovic S, Vukicevic J, Djordjevic S, Jankovic J, Marinkovic J: Quality of life among schoolchildren with acne: results of a crosssectional study. Indian J Dermatol Venereol Leprol 2012;78:454–458. 16 Tanghetti EA: The noncompliant patient with acne. Skin Therapy Lett 2011;16:4–5. 17 Feldman SR, Camacho FT, Krejci-Manwaring J, Carroll CL, Balkrishnan R: Adherence to topical therapy increases around the time of office visits. J Am Acad Dermatol 2007;57: 81–83. 18 Balato N, Megna M, Di Costanzo L, Balato A, Ayala F: Educational and motivational support service: a pilot study for mobile-phonebased interventions in patients with psoriasis. Br J Dermatol 2013;168:201–205. 19 Chow CK, Redfern J, Thiagalingam A, Jan S, Whittaker R, Hackett M, Graves N, Mooney J, Hillis GS: Design and rationale of the tobacco, exercise and diet messages (TEXT ME) trial of a text message-based intervention for ongoing prevention of cardiovascular disease in people with coronary disease: a randomised controlled trial protocol. BMJ Open 2012; 2: e000606. 20 Petrie KJ, Perry K, Broadbent E, Weinman J: A text message programme designed to modify patients’ illness and treatment beliefs improves self-reported adherence to asthma preventer medication. Br J Health Psychol 2012;17:74–84.
Fabbrocini/Izzo/Donnarumma/Marasca/ Monfrecola
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1 Zaraa I, Belghith I, Ben Alaya N, Trojjet S, Mokni M, Ben Osman A: Severity of acne and its impact on quality of life. Skinmed 2013;11: 148–153. 2 Bhate K, Williams HC: Epidemiology of acne vulgaris. Br J Dermatol 2012;168:474–485. 3 Zaghloul SS, Cunliffe WJ, Goodfield MJ: Objective assessment of compliance with treatments in acne. Br J Dermatol 2005;152:1015– 1021. 4 Miyachi Y, Hayashi N, Furukawa F, Akamatsu H, Matsunaga K, Watanabe S, Kawashima M: Acne management in Japan: study of patient adherence. Dermatology 2011;223:174– 181. 5 Foreman KF, Stockl KM, Le LB, Fisk E, Shah SM, Lew HC, Solow BK, Curtis BS: Impact of a text messaging pilot program on patient medication adherence. Clin Ther 2012; 34: 1084–1091. 6 Doshi A, Zaheer A, Stiller MJ: A comparison of current acne grading systems and proposal of a novel system. Int J Dermatol 1997; 36: 416–418. 7 Finlay AY, Khan GK: Dermatology Life Quality Index (DLQI): a simple practical measure for routine clinical use. Clin Exp Dermatol 1994;19:210–216. 8 Section of Dermatology, School of Medicine, Cardiff University: Cardiff Acne Disability Index (CADI). http://www.dermatology.org. uk/quality/cadi/quality-cadi.html (accessed November 25, 2011).
Received: October 22, 2013 Accepted after revision: April 10, 2014 Published online: July 8, 2014
Acne Smart Club: An Educational Program for Patients with Acne Gabriella Fabbrocini Rosanna Izzo Marianna Donnarumma Claudio Marasca Giuseppe Monfrecola Section of Dermatology, Department of Clinical Medicine and Surgery, University Federico II, Naples, Italy
Abstract Objective: To evaluate adherence to therapy in acne patients using mobile phones and Short Message Service (SMS) to communicate. Methods: 160 patients were randomly assigned to two groups: the SMS group received 2 text messages twice a day for a period of 12 weeks; the control group did not receive any messages. Before and after 12 weeks, the following evaluations were performed in all patients: digital photographs, the Global Acne Grading System, the Dermatology Life Quality Index, the Cardiff Acne Disability Index, the doctor-patient relationship evaluated through the Patient-Doctor Depth-of-Relationship Scale, and the adherence to treatment evaluated by asking patients how many days a week they had followed the therapy. For statistical analysis we used Student’s t test. Results: The SMS group had a better improvement of all parameters compared to the control group. Conclusion: Adherence and compliance are higher for patients who are included in a strategy of control. © 2014 S. Karger AG, Basel
© 2014 S. Karger AG, Basel 1018–8665/14/2292–0136$39.50/0 E-Mail [email protected] www.karger.com/drm
Introduction
Acne is a common skin disease affecting 70–80% of adolescents; it persists into the 20s and 30s in around 64 and 43% of individuals, respectively, with a considerable psychological and social impact [1, 2]. As acne is a chronic condition and its treatment lasts several years, the patient’s adherence to the therapeutic program represents a key point [3]. Several studies, in fact, suggest that adherence to acne medications is often poor; factors with an impact on adherence included satisfaction with treatment and the experience of side effects [4]. There is no unique validated score to measure adherence worldwide and some strategies can be very helpful to implement it. According to data from the literature, patients with chronic diseases who receive text messages to remind them of their therapy have significantly higher adherence to therapy compared with subjects not opting to receive medication-specific text messages [5]. Since acne affects mostly teenagers who often use mobile phones and Short Message Service (SMS), we evaluated adherence to the therapeutic program of acne patients to whom mobile phone text messages were delivered during the 12 weeks of treatment. Prof. Gabriella Fabbrocini, MD Section of Dermatology, Department of Clinical Medicine and Surgery University Federico II of Naples Via Pansini 5, IT–80131 Naples (Italy) E-Mail gafabbro @ unina.it
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Key Words Acne · Acne Smart Club · Educational program · Mobile phone · Short Message Service · Adherence · Compliance
Table 1. Text messages sent to acne patients
160 patients with mild, moderate or severe acne were enrolled in this randomized, controlled, physician-blinded prospective pilot study at our outpatient specific service for acne in the month of December 2012. The inclusion criteria were the following: (1) age between 14 and 28 years; (2) current systemic and topical treatment; (3) a Global Acne Grading System (GAGS) score of 1–39; (4) having a mobile phone able to receive text messages and the ability to use it; (5) severe psychological discomfort observed using the Cardiff Acne Disability Index (CADI) questionnaire, with a value of >7. Patients were randomly allocated in a 1: 1 ratio to the SMS or control group; randomization was done by a computer-generated random number list to group assignment which was stored electronically. The dermatologists were blinded to SMS or control group assignment until the end of the study. A group of young collaborators, who performed the randomization and had no contact with the enrolled patients, were also responsible for sending the text messages to the patients. Initially, 200 patients were recruited randomly. 20 patients refused to take part in the study, and another 20 patients, for other reasons, were considered not eligible for the study; 6 patients in the SMS group and 9 patients in the control group were lost to follow-up (fig. 1). All patients who participated in our study were matched for similar level of education; all patients of both groups had a mobile phone. Patients were randomly assigned to one of the two groups. In the SMS group, the patients received 2 text messages twice a day for a period of 12 weeks; in the control group, the patients did not receive any messages. All patients gave informed consent before taking part in the study. We used a simple and familiar language in our text messages, considering the frequently asked questions about acne medications (administration, side effects, daily dose) (table 1). The text messages were reminder messages, identical for all patients and not created or chosen for individual patients; the text messages were sent in the same order for all subjects, in a predefined sequence defined by our collaborators: 2 text messages a day, one in the morning and one in the evening, for a sequence of 11 days, after which the messages were sent in the same sequence. Before starting the study and after 12 weeks, the following evaluations were performed in all patients: digital photographs, the GAGS [6], the Dermatology Life Quality Index (DLQI) [7], the CADI [8], the doctor-patient relationship evaluated through the Patient-Doctor Depth-of-Relationship Scale (PDDRS) [9] (a patient self-completed questionnaire designed to measure patient-doctor relational depth), and the adherence to treatment, evaluated by asking patients how many days a week they had followed the therapy. This medication adherence was assessed asking patients to complete a 7-day recall calendar, marking the days during the last week when they had been adherent to the treatment [10]. Finally we asked, through a questionnaire, whether patients were satisfied and whether they considered our SMS service useful (choosing between ‘very much satisfied’, ‘somewhat satisfied’, ‘not much satisfied’ and ‘not at all satisfied’). Pre- and post-treatment scores were compared using Student’s t test.
Morning
Evening
Remember to apply your creams and cleanser
Remember to use your products in the evening
Follow well and daily our therapeutic indications to obtain your goal!
If you have itch, you can apply a lenitive cream
Avoid excessive sun exposure if you are applying retinoid or after peeling
Remove your makeup and cleanse your skin well
Remember to use sunscreen before going out
If you are on isotretinoin regimen, remember to always use contraceptive pill
If you have redness, don’t worry: this is an effect of therapy
In the first days you will see few improvements, but don’t worry and continue therapy!
If the redness is source of anxiety, contact us
Continue your therapy, don’t give up!
Remember to not abuse topical retinoids, you may have excessive dryness
Remember to apply the topical antibiotic only on the pustules
Apply only oil-free makeup to avoid worsening your acne
Remember to inform your dermatologist in case of pregnancy
Before doing esthetic treatment on your face, consult your dermatologist
Avoid sunlamps
If you are on isotretinoin therapy, remember to perform blood analysis monthly (GOT, GPT, total and HDL cholesterol)
Avoid touching and scratching the lesions, you may worsen your acne and more easily create an infection
In case of side effects, consult your dermatologist
If you have excessive dryness of the lips, remember to apply the hydrating products prescribed by your dermatologist
Evaluation of Adherence to Therapy in Acne Patients Using Mobile Phones
Dermatology 2014;229:136–140 DOI: 10.1159/000362809
Results
The baseline characteristics of the SMS group and the control group are reported in table 2. Our study showed that adherence to treatment in the SMS group increased from 4.10 to 6.6 days/week; on the contrary, in the control group, there was no significant increase in this parameter at the end of treatment (from 4.3 to 4.9 days/week) (p < 0.0001) (fig. 2a). The average GAGS score at T0 was 25.3 ± 8.9 for the SMS group and 24.7 ± 7.6 for the control group. After 137
Downloaded by: Karolinska Institutet, University Library 130.237.122.245 - 10/23/2017 5:33:26 AM
Patients and Methods
Enrollment
Patients potentially eligible (n = 200) Refused (n = 20) Other reason (n = 20)
Control group
Allocated to intervention (n = 80)
Allocated to intervention (n = 80)
Follow-up
SMS group
Lost to follow-up (n = 6)
Lost to follow-up (n = 9)
Analysis
Allocation
Randomized (n = 160)
Analyzed (n = 74)
Analyzed (n = 71)
8
30 25
6
20
4
10
2
a
Fig. 2. Adherence to treatment evaluated by asking patients how many days a week they had followed the therapy (a), GAGS (b), DLQI (c), CADI (d) and PDDRS (e).
5 T0 T1 Adherence to treatment at T0 and T1
b
10
10
8
8
6
6
4
4
2
2
0
c
T0 T1 DLQI at T0 and T1
12 weeks of treatment the SMS group had a significant improvement, with a reduction in GAGS score (the average GAGS score at T1 was 8.7 ± 3.6), while there was no significant variation in the control group (the average GAGS score at T1 was 16.2 ± 5.6) (p < 0.0001) (fig. 2b). Our results showed that patients’ compliance in the SMS group was higher; this was confirmed by the DLQI and CADI tests, showing a statistical improvement in SMS patients’ quality of life compared to the control group. The DLQI score in patients changed from 9.2 ± 138
0
Dermatology 2014;229:136–140 DOI: 10.1159/000362809
0
d
T0 T1 GAGS at T0 and T1
T0 T1 CADI at T0 and T1
35 30 25 20 15 10 5 0
e
T0 T1 PDDRS at T0 and T1
2.2 at T0 to 5.4 ± 1.8 at T1, while in the control group it moved from 9.5 ± 1.8 at T0 to 8.0 ± 1.4 at T1 (p < 0.0001) (fig. 2c). The CADI score decreased from 8.6 ± 1.3 at T0 to 2.0 ± 0.8 at T1 in the SMS group and from 7.8 ± 1.2 at T0 to 5.1 ± 0.8 at T1 in the control group (p < 0.0001) (fig. 2d). Finally, all these data led to an improvement in PDDRS (including 8 items with a score ranging from 0 to 32) from 15 at T0 to 29 at T1 in the SMS group and from 11 at T0 to 18 at T1 in the control group (fig. 2e). Fabbrocini/Izzo/Donnarumma/Marasca/ Monfrecola
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0
SMS group Control group
15
Color version available online
Fig. 1. CONSORT diagram.
Male Female Mean age, years Education High school University GAGS Mild acne (GAGS 1 – 18) Moderate acne (GAGS 19 – 30) Severe acne (GAGS 31 – 38) DLQI CADI PDDRS Adherence to treatment
SMS group
Control group
35 45 19.5
38 42 18.5
44 36 25.3 ± 8.9 24 36 20 9.2 ± 2.2 8.6 ± 1.3 15 4.1
44 36 24.7 ± 7.6 23 38 19 9.5 ± 1.8 7.8 ± 1.2 12 4.3
From our questionnaire evaluating the satisfaction with the text message service, the data showed that 65% of patients was very much satisfied, 30% was quite satisfied, 4% was not much satisfied and only 1% not at all satisfied.
Discussion
Acne is a disease that can have negative consequences on the patients’ psyche, which can cause depression and loss of self-esteem with important effects on their social life [11–15]. Since acne is a chronic disease, it typically requires prolonged treatment. Clinical experience and recent published data suggest that adherence is the main critical aspect for the therapy’s success [16]; non-adherence to treatment, in fact, is a well-known challenge associated with poor health outcomes and increased utilization of healthcare resources. Miyachi et al. [4] reported that in Japanese acne patients there was an overall rate of poor adherence in 76% of subjects; adherence to topical medication was poor in 52% of patients treated with only one topical product, and among those taking combination therapies, adherence to the topical portion of therapy was poor in 49% of subjects. Feldman et al. [17] observed that frequent outpatient visits seem to improve adherence to therapy. Despite various more or less complex behavioral and educational strategies that have been suggested to improve patient medication adherence, such as cognitive-educational inEvaluation of Adherence to Therapy in Acne Patients Using Mobile Phones
terventions, behavioral-counseling interventions or interventions based on electronically monitored adherence feedback, monitored feedback cell phone text messages can represent a new and innovative modality to improve adherence to therapy [5]. Several studies demonstrated higher compliance to therapy in patients followed up with text messages in several diseases such as chronic cardiovascular disease, pulmonary disease and psoriasis [18– 20], but not in acne. Our study suggests that these findings can be useful also for acne treatment. Our study showed that patients who received text messages had higher adherence to therapy. The GAGS score confirmed that patients in the SMS group had better results. It is well known that acne can affect patients’ quality of life: the DLQI and CADI showed that patients in the SMS group had a better quality of life than controls. It is important to note that the text messages can improve the relationship between the doctor and the patient, and the patients are very much satisfied with this service. Our study showed some limitations, such as the nonvalidated self-reported measurement of treatment adherence and the small sample size. There is no unique validated score to measure adherence, and most studies in dermatology are based on self-reported measures. These simple self-reported measures are commonly used in clinical practice for their advantage of being quick and easy to use. Our study showed some adherence improvement using the SMS strategy. Even if the sample size is not too large, it could be representative of those young individuals who would be most likely to want to integrate text messages into the delivery of their healthcare. The majority of the participants was under the age of 30 and they were recruited following worldwide validated procedures. Our data show that text messages can be a high statistical significance strategy to improve the satisfaction with and adherence to therapy, probably because the study was performed in a population of young people, who more frequently use mobile phones and make large use of text messages. According to our data, this experimental setup based on text message service is inexpensive and easy to use, and it could be a good strategy to encourage young patient to adhere to therapy.
Disclosure Statement The authors have no conflict of interest.
Dermatology 2014;229:136–140 DOI: 10.1159/000362809
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Table 2. Baseline characteristics of the SMS and the control group (standard deviation given for GAGS, DLQI and CADI)
References
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9 Ridd MJ, Lewis G, Peters TJ, Salisbury C: Patient-doctor depth-of-relationship scale: development and validation. Ann Fam Med 2011;9:538–545. 10 Pena-Robichaux V, Kvedar JC, Watson AJ: Text messages as a reminder aid and educational tool in adults and adolescent with atopic dermatitis: a pilot study. Dermatol Res Pract 2010;2010:894258. 11 Motley RJ, Finlay AY: Practical use of a disability index in the routine management of acne. Clin Exp Dermatol 1992;17:1–3. 12 Girman CJ, Hartmaier S, Thiboutot D, Johnson J, Barber B, DeMuro-Mercon C, Waldstreicher J: Evaluating health-related quality of life in patients with facial acne: development of a self-administered questionnaire for clinical trials. Qual Life Res 1996;5:481–490. 13 Gupta M, Johnson AM, Gupta A: The development of an acne quality of life scale: reliability, validity, and relation to subjective acne severity in mild to moderate acne vulgaris. Acta Derm Venereol 1998;78:451–456. 14 Tan J, Fung KY, Khan S: Condensation and validation of a 4-item index of the Acne-QoL. Qual Life Res 2006;15:1203–1210.
Dermatology 2014;229:136–140 DOI: 10.1159/000362809
15 Jankovic S, Vukicevic J, Djordjevic S, Jankovic J, Marinkovic J: Quality of life among schoolchildren with acne: results of a crosssectional study. Indian J Dermatol Venereol Leprol 2012;78:454–458. 16 Tanghetti EA: The noncompliant patient with acne. Skin Therapy Lett 2011;16:4–5. 17 Feldman SR, Camacho FT, Krejci-Manwaring J, Carroll CL, Balkrishnan R: Adherence to topical therapy increases around the time of office visits. J Am Acad Dermatol 2007;57: 81–83. 18 Balato N, Megna M, Di Costanzo L, Balato A, Ayala F: Educational and motivational support service: a pilot study for mobile-phonebased interventions in patients with psoriasis. Br J Dermatol 2013;168:201–205. 19 Chow CK, Redfern J, Thiagalingam A, Jan S, Whittaker R, Hackett M, Graves N, Mooney J, Hillis GS: Design and rationale of the tobacco, exercise and diet messages (TEXT ME) trial of a text message-based intervention for ongoing prevention of cardiovascular disease in people with coronary disease: a randomised controlled trial protocol. BMJ Open 2012; 2: e000606. 20 Petrie KJ, Perry K, Broadbent E, Weinman J: A text message programme designed to modify patients’ illness and treatment beliefs improves self-reported adherence to asthma preventer medication. Br J Health Psychol 2012;17:74–84.
Fabbrocini/Izzo/Donnarumma/Marasca/ Monfrecola
Downloaded by: Karolinska Institutet, University Library 130.237.122.245 - 10/23/2017 5:33:26 AM
1 Zaraa I, Belghith I, Ben Alaya N, Trojjet S, Mokni M, Ben Osman A: Severity of acne and its impact on quality of life. Skinmed 2013;11: 148–153. 2 Bhate K, Williams HC: Epidemiology of acne vulgaris. Br J Dermatol 2012;168:474–485. 3 Zaghloul SS, Cunliffe WJ, Goodfield MJ: Objective assessment of compliance with treatments in acne. Br J Dermatol 2005;152:1015– 1021. 4 Miyachi Y, Hayashi N, Furukawa F, Akamatsu H, Matsunaga K, Watanabe S, Kawashima M: Acne management in Japan: study of patient adherence. Dermatology 2011;223:174– 181. 5 Foreman KF, Stockl KM, Le LB, Fisk E, Shah SM, Lew HC, Solow BK, Curtis BS: Impact of a text messaging pilot program on patient medication adherence. Clin Ther 2012; 34: 1084–1091. 6 Doshi A, Zaheer A, Stiller MJ: A comparison of current acne grading systems and proposal of a novel system. Int J Dermatol 1997; 36: 416–418. 7 Finlay AY, Khan GK: Dermatology Life Quality Index (DLQI): a simple practical measure for routine clinical use. Clin Exp Dermatol 1994;19:210–216. 8 Section of Dermatology, School of Medicine, Cardiff University: Cardiff Acne Disability Index (CADI). http://www.dermatology.org. uk/quality/cadi/quality-cadi.html (accessed November 25, 2011).
