As clinicians who have been in practice for even a relatively short period of time know, patient compliance is an integral aspect of achieving optimal patient outcomes. However, studies show that patient compliance with treatment of many dermatologic disorders, including acne and psoriasis, is often poor.1,2
In 2007, Feldman showed that patients are more likely to use their products in the days before and the days after their dermatologist visit.3 He suggested that more frequent office visits would boost compliance. I have found that this is true and I recommend seeing patients every 4 weeks when implementing a new treatment regimen. I have also found that combining prescription medications with the proper corresponding skin care products helps decrease side effects and speed results when patients apply the products correctly.
Dr. Leslie S. Baumann
To increase the chance of patients using the products correctly, they should be educated about how and when to use the products. I cannot overemphasize the importance of this, as illustrated by the following story of a patient who came in with facial redness and irritation. Upon questioning, I learned that she was using her facial cleanser but was not washing it off and left it on all day. She said, “No one told me to wash it off!” While washing a cleanser off may seem obvious, cultural, gender, ethnic, and geographical differences can lead to misunderstandings.
The problem with patient education is that it takes time. It is best if education is provided by staff, but keeping them trained and up to date is also difficult. Most dermatologists only have 3-5 minutes per patient so streamlining the process of designing a treatment plan and educating the patient and recruiting your staff to help is crucial. Before I discuss how to streamline the process, let’s first look at our goals for patients.
To achieve good patient outcomes, the patient needs to:
- Understand what medications and products to use.
- Understand when and how to use the products.
- Understand the order in which to use the products (step 1, step 2, etc.).
- Purchase the products (from you or elsewhere).
- Tell you if they do not purchase the products, for whatever reason (insurance will not cover, too expensive, could not find them, etc.).
- Use the products consistently.
- Inform you if they do not use the products (too busy, did not have them on a trip, etc.).
- Report any side effects so you can adjust the therapy accordingly.
You can see why it is so difficult to get patients to be compliant. Many factors – such as time, memory, education level, understanding, motivation, cost, convenience, and insurance coverage – can get in the way of these important components. Giving patients a printed regimen with instructions, selling the products in your practice, and providing some sort of interaction to keep patients engaged is key. In my June 2015 Dermatology News column, I discussed why you should consider selling products in your practice. In the future, I will discuss ways to engage your patients, but for now, let’s focus on how to quickly and effectively provide your patients with printed regimens and patient instructions without increasing office visit times.
Streamlining the Process of Generating a Skin Care Regimen That Includes Prescription Medications
Identify patients’ phenotypes
Divide patients into phenotypes based on skin care needs to save yourself time with the recommendation process.
Many doctors do this with a disease-based approach, such as acne, rosacea, eczema, psoriasis, etc. I prefer to classify my patients according to 16 Baumann Skin Types based on four parameters: hydration status, propensity for inflammation; presence or absence of uneven pigmentation; and presence of lifestyle habits, such as sun exposure, that increase an individual’s risk of skin aging.4,5,6 To quickly diagnose the patient as a particular Baumann Skin Type, I use a tablet-based validated questionnaire called the Baumann Skin Type Indicator (BSTI).7 This questionnaire is self-administered by the patient in the waiting room and serves several purposes that facilitate my practice:
- To collect historical and current data.
- To diagnose skin type.
- To ask specifically about skin allergies.
- To learn preferences such as tinted vs. nontinted, or chemical vs. physical sunscreen.
- To inquire about what issues the patient wants to discuss, such as thinning eyelashes, hair loss, dry body skin, toenail fungus, warts, eczema, and other topics that might not come up during the appointment.
- To learn and document habits that affect the skin, such as tanning bed exposure, sun exposure, and smoking.
- To stimulate the patient to think about how daily actions such as sunscreen use and sun exposure affect their skin health.
Whether you choose to use my questionnaire or one of your own, using a validated method that can be initiated by staff in the waiting room saves time in the exam room.
Include prescription medications in the skin care regimen
Often, we think of skin care regimens and prescription medications as two different entities. In actuality, these should be combined.
For example, when treating acne, every item the patient uses plays a role. For example, if they are washing the face with Ivory soap and then applying benzoyl peroxide and a retinoid they will experience dryness and irritation. Then they will buy a moisturizer that might cause acne. (It is very hard for them to know which moisturizers and sunscreens will not worsen acne). By providing them with the exact names of cleansers, moisturizers, and sunscreens to use, they will be better able to tolerate their prescription acne medications.
The same is true with psoriasis, eczema, seborrheic dermatitis, contact dermatitis, and most of the other ailments that dermatologists treat. You must also tell them the order to use them in. For example, I always have patients apply the retinoid over the noncomedogenic moisturizer for the first few weeks to help them adjust to the retinoid. Later, once they have passed the high-risk period of retinoid dermatitis, I move the retinoid to under the moisturizer.
Psoriasis treatment (topical) is another good example. If they are going to use a surfactant-laden soap on their skin, they will impair their barrier and absorb more of the topically applied drug. Conversely, if they use a barrier repair moisturizer, they will absorb less. Telling the patients exactly which body cleansers and moisturizers to use with topical psoriasis medications will help standardize the response. For this reason, giving patients printed regimens is not limited to treatment of acne, rosacea, and photoaging, but rather should be done for patients with all skin issues and phenotypes.
Have informational material for each phenotype at your fingertips
You can have a plan for each patient phenotype that is designed ahead of time. You will save yourself hours of time if you have preprinted instructions sheets made for each of these phenotypes. You can use Touch MD, The Canfield Visia Camera Patient Portal, your EMR, or other systems to organize this material and deliver it to patients.
I personally use the Skin Type Solutions Software System (STSFranchise.com) that I developed and patented to house and export my patient instructions. Using a standardized methodology to provide educational information through video, preprinted sheets, emails, and other methods allows you to educate your patients at their pace and in the media with which they are most comfortable. To have this flexibility, the educational information must be developed prior to the patient visit. Categorizing the education information by phenotype makes this possible.
What the informational material should contain
Educational information should include important information about the phenotype, the do’s and don’ts for the phenotype, an exact skin care regimen containing clear steps that include product names including brand names, prescription medications, the order in which the products should be applied, and clear instructions on how to use the products.
The patient should be informed about what to do if anticipated adverse events occur, such as redness and peeling from retinoids or dryness from benzoyl peroxide. The same is true about injectable biologic medications for psoriasis. The patients need information on where to inject the product, how often, how to clean the skin beforehand, and what to put on the skin after the injections. It is always important with any skin issue for the patient to know when to contact the office. The American Academy of Dermatology and other organizations offer educational brochures for patients, but they cannot be customized. Patients prefer a customized approach to educational material. They don’t want to read information that does not apply to them. I have found that dividing patients into 16 distinct Baumann Skin Types helps target the right information to the corresponding skin phenotypes.
Summary
Patients need education and guidance to be compliant and improve their outcomes. Your staff needs to be a part of the education process, but taking the time to train your staff and educate your patients is always an issue. Developing a standardized methodology will help overcome these hurdles and solve this problem. The methodology should provide directed education and clear communication with written instructions delivered in the media of the patient’s choice. Doing this will yield better compliance and outcomes.
If you have any questions, suggestions or ideas of how to solve these issues, please share them with me at DrB@skintypesolutions.com.
Dr. Baumann is a private practice dermatologist, researcher, author, and entrepreneur who practices in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote two textbooks: “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002), and “Cosmeceuticals and Cosmetic Ingredients,” (New York: McGraw-Hill, 2014), and a New York Times Best Sellers book for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Evolus, Galderma, and Revance. She is the founder and CEO of Skin Type Solutions Franchise Systems LLC.
References
1. JAMA Dermatol. 2015 Jun;151(6):623-6.
2. J Am Acad Dermatol. 2004 Aug;51(2):212-6.
3. J Am Acad Dermatol. 2007 Jul;57(1):81-3.
4. Dermatol Clin. 2008 Jul;26(3):359-73.
5. Baumann L. Cosmetics and skin care in dermatology. In: Wolff K, ed. Fitzpatrick’s Dermatology in General Medicine, 7th ed. New York, NY: McGraw-Hill; 2008:2357-2364.
6. Baumann L. The Baumann skin typing system. In: Farage MA, Miller KW, Maibach HI, eds. Textbook of Aging Skin. Berling, Germany: Springer-Verlag; 2010:929-944.
7. Journal of Cosmetics, Dermatological Sciences and Applications. 2016;6(1):34-40.