Moisturizers

Daily moisturizer use is standard of care treatment for AD prevention and maintenance therapy [12]. Moisturizers include emollients, humectants, and occlusive agents. Nonadherence may be an issue if these agents misalign with patient preference and cause inconvenience. The most commonly cited reasons for nonadherence to moisturizers are skin discomfort (27%), time-consuming application (22%), and cost (23%) [13]. Although providers prefer creams and ointment moisturizer vehicles due to their effectiveness, their thicker consistency, in contrast to lotions, may impede adherence. Occlusive agents are very greasy, have a strong odor, contain potential allergens, and cause folliculitis when inappropriately used [14]. AD patients prefer a moisturizer based on “consistency,” whether it “absorbs fast,” and is “nice to wear.” [15].

In addition to inconvenient moisturizer application, 23% of AD patients believe that moisturizers play a minimal role in managing eczema [13]. About 75% of AD caregivers believe emollients provide short-term relief but there are barriers for long-term use [16]. Some caregivers believe emollients are “unnatural,” contain “chemicals,” and the skin gets “used to emollients” thus losing effectiveness with regular use [16]. Patient belief is a large barrier to nonadherence. Although most caregivers agree emollients help with active disease, some reported mixed feelings when using emollients during disease remission [16].

Wet-Wrap Therapy

Wet-wrap therapy is indicated for severe or refractory AD [12]. Wet-wrap therapy consists of a wet layer of occlusive bandages followed by dryer outer layer. Wet-wrap therapy increases contact time with topical therapies resulting in increased absorption. Due to its messiness, inconvenience, feasibility, and time-consuming application, it may be a less attractive option for children and caregivers. Other common adherence barriers to wet-wrap therapy include high cost, special training in usage, unpleasant sensation of cold damp wraps, increased risk of cutaneous infection , and poor tolerability [17].

Topical Phosphodiesterase 4 Inhibitors

Crisaborole has been recently FDA-approved for mild-to-moderate AD in patients 2 years and older. Although crisaborole does not have the adverse effect profile of topical corticosteroids, application site pain is a common finding that may impede adherence [19]. Other reasons for nonadherence include high cost and slow onset of action.

Knowledge Gaps and Fears of Adverse Effects

Often, patients may not be fully aware of the benefits of moisturizers and adjunctive therapies such as TCI in managing AD and fear the risks of TCS [22]. In a survey of caregivers with children suffering from dermatological conditions, the most commonly cited concern about medication use was a fear of side effects [23]. Of 208 AD patients, 80.7% reported fear of TCS. There was a positive correlation between the fear of TCS and the belief that topical corticosteroids pass through the skin into the bloodstream (B-coefficient = 0.63, P < 0.001), inconsistent information about the quantity of cream to apply (B-coefficient = 0.34, P < 0.05), and poor treatment adherence (B-coefficient = 0.53, P < 0.05) [24]. Of 77 caregivers, 64% reported that they worry a lot about using topical corticosteroids on their child. Caregivers most frequently worry over skin atrophy [25].

Poor Communication

Poor communication and misalignment with patients’ preferences are common impediments to adherence. Patients may be confused about the different potencies of TCS and how to appropriately apply the medication [26]. In a survey identifying reasons for nonadherence to topical therapies, 18.2% reported unclear instructions as a common barrier to optimal management [27]. With complex treatment regimens, only 24% of AD caregivers feel confident they can manage AD flares and 75% felt that the most important determinant in their child’s quality of life was effectively controlling their AD [6].

Patients may prefer some types of treatments over others in order to minimize inconvenience arising from messy application, strong odor, and time-consuming regimens [22]. Patients may also prefer a particular type of vehicle in regards to topical corticosteroids and moisturizers [9, 28].

Forgetfulness

Forgetfulness is a common cause of unintentional nonadherence, especially in chronic diseases like AD. About 80% of nonadherent subjects attribute poor adherence to forgetfulness [27]. To address forgetfulness, incorporating required medications into an existing daily routine may help. One approach might be to apply the medication every morning after breakfast [29]. Pediatric AD patients may benefit from sticker calendar charts. A sticker is placed on each day of the calendar following appropriate use of the medication providing positive reinforcement and a reminder for the next dose [30].