Patient Noncompliance

We strive for error-free medicine in a world that is sometimes all too human.Michael Burgess (1950–)

Even with a correct diagnosis of a hair condition and appropriate treatment for that specific condition, a proportion of patients do not get better. Urquhart proposed three categories of nonresponse to treatment: (1) pharmacodynamic (nonresponse), (2) pharmacokinetic (nonabsorption), and (3) pharmionic (noncompliance).

Pharmacodynamics involves problems due to deficient receptors or when the condition is too severe for the agent to work. Examples are the use of oral finasteride in some women or in men with advanced androgenetic alopecia.

Pharmacokinetic reasons include problems with drug absorption or with rates of drug metabolism, resulting in insufficient concentrations of the active drug. Examples are the use of oral methotrexate where bioavailability is unreliable or of topical minoxidil in patients with low sulfotransferase activity.

Finally, pharmionic refers to poor adherence to treatment. When it comes to topical treatments, poor adherence is the most likely reason for nonresponse. Quantitative studies of topical treatment have begun to reveal patients’ less than ideal adherence behavior.

Therefore, when we see nonresponse, we should consider the possibility of an adherence problem. Managing patient compliance may be just as important as making the correct diagnosis and prescribing the appropriate treatment.

Treatment success relies on patient compliance that, on its part, relies on confidence and motivation. Noncompliance is a major obstacle to the delivery of effective hair loss treatment. More often than being a failure of the patient, patient noncompliance results from failure of the physician to ensure that essential confidence and motivation for successful treatment.

Patient compliance describes the degree to which a patient correctly follows medical advice and instruction. It most commonly refers to drug prescriptions, but it can also apply to the use of medical devices, self-care, or therapeutic sessions. Patient perception of the balance between the necessity for treatment and concerns over its use is a powerful predictor of adherence with treatment. This perception of the risk–benefit ratio of treatment explains why compliance with therapy for long-term conditions can be particularly poor. Since both the patient and the healthcare provider affect compliance, a positive physician–patient relationship and regular follow-up visits are the most important factor in determining the degree of patient compliance. The major barriers to compliance are listed in Table 7.1.

Table 7.1

Major barriers to patient compliance

Denial of the problem

Lack of comprehension of treatment benefits

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