Plaque psoriasis, also known as psoriasis vulgaris, is a chronic inflammatory disease characterized by erythematous scaly plaques of varying severity that form on the surface of the skin.1 The estimated prevalence in Spain is 2.3%; 55.6% of patients have mild plaque psoriasis, 37.6% moderate, and 6.6% severe.2,3

Topical treatment is one of the mainstays of psoriasis management.4 It is generally recommended for mild to moderate psoriasis and can be used as an adjuvant to systemic therapy and/or phototherapy in patients with moderate to severe disease.5 Patient satisfaction with topical treatments, however, is lower than that generally reported for other treatments, and this affects treatment adherence. Alternative topical treatments that meet patients’ needs and ensure proper adherence are needed.6

The reformulation of known active ingredients into a new vehicle is a promising strategy for improving treatment effectiveness and convenience.7 One such example is the fixed combination of the vitamin D analog calcipotriol (Cal) and betamethasone dipropionate (BD) in an aerosol foam.8 Clinical trials have shown that Cal/BD aerosol foam has superior efficacy to Cal and BD used in isolation9 and to Cal/BD in ointment10,11 and gel12 formulations, while offering a similarly favorable safety profile.13,14

Cal/BD in aerosol foam is more effective than Cal/BD in other formulations because the active ingredients are dissolved in volatile propellants that evaporate when the product is applied to the skin. This creates a foam layer containing Cal/BD at a higher concentration than their maximum solubility point (supersaturation), enabling enhanced penetration of the drug through the epidermis.15,16

One way of improving adherence to topical treatments in psoriasis is to improve patient satisfaction. We conducted an observational study, the first of its kind, to assess satisfaction among both patients and physicians with Cal/BD aerosol foam for the treatment of plaque psoriasis on the body in routine practice in Spain.

A Delphi survey organized by the Spanish Psoriasis Group in 2012 determined that the main factors associated with adherence to topical treatments for psoriasis were effectiveness, convenience of use, frequency of application, and vehicle formulation and organoleptic properties.18 All these factors highlight the important link between satisfaction, treatment adherence and health-related quality of life.18 The aim of this study was to determine how satisfied patients and their physicians were with the use of the novel Cal/BD aerosol foam in routine practice in Spain.

The results for the effectiveness domain of the TSQM-9 show that over 80% of patients were satisfied, very satisfied, or extremely satisfied with the ability of Cal/BD aerosol foam to prevent or treat their psoriasis (84%), relieve their symptoms (84.4%), and act fast (82.8%). These positive ratings are consistent with results from previous studies. The advantages of Cal/BD aerosol foam in psoriasis have been demonstrated in several randomized clinical trials that have shown superior results for modified Psoriasis Area and Severity Index scores and treatment success (physician global assessment 0/1).9,12,19 The high satisfaction levels observed for the foam's ability to relieve symptoms is also consistent with findings from other studies that have reported itch relief9,19 and improved overall clinical assessment scores.10 Improvements in itch are closely linked to quality of life, as itching can cause a considerable loss of sleep and productivity.20 The high levels of satisfaction expressed for onset of action are also consistent with previous findings showing that Cal/BD aerosol foam produced significant itch relief by day 3 and a 70% reduction in itch by week 4 in 83.5% of patients.19 The results for the effectiveness domain are also consistent with findings from the PSO-ABLE trial, in which 88.3% of patients perceived Cal/BD aerosol foam as being more effective than previous treatments.12 In brief, the results of our survey on patient satisfaction with Cal/BD aerosol foam support previous findings on satisfaction with treatment effectiveness and are very important considering that effectiveness is the strongest determinant of treatment satisfaction.6,18,21

Perceived convenience is also important as it is closely linked to treatment adherence. According to one study of patient preferences regarding topical vehicles, the most important attributes are a non-greasy or oily texture, ease of application, and a formulation that does not stain.22 Perhaps the high satisfaction levels observed in the convenience domain of our survey are linked to some of these attributes. Our findings regarding convenience and ease of use are consistent with those of an observational study in which 88.6% of patients stated that they found it easy or quite easy to apply the foam.23 In the PSO-ABLE trial, 76.5% of patients also stated that the foam was easy to apply.12 In another study, although similar preference rates were found for Cal/BD gel and aerosol formulations, “immediate feeling of relief” and “felt soothing” were mentioned as benefits of the foam formulation.24

Confidence in Cal/BD aerosol foam was also high in our survey, with a large proportion of patients mentioning that they were very or extremely confident that the treatment would be good for them and that its advantages outweighed its disadvantages. The group as a whole also expressed high levels of global satisfaction. These findings are consistent with the high satisfaction rates observed in the effectiveness and convenience domains and probably indicate increased adherence rates.

In general, our findings related to satisfaction with Cal/BD aerosol foam treatment in routine practice support findings from clinical trials such as PSO-ABLE, which showed that 83.7% of patients preferred Cal/BD aerosol foam to previous topical treatments, as it was perceived as more effective (88.3%) and easier to apply (76.5%) and tolerate (81.0%).12

Good physician-patient communication based on shared decision-making is another important determinant of treatment adherence.25 The goal thus should be to align physician and patient satisfaction. One of the novel aspects of the current study is that we analyzed the opinions of both patients and their physicians. The results from the Likert scale generally show that physicians had similar perceptions to their patients regarding the different attributes of Cal/BD aerosol foam. They were very satisfied with the treatment overall, with the vehicle, and with the product's ability to improve symptoms. These findings coincide with the patients’ scores on the TSQM-9. The most highly rated aspect by physicians was improvement in treatment adherence. As mentioned, this perception is probably linked to the high rates of satisfaction with effectiveness and convenience reported by patients. It is also noteworthy that the physicians also expressed satisfaction with improvements in emotional well-being, as plaque psoriasis is known to have a considerable psychosocial impact.26

The main limitation of this study is that we did not study adherence to treatment or analyze satisfaction levels in relation to duration of Cal/BD treatment or previous treatments.

This study, the first of its kind, has shown that patients were very satisfied with the effectiveness and convenience of Cal/BD aerosol foam compared with previous treatments. These perceptions are consistent with the positive views of physicians in terms of the product's ability to improve symptoms, emotional well-being, and treatment adherence. These favorable perceptions of the different attributes of Cal/BD aerosol foam could lead to improved adherence in clinical practice.

This study was funded by LEO Pharma S.A.

Manel Velasco has been engaged as a speaker or consultant by Abbvie, Janssen, Novartis, Lilly, Pfizer, and LEO Pharma Silvia Pérez-Barrio has been engaged as a speaker or consultant by Abbvie, Janssen, Novartis, Lilly, LEO Pharma, UCB, Pfizer, and Celgene. The other authors declare no conflicts of interest.