Seborrheic dermatitis, along with dandruff, is a common skin condition affecting the scalp and is characterized by redness, itching, and scaling. The mechanisms that might be responsible for seborrheic dermatitis are disruption of skin microbiota, increased number of unsaturated fatty acids on the skin, and shedding of keratinocytes.

The prevalence is estimated at 50–70% of the population. The pathogenesis of seborrheic dermatitis can be due to factors like

1. sebaceous gland function

2. the proliferation of Malassezia furfur yeast (Pityrosporum ovale) on the skin

3. the individual immunological response to the yeast³

Reducing Malassezia counts with anti-fungal agents is effective in providing relief for SD and dandruff. The main treatment options are 1) anti-fungal agents 2) flake-removing agents and 3) anti-inflammatory agents

WHO defined medication adherence as the degree to which a patient adheres to the recommendations from the healthcare provider. Failure to adhere to the recommendations from the healthcare provider leads to medication non-adherence. Medication non-adherence leads to treatment failure, which causes worsening of disease and increased costs, and even if the condition is serious, it might also lead to death. 

Non-adherence is of different types:

1. Primary non-adherence: the provider writes the prescription but the medications are not filled.

2. Non-persistence: the patient decides to stop the medication without the consent of the healthcare provider, which might happen because of a lack of communication.

3. Non-conforming: the patient does not take the medication as prescribed. For example, missing doses or taking them at inappropriate times.

According to a study, John Urguhart described that treatment failure happens because of three reasons: failure of 1) pharmacokinetics 2) pharmacodynamics, and 3) pharmionic. Pharmacokinetic and dynamic are related to drug absorption and action, and pharmionic refers to poor adherence.²

Medication non-compliance is common in most diseases but very predominant in dermatological diseases. Usually, for dermatological diseases, topical preparations are recommended, which might contribute to non-compliance. The topical solutions can be messy to use, might stain, smell unacceptable, and might also cause a burning or itchy sensation.

According to a study, 37 patients with atopic dermatitis were prescribed 0.1% triamcinolone ointment for eight weeks twice daily. The mean adherence from starting to the end of treatment was 32%.² According to another study, adherence to oral and topical therapy for psoriasis was recorded as 61%. Almost 30–40% of patients do not adhere to medications as prescribed.²

It is also important to identify the factors involved in patient non-adherence. After identification, proper strategies should be developed to overcome the barriers. The factors that might affect the patient's adherence to medication are lack of appropriate communication between patient and provider, lack of knowledge on the medication and its use, long-term usage, side effects, complex regimens with varying drug schedules, costs involved, etc. To counter these, the methods employed are simplifying the regimen, ensuring proper communication with the patient, scheduling regular follow-ups to assess the adherence, patient and family education on the treatment plan, and considering prescribing cost-effective treatment.

FRAGRANCE, TEXTURE, AND PACKAGING CORRELATION WITH COMPLIANCE:

FRAGRANCE:

According to an intersectional study that was conducted on patients diagnosed with dandruff and aged between 18-70 years prescribed with 2.5% selenium sulfide shampoo for 4 weeks to be applied every 3 days, the outcomes of the study were

1. Total dandruff reduction in all participants and the shampoo fragrance was acceptable.

2. Absence of itching and reduction in sebum oil

3. Patient satisfaction was reported as good.

4. No adverse events were reported during the study.⁴

So selenium sulfide shampoo was found to be effective in treating dandruff, as there was a 90% reduction in itching and a 63% reduction in flaking after the 1st wash.⁴ The patients were satisfied with the fragrance of the selenium sulfide shampoo as it had an acceptable odor, and they would prefer it for managing dandruff and also recommend others.

TEXTURE: 

According to an article published in PubMed, hair condition plays an important role in compliance for using shampoo consistently for dandruff. In this study, 40 women were enrolled, and all of them were prescribed to use two shampoos, 1% pyrithione zinc, and 2% ketoconazole shampoo, for 1 week. The patients preferred 1% pyrithione zinc over the other one by 75%, as it was better in terms of hair combing ease, hair smoothness, and hair fizz.⁵

According to a study conducted using herbal and zinc pyrithione-based shampoo, zinc pyrithione reduces the proliferation of Malassezia furfur yeast (Pityrosporum ovale).³ Overall, all the ingredients reduced sebum production, acted as anti-inflammatory, and improved SD. 

PACKAGING: 

In a study, patients were enrolled in the medication adherence packaging (RxMAP) service. This service consists of multi-dose blister packaging in 28-day cycles, medication synchronization, monthly touchpoint calls, and delivery/mailing. Out of all the patients, 88% missed fewer doses, 71% were likely to take every day on time, 86% were confident in managing medications, and 64% showed improved quality of life. This concludes that medication adherence packaging (RxMAP) service can improve medication compliance and quality of life.⁶

Patient-centric pharmaceutical drug product design (PCDPD) can be defined as the “process of identifying the needs of the target population and designing pharmaceutical drug products that provide benefit over the intended duration of treatment.” Several packages have been developed to improve medication compliance. They are:

1. Braille inscription for helping in remembering when to take the medication or assist in reading labels

2. Inhalers

3. Applicators for topical treatments to ease the use of hand

4. Multidose dispensing system

5. Calendar packaging

6. Pillboxes

7. Blister and bubble packages

Drummond et al., after reviewing, found that wing top and screw cap openings, push-through blisters, and suppositories with a slide system were preferred. According to a meta-analysis, when packaging interventions like blister packs and pillboxes were employed, medication adherence was reported to be 71%.⁷ Fixed-dose combinations can also improve medication compliance as they reduce the frequency of medications. Novel treatments like 3D printing, which involves the preparation of personalized medicine, can also play a crucial role in medication compliance.

REFERENCES:

1. Jimmy, B., & Jose, J. (2011). Patient medication adherence: measures in daily practice. Oman Medical Journal, 26(3), 155–159. https://doi.org/10.5001/omj.2011.38

2. Valia, R. (2008). Non-compliance in dermatologic diseases. Indian Journal of Dermatology Venereology and Leprology, 74(6), 553. https://doi.org/10.4103/0378-6323.45095

3. Barak-Shinar, D., & Green, L. J. (2018, January 1). Scalp seborrheic dermatitis and dandruff therapy using a herbal and zinc pyrithione-based therapy of shampoo and scalp lotion. PubMed Central (PMC). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5788265/

4. Godse, G., & Godse, K. (2024). Safety, Efficacy and Attributes of 2.5% selenium sulfide shampoo in the treatment of dandruff: a Single-Center Study. Cureus. https://doi.org/10.7759/cureus.57148

5. Draelos, Z. D., Kenneally, D. C., Hodges, L. T., Billhimer, W., Copas, M., & Margraf, C. (2005). A comparison of hair quality and cosmetic acceptance following the use of two Anti-Dandruff shampoos. Journal of Investigative Dermatology Symposium Proceedings, 10(3), 201–204. https://doi.org/10.1111/j.1087-0024.2005.10127.x

6. Phi, C., Berenbrok, L. A., Carroll, J. C., Firm, A., McGivney, M. S., & Coley, K. C. (2021). Impact of a medication adherence Packaging service on Patient-Centered Outcomes at an independent community pharmacy. Pharmacy, 9(1), 11. https://doi.org/10.3390/pharmacy9010011

7. Menditto, E., Orlando, V., De Rosa, G., Minghetti, P., Musazzi, U., Cahir, C., Kurczewska-Michalak, M., Kardas, P., Costa, E., Lobo, J. S., & Almeida, I. (2020). Patient Centric Pharmaceutical Drug Product Design—The Impact on Medication Adherence. Pharmaceutics, 12(1), 44. https://doi.org/10.3390/pharmaceutics12010044

By Dr. Siddiqua Parveen