***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: The amount of topical medication  needed to cover the body thinly by self-application was measured in twenty-nine adults . It averaged 22 gm and varied with surface area and size of container , but not with sex or instruction . There was no difference in amount used between cream and ointment or between alcoholic liquid and creamy liquid . Application by a trained attendant required less medication than self-application . Self-application of a fluorescent sunscreen skipped many areas BACKGROUND Adherence is essential to a positive treatment outcome . Whether adequate doses of topically applied drugs are used among patients with dermatologic conditions has not been investigated adequately . OBJECTIVES The objective of this prospect i ve study was to determine to what extent first-time out patients with dermatologic conditions apply the appropriate dosage of initial treatment with topically administered medication . METHODS Consultations with first-time patients in the dermatologic outpatient clinic were observed . Patients receiving a prescription for a previously untried topically administered drug were eligible . The expected quantity of topical treatment  to be used by each patient was calculated from the affected skin area to be treated . The affected area was estimated in numbers of palms of the h and , and an amount of 0.25 g of ointment or cream was chosen as sufficient treatment to cover the area of one palm . Two weeks after the consultation , a question naire with items regarding the size of the affected area , intentions to follow the treatment , and the applied dose the previous day was mailed to each patient . The question naires were personally collected from the patients ' homes and at the same visit the patients ' topical drug containers were weighed on a balance . Both patients and staff were blinded to the particular study purpose concerning adherence and dosing . RESULTS In all , 17 patients were eligible . The majority received a prescription for  topical corticosteroids  , and the median area to be treated was 3 palms of the h and ( interquartile range : 1.5 - 8 ) . Two patients did not redeem their prescriptions . Only one patient used the expected dosage ; in general median 35 % ( interquartile range : 22%-50 % ) of the expected individual dosages were used . LIMITATIONS Only first-time patients who received a new and previously untried topical treatment were included , result ing in a small study size . CONCLUSIONS Most first-time patients with dermatologic conditions underdose new topical treatments . Consequently , clinicians should always consider nonadherence when topical therapies fail Treatment adherence is a vital determinant to achieving successful outcomes for patients using long-term therapy for a chronic disease . Poor adherence to treatment of chronic diseases is a worldwide problem and a key factor impacting the real-life effectiveness of treatment , as defined by a combination of clinical efficacy , adherence and safety . Over the last 50 years there has been a global shift in disease burden from acute to chronic diseases , according to the World Health Organization ( WHO ) . Therefore , as the prevalence of chronic diseases continues to increase , the challenge of poor adherence is likely to rise in magnitude . Adherence is a complex issue that can have a significant impact on quality of life for patients and methods aim ing to improve the patient experience are widely sought . There has been a transition over time from a more traditional ‘ compliance’-focused medical environment to one of ‘ adherence ’ , which actively involves the patient in their care regimen and this change is promoted by WHO as part of a multifaceted approach . In a study investigating the redemption of initial prescriptions of topical and systemic treatments for dermatologic conditions , psoriasis patients appeared to be least adherent with nearly 50 % of prescriptions unfilled . To maximize positive patient outcomes to therapy for psoriasis , it is essential that we underst and the reasons underlying non-adherence . In psoriasis , adherence has been linked with factors including efficacy , safety perceptions , ease of use , and the healthcare professional – patient relationship . For topical products , non-adherence may be further exacerbated by the necessity of application , which can be cumbersome and time consuming ; this is combined with patients ’ poor acceptability of certain treatment vehicles , such as ointments , that tend to be perceived as messy . Psoriasis , although generally not life-threatening , can have a significant impact on physical , psychological and social wellbeing , particularly related to the overt appearance of skin lesions and the psychological burden of stigma . Nonadherence and the challenges that ensue are discussed in greater depth with respect to topical psoriasis treatment in the article entitled , ‘ Non-adherence and measures to improve adherence in the topical treatment of psoriasis ’ , pages 4–9 within this supplement . Current guidelines for the first-line treatment of mild-tomoderate psoriasis recommend the topical use of vitamin D analogues and corticosteroids . The development of a fixeddose combination topical gel containing the vitamin D analogue calcipotriol and the corticosteroid betamethasone dipropionate has provided a user-friendly once-daily therapy option and shows superior efficacy over the individual active components administered as monotherapies and is well tolerated in patients with mild-to-moderate psoriasis .  Safety concerns associated with the single agents are also attenuated as the steroid component of the fixed combination gel lowers the incidence of skin irritation sometimes experienced with use of vitamin D analogues , and calcipotriol potentially reduces steroid-induced skin atrophy . Twelve clinical trials have evaluated the efficacy and safety of calcipotriol plus betamethasone dipropionate gel ( referred to here as a ‘ fixed combination ’ gel ) , for the treatment of psoriasis of the scalp ( seven studies ) and body ( five studies ) , with 3767 patients receiving this treatment in total . All studies demonstrated improved efficacy of the fixed combination gel versus active and vehicle comparators with a favourable safety and tolerability profile . Four international , Phase 3 trials ( two each for scalp and body psoriasis ) assessed short-term ( 8-week ) treatment , and an additional Phase 3 study in scalp psoriasis assessed the safety of long-term ( 52-week ) treatment . Across all clinical trials , increased efficacy over time ( week 8 versus week 4 ) has been demonstrated with the fixed combination gel for treatment of psoriasis of both body and scalp . A recent , pooled analysis of 8-week safety data from 9 of these 12 clinical trials evaluating once-daily fixed combination gel treatment of the scalp ( six studies ) and body ( three studies ) , is presented in an article within this supplement by Kragballe and van de Kerkhof , pages 10–21 . The incidence of adverse events and adverse drug reactions is consistently low in patients treated with the fixed combination gel , providing evidence for the good overall tolerability of this topical treatment for psoriasis . Accompanying pharmacovigilance data supports the favourable tolerability profile demonstrated in the clinical trials for the fixed combination gel and also its use in a real-world setting . The notion of real-life effectiveness of treatment has been described as a product of clinical efficacy , adherence and safety . However , in a real-life setting , less constrained by clinical rigours , there is a paucity of data to shed light on effectiveness . As described in the article on expert recommendations , of which we are co- authors , pages 22–32 , only two prospect i ve , short-term ( 4-week ) , non-interventional studies assessing the effectiveness of the fixed combination gel in daily practice ( both in Germany ) have been published to date . By the end of treatment there was an approximate decrease of 60–70 % in the proportions of patients presenting with at least moderate severity scalp psoriasis , as assessed by the investigator ’s global assessment ( IGA ) OBJECTIVE To assess patient  compliance with psoriasis treatment . DESIGN Open prospect i ve study . Patients with psoriasis were examined and completed a brief medical and social history , a compliance assessment sheet , and the Dermatology Life Quality Index ( DLQI ) . Patients were reexamined at 3 months , and their actual treatment use was assessed and compared with the expected use . Medication adherence was assessed by direct question ing . SETTING Dermatology outpatient clinic . PATIENTS Two hundred ninety-four patients fulfilled the inclusion criteria , and 201 completed the study . MAIN OUTCOME MEASURE Adherence with  topical and oral therapies  , using objective and self-reporting methods and description of factors affecting compliance . RESULTS The overall mean + /- SD medication adherence was 60.6 % + /- 33.0 % ( range , 0%-169 % ) . The mean + /- SD DLQI in the study was 17.4 + /- 8.9 ( range , 0 - 30 ) . There was a highly significant negative correlation ( r = -0.92 ) between these variables . Being female , married , employed , and not paying for prescriptions were characteristics associated with increased medication adherence and a lower DLQI . Medication adherence was greater for topical or combined therapy , for once-daily treatment , and for first-time use of treatment . Adverse effects reduced compliance . The major reasons for missing treatment were drinking alcohol , being fed up , forgetfulness , and being too busy .  Patients with facial disease and with more extensive disease had lower medication adherence . CONCLUSIONS A range of disease-related and social factors may affect compliance with psoriasis treatment . The inversely proportional relationship between DLQI and medication adherence reflects the interaction of physical and psychological factors , as well as perceived treatment failure INTRODUCTION Medication nonadherence is common throughout medicine , and research into this area is increasing ; however , knowledge about topical medication adherence is limited . METHODS A total of 30 patients were enrolled in a clinical trial for psoriasis and followed up for 8 weeks using 3 methods of adherence monitoring : electronic monitoring caps ; medication logs ; and medication usage by weight . RESULTS Adherence rates calculated from the medication logs and medication weights were consistently higher than those of the electronic monitors ( P < .05 ) . Electronically measured adherence rates declined from 84.6 % to 51 % during the 8-week study ( P < .0001 ) . Female sex and increasing age by 1 year predicted improved adherence of 5 % and 0.8 % , respectively ( P < .0001 ) . The number of treatment gaps increased from the first half to the last half of the study , and weekend days were overrepresented in treatment gaps . CONCLUSION Medication logs and weights do not ensure medication adherence to topical therapy . Electronic monitoring allows a more precise method of adherence measurement OBJECTIVE This study examined the relationship between depressive symptoms and related medication adherence and health care costs in older adults ( age > or = 65 years ) with psoriasis . DESIGN Prospect i ve longitudinal cohort study over a 2-year post enrollment period in a population of older adults with psoriasis enrolled in managed care . SETTING A Medicare Health Maintenance Organization ( HMO ) in southeastern United States with prescription benefits . PARTICIPANTS Sixty-three older adults with psoriasis using topical corticosteroids therapy and enrolled in a Medicare HMO for a 2-year continuous period . MEASUREMENT Upon enrollment , each enrollee was mailed a comprehensive health status assessment battery , which included the Center for Epidemiologic Studies Depression ( CES-D ) scale . Information on medication adherence ( using medication possession ratio ) and total health care utilization/costs following enrollment were retrieved from the Medicare HMO data base . RESULTS Nearly one-fifth of the patient population had depressive symptoms .  Patients with psoriasis who had depressive symptoms at the time of enrollment were less likely to be adherent to topical corticosteroid medication  ( r= -0.29 , p<0.01 ) and less likely to utilize health care re sources as evidence d by lower health care costs ( r= -0.27 , p<0.05 ) , after confounder adjustment . CONCLUSIONS The prevalence of depressive symptoms in older adults with psoriasis is commonplace , with strong , yet unexplained correlations between presence of depressive symptoms and lower rates of medication and health care service use among these patients Background Patients are commonly nonadherent to medication regimens . In dermatology , there has been little study of the effect of nonadherence on outcomes Paper diaries are commonly used in health care and clinical research to assess patient experiences . There is concern that patients do not comply with diary protocol s , possibly invalidating the benefit of diary data . Compliance with paper diaries was examined with a paper diary and with an electronic diary that incorporated compliance-enhancing features .  Participants were chronic pain patients and they were assigned to use either a paper diary instrumented to track diary use or an electronic diary that time-stamped entries . Participants were instructed to make three pain entries per day at predetermined times for 21 consecutive days . Primary outcome measures were reported vs actual compliance with paper diaries and actual compliance with paper diaries ( defined by comparing the written times and the electronically-recorded times of diary use ) . Actual compliance was recorded by the electronic diary . Participants su bmi tted diary cards corresponding to 90 % of assigned times ( + /-15 min ) . However , electronic records indicated that actual compliance was only 11 % , indicating a high level of faked compliance . On 32 % of all study days the paper diary binder was not opened , yet reported compliance for these days exceeded 90 % . For the electronic diary , the actual compliance rate was 94 % . In summary , participants with chronic pain enrolled in a study for research were not compliant with paper diaries but were compliant with an electronic diary with enhanced compliance features . The findings call into question the use of paper diaries and suggest that electronic diaries with compliance-enhancing features are a more effective way of collecting diary information B 
    Output:
    
The use of a dosing device could improve its accuracy and be helpful to clearly instruct the patients about the correct dose .