Physician-patient communication and patient-reported outcomes in the actinic keratosis treatment adherence initiative (AK-TRAIN): a multicenter, prospective, real-life study of treatment satisfaction, quality of life and adherence to topical field-directed therapy for the treatment of actinic keratosis in Italy

J Eur Acad Dermatol Venereol. 2019 Jan;33(1):93-107. doi: 10.1111/jdv.15142. Epub 2018 Jul 8.


Background: Patients with multiple actinic keratoses (AKs) should be treated with field-directed therapy. Such treatments challenge patients' adherence due to out-of-pocket costs, length of treatment and severity of local skin reactions (LSRs). Effective physician-patient communication (PPC) may buffer therapy-related distress, thus improving quality of life, treatment satisfaction and adherence.

Objectives: We evaluated the interplay between PPC, LSR intensity (safety) and lesion clearance rates (effectiveness) on treatment satisfaction, quality of life and treatment adherence among patients with multiple AKs receiving topical field-directed therapies.

Methods: In this observational, multicentre, longitudinal, cohort study, we included 1136 adult patients with discrete, clinically detectable, visible, multiple (three or more lesions in a 25 cm2 area), Grade I/II AKs, for whom the attending dermatologist has prescribed treatment with a topical field-directed therapy. We matched self-reported data and medical information recorded by dermatologists in standard clinical forms. Patients were followed up at two time points (T1: 8 days; T2: 25-30 days) RESULTS: Most patients were elderly, married, men with poor socio-economic status and multiple lesions of the scalp or face. The majority (n = 961) had a prescription of ingenol mebutate (IMB) and 175 received either diclofenac 3% in hyaluronic acid (DHA) or imiquimod 5% (IMQ). Clearance rate at 1 month was 84%. Most patients felt very supported (n = 819, 73%) and rated dermatologist's explanations very clear (n = 608, 54%). Treatment satisfaction (effectiveness and convenience scales) increased along the follow-up, especially for those on IMB (Δpre-post = -4.00; other: Δpre-post = -0.25; interaction P < 0.001). Communication clarity was associated with higher treatment satisfaction scores (β = 0.4-0.6, P < 0.01) and lower risk of non-adherence among IMB patients (risk difference: 16%, P < 0.01).

Conclusion: Communication clarity was associated with patient-reported outcomes and adherence beyond AK-related clinical parameters. Our study questions the current episodic approach to AK management and provides the rationale to develop chronic care models fostering patients' engagement and treatment alliance.

Publication types

  • Multicenter Study
  • Observational Study

MeSH terms

  • Administration, Cutaneous
  • Aged
  • Aged, 80 and over
  • Anti-Inflammatory Agents, Non-Steroidal / therapeutic use
  • Antineoplastic Agents / therapeutic use
  • Communication*
  • Diclofenac / therapeutic use
  • Diterpenes / therapeutic use
  • Drug Eruptions / etiology
  • Female
  • Humans
  • Imiquimod / therapeutic use
  • Italy
  • Keratosis, Actinic / drug therapy*
  • Longitudinal Studies
  • Male
  • Medication Adherence*
  • Middle Aged
  • Patient Reported Outcome Measures
  • Patient Satisfaction*
  • Physician-Patient Relations*
  • Prospective Studies
  • Quality of Life


  • 3-ingenyl angelate
  • Anti-Inflammatory Agents, Non-Steroidal
  • Antineoplastic Agents
  • Diterpenes
  • Diclofenac
  • Imiquimod