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Original Research (Original Article) 


Ibrahim Al-Omair et al, 2019;3(7):570–576.

International Journal of Medicine in Developing Countries.

Topical corticosteroid phobia among patients with dermatological diseases

Ibrahim Al-Omair1, Leena Emad Alghamdi2, Deema Abdulwahab AlSadoun2, Saad Altalhab3*, Abdulrahman Abdullah Al-Omair4, Sara Mohamed Alkassimi5

Correspondence to: Saad Altalhab

*Assistant Professor and Consultant in Dermatology, Dermatologist, Department of Dermatology, College of Medicine, Al-Imam Mohammad Ibn Saud Islamic University, Riyadh, Saudi Arabia.

Email: saadaltalhab [at] gmail.com

Full list of author information is available at the end of the article.

Received: 10 January 2019 | Accepted: 20 March 2019


ABSTRACT

Background:

Topical corticosteroids (TCS) are widely prescribed for the treatment of dermatological diseases. Patients concerns and fear regarding the TCS are found to interfere with their compliance toward the treatment, resulting in relapses and poor outcome. The present study aimed to assess the patients’ origin and prevalence of TCS phobia, their knowledge about corticosteroids and their compliance toward the treatment.


Methodology:

A cross-sectional study was conducted in Light and Derma Clinic in Riyadh, Saudi Arabia during the period between 2018 and 2019. Patients with eczema, psoriasis, alopecia areata, and vitiligo were asked to respond to a self-administered questionnaire. The questionnaire included socio-demographic data, data regarding the prevalence of TCS phobia, beliefs and behaviors, and sources of information concerning the safety and risks of TCS.


Results:

Two hundred and three patients were included in this study. A fear from TCS was expressed by 80.8% of respondents with varying degrees. Multiple regression analysis showed that having eczema or vitiligo was significantly associated with a higher degree of fear. Most TCS-related concerns of the patients were about their safety.


Conclusion:

TCS phobia was found widespread among patients with dermatological diseases. Most fears were related to safety issues. These fears were found to affect patient’s behaviors, and hence their compliance toward the treatment. Providing public awareness and health education programs addressing the adverse effects of TCS and steps to avoid or decrease their usage could play a pivotal role in reducing TCS phobia. The study recommends the dermatologists to dedicate adequate time to provide health education to their patients.


Keywords:

Topical corticosteroids, atopic dermatitis, alopecia areata, psoriasis, vitiligo.


Introduction

Topical corticosteroids (TCS) are widely used in the treatment of various dermatological problems [1]. Both dermatologists and primary care physicians prescribe them in many skin disorders [2]. They are available in different formulations with different potencies. Mild formulations are usually used for children and for the application at the sensitive areas. Although topical preparations are used for therapeutic purposes in many skin diseases, they are contraindicated in some other diseases and might cause side effects if used inappropriately. The side effects include atrophy, striae, telangiectasia, hypo-pigmentation, acne, rosacea, perioral dermatitis, and hypertrichosis, as well as systemic side effects, including cataract, hyperglycemia, and hypothalamic–pituitary–adrenal suppression [3]. When TCS were first introduced, they lacked basic prescription criteria. This led to TCS abuse, causing several adverse effects that possibly resulted in the current steroid phobia [4]. After the tremendous advancement of mass media in the 1990s, the information related to adverse effects associated with TCS overuse became readily available, further fueling the unwarranted fear of TCS. A major part of the population became reluctant to use TCS because of a vague steroid phobia, which further resulted in disease exacerbation [5]. Identifying the exact aspects and causes for the fear created among people TCS usage could help in designing effective health education programs that could address appropriate communities and decrease the TCS phobia. This study aimed to assess the patients’ origin and prevalence of TCS phobia, their knowledge about corticosteroids and their compliance toward the treatment. The present study also aims at patient’s safety which could be achieved by guiding the public regarding the appropriate use of TCS.


Subjects and Methods

A cross-sectional study was conducted in Light and Derma Clinic (Riyadh city, Saudi Arabia) between September 2018 and January 2019. Participants of this study were patients with dermatological diseases, including eczema, psoriasis, alopecia areata, and Vitiligo (both males and females, 15-year-old and above) who visited Light and Derma Clinic. A total of 203 patients were included in the study. Data were collected during regular work time using a self-administered questionnaire. Patients were briefed about the study objectives and instructions regarding how to fill the questionnaire appropriately by the investigators. The questionnaire included socio-demographic data relevant to the topic, data regarding the prevalence of topical corticosteroid phobia, beliefs, and representations about TCS, patient behaviors concerning treatment, and sources of information concerning the safety and risks of TCS. Statistical analysis was conducted using Statistical Package for the Social Sciences software for Windows, version 22. Descriptive statistics were performed as mean and standard deviation for the numerical variables and as number and percent for the categorical variables. The statistical analysis summarized the characteristics and responses of the studied sample. For the univariate analysis, relationships between TCS phobia, as assessed with the visual analog scale (VAS), and the numerical variables were evaluated using Spearman's correlation coefficient, whereas its relationship with categorical variables was assessed using Pearson's Chi-square test, Fisher exact test, or Fisher–Freeman–Halton exact test as appropriate. Multivariate analysis, in the form of multiple linear regression, was carried out to identify factors contributing significantly to TCS fear. A p-value of less than 0.05 was considered statistically significant. Informed consent was obtained from each patient. Patients were informed that participation in the study is voluntary and that the data collected were anonymous, confidential, and restricted for this study only. Additionally, withdrawal from the study was guaranteed at any time.


Results

In this study, 203 patients responded to the questionnaire. Table 1 summarizes the sociodemographic data of the respondents. About half the respondents were 15- to 25-year old and about one third were 26-35-year old. Women outnumbered men (62.6% and 37.4%, respectively). Most respondents had a university education (64.2%). Unemployed patients and students accounted for 28.1% and 35.5%, while subjects with professional jobs (doctors, engineers, and teachers) accounted for 24.1% of respondents. Most patients suffered from atopic dermatitis (65.5%), followed by vitiligo (13.3%), psoriasis (11.3%), and alopecia areata (9.9%). Respondents who admitted feeling no fears constituted 19.2%, while those with little, moderate, a lot of and very much fears constituted 24.6%, 28.6%, 12.8%, and 14.8%, respectively (Figure 1). About one-third of respondents stated they feel “cautious,” while those expressing extreme feelings (confidence or increased anxiety) constituted a small percentage (Figure 2). Multiple linear regression was conducted to evaluate the contribution of patient characteristics to the degree of fear from RCS. Age, gender, and education were not associated significantly with the degree of fear. All dermatological diseases were associated significantly with a higher degree of fear (p < 0.001) (Table 2). The multiple regression analysis revealed that some questionnaire items were significantly associated with fear of TCS treatment, including: TCS effective for a short time (p < 0.001) or a long time (p = 0.029), believing that TCS treatment calms symptoms but do not treat the cause (p = 0.029); believing that TCS can affect future health (p = 0.001), even fear regardless of their side effects (p = 0.003), fear of applying too much cream (p = 0.006), using the cream for too long (p = 0.033), and putting the cream on certain zones (p = 0.010). Moreover, TCS fear was inversely associated with believing that TCS helps to improve the quality of life (p = 0.007). Fear of TCS was associated with more factors concerning safety (Tables 3 and 4). Regarding the safety, efficacy, and compliance components of the questionnaire, it was correlated positively and significantly with the degree of fear of TCS, while the quality of life was correlated negatively and significantly with the degree of fear. The degree of correlation was moderate for safety (r = 0.615), efficacy (r = 0.437), and quality (r = 0.313), while the correlation was weak for compliance (r = 0.237) (Table 5). Finally, knowledge about TCS was derived from personal experience among 35.5% of respondents, from doctors among 25.1% and from the internet sites among 25.1%. Other less common sources included family and friends (7.9%), medical books (4.9%), newspapers (1.0%), and TV (0.5%) (Figure 3).

Table 1. Sociodemographic data of the studied patients (n = 203)

n %
Age groups 15–25 102 50.2
26–35 61 30.0
36–45 21 10.3
46–55 14 6.9
56 or above 5 2.5
Gender Female 127 62.6
Male 76 37.4
Educational level Secondary school 59 29.1
University 125 61.6
Post graduate 19 9.4
Occupation Private 18 8.9
Student 72 35.5
Professional 49 24.1
Military 7 3.4
Unemployed 57 28.1
Do you suffer from one of the following skin diseases? Atopic dermatitis 133 65.5
Vitiligo 27 13.3
Alopecia areata 20 9.9
Psoriasis 23 11.3

Figure 1. Fear of TCS on the VAS scale (n = 203).

Figure 2. Feelings of the studied patients toward TCS (n = 203).

Table 2. Multiple regression analysis for variables associated with increased fear from TCS (n = 203).

B (95% CI) p
Age 0.060 (−0.100 to 0.220) 0.461
Female gender −0.235 (−0.613 to 0.143) 0.222
High education −0.349 (−0.747 to 0.049) 0.086
Eczema 3.137 (2.482–3.792) <0.001*
Vitiligo 3.125 (2.268–3.982) <0.001*
Psoriasis 3.679 (2.824–4.534) <0.001*
Alopecia 3.699 (2.783–4.615) <0.001*

B: regression coefficient; CI: confidence interval;

*Significant at p < 0.05.


Discussion

In the present study, we investigated the prevalence of corticophobia among patients treated with TCS for four common dermatological diseases (atopic dermatitis, vitiligo, psoriasis, and alopecia areata). To the best of our knowledge, this is the first study of its type to be conducted on the Saudi population. Secondary objectives of the present study were to determine the knowledge about TCS among patients of dermatological diseases and to analyze the effect of TCS phobia on patients' compliance with the treatment. The study found that the fear of TCS was common among the studied population, with only about one-fifth of them admitting the absence of TCS fear. The remaining patients expressed variable levels of fear, with 27.6% describing it as “a lot” or “very much.” This attitude was reflected also in their feelings toward TCS use, as more than half the respondents were cautious or anxious. Similarly, high rates of TCS fears have been reported by Charman et al. [6] as 72.5% of their study sample worried about using TCS on their own or their child’s skin. In the current study, we evaluated the potential factors that contribute to TCS fear. Our results revealed that the fear of TCS was significantly associated with issues related to safety rather than efficacy or the quality of life. These findings are concordant with previous studies which stated that the predominant concerns about TCS were cutaneous side-effects (as skin thinning and worsening of skin disease) and failure to thrive [69]. The present study also showed that fear of TCS was significantly associated with behavioral factors such as the fear of applying too much cream, with using it for a too long time or with applying it to certain zones. Such fears are anticipated to interfere with the proper application of TCS. Thus, reduced compliance may cause prolonged and frequent relapses, which further decreases the trust in the treatment, and hence compliance is further decreased, and so a vicious circle develops [1013]. The magnitude of the problem was realized when we considered that the TCS-related non-adherence has been reported in 36%–58% of patients prescribed TCS [7,14]. The fear related to TCS and the resultant vicious circle could be reduced by effective assurance and health education provided by the doctor to the patients. Several studies have emphasized the important role of the patient-doctor relationship in dealing with corticophobia [68,15,16], which is supported by our finding that the need of reassurance about TCS was desired “always” by about half the respondents and “often” by 20.2%. As TCS fear was associated mainly with treatment safety, treating doctors should identify the patients’ fear of TCS and address any misconceptions by providing patients with clear, evidence-based explanations, in order to improve the patients’ trust and compliance. Increased level of fear was significantly associated with all dermatological diseases investigated in this study. There was no significant association between the degree of fear and age, gender, or education. Similarly, El Hachem et al. [9] have reported a lack of association between patients’ characteristics and TCS fear. On the other hand, previous studies have demonstrated that the female gender was associated with TCS fear in dermatological diseases and similar results were reported when the caregiver was female. Kojima et al. [17] looked for TCS in caregivers of children with atopic dermatitis in Japan and were the first to notice that the patient being female was associated with TCS fear. Raffin et al. [18] evaluated TCS among French pharmacists and determined that male pharmacists were more confident about TCS. Muller et al. [19] reported the same findings after investigating TCS regardless of the underlying dermatological disease in children and adults. Gonzales et al. [20] noticed that being a parent of a girl was associated with higher TCS. This controversy between the results of the studies may be attributed to variations in the studied patient's age and dermatological illness, as well as cultural differences. The present study results showed that the most common sources of respondents' knowledge about TCS were personal experience, doctors, and internet web sites. These sources may have contributed to the increased prevalence of TCS-related fears. A recent study [21] have observed that high rates of messages about TCS “risk” from family/friends and the internet may affect patient/parent understanding about TCS safety and consequently may cause treatment non-adherence. Parents often cite that they have been warned of the dangers of TCS, not only by friends, relatives, and the media but also by traditionally trusted sources including their doctors and pharmacist [16]. This helps to create a negative cultural environment for parents of children and for adults with chronic dermatoses. Unfortunately, the doctors represented a source of knowledge about TCS to only one-quarter of our respondents. This defect in the doctors' educational role was observed also by Kim et al. [4] who found that more than half of the patients said they obtained their information about TCS from sources other than the dermatologist. The present study had several points of strength. It is the first study of its kind to be conducted among Saudi dermatological patients. Also, this study investigated not only the prevalence of TCS phobia, but it analyzed its possible causes (safety, efficacy, and quality of life issues). The effect of the fear on compliance with treatment was also investigated. The sample size was adequate, and we included four of the most common dermatological diseases. The main limitation of the study was being a single center study. Moreover, the authors did not analyze the association between corticosteroid type and potency and the degree of fear. The study recommends further elaborated studies on TCS phobia overcoming the limitations mentioned above and including more dermatological diseases.

Table 3. Frequencies of respondents’ answers to questions concerning fears and beliefs about TCS and multiple regression results of their contribution to fear from TCS (n = 203).

I completely disagree I agree to a certain extent I completely agree B (95% CI; p-value)
n % n % n %
Fears & beliefs: efficacy
TCS are effective over a short time period 17 8.4 73 36.0% 113 55.7% 0.540 (0.312–0.768; <0.001*)
TCS are effective over a long-time period 119 58.6 68 33.5 16 7.9 0.320 (0.034–0.605; 0.029*)
TCS become inefficient over time 68 33.5 83 40.9 52 25.6 0.116 (−0.165 to 0.397; 0.417)
TCS calm symptoms but don’t treat the cause 40 19.7 67 33.0 96 47.3 0.249 (0.025–0.473; 0.029*)
TCS make your skin disease worse 120 59.1 63 31.0 20 9.9 0.274 (−0.040 to 0.588; 0.087)
TCS treatment takes time and effort 107 52.7 67 33.0 29 14.3 −0.054 (−0.333 to 0.225; 0.703)
Fears & beliefs: safety
TCS pass into blood stream 74 36.5 86 42.4 43 21.2 0.176 (−0.060 to 0.411; 0.144)
TCS prevent growth 138 68.0 56 27.6 9 4.4 0.082 (−0.242 to 0.407; 0.617)
TCS can lead to infection 145 71.4 45 22.2 13 6.4 0.089 (0.205–0.384; 0.550)
TCS make you fat 117 57.6 49 24.1 37 18.2 −0.057 (−0.293 to 0.179; 0.635)
TCS damage your skin 69 34.0 86 42.4 48 23.6 0.075 (−0.186 to 0.336; 0.572)
TCS will affect my future health 58 28.6 81 39.9 64 31.5 0.446 (0.180–0.712; 0.001*)
There is a dependency risk 85 41.9 62 30.5 56 27.6 0.101 (−0.112 to 0.315; 0.351)
I can become resistant to TCS 47 23.2 108 53.2 48 23.6 0.137 (−0.149 to 0.423; 0.345)
TCS can lead to asthma 139 68.5 40 19.7 24 11.8 0.160 (−0.135 to 0.455; 0.286)
I don't know of any side effects but I'm still afraid of TCS 67 33.0 84 41.4 52 25.6 0.336 (0.113–0.558; 0.003*)
TCS are more dangerous than CS in tablet form 154 75.9 37 18.2 12 5.9 −0.228 (−0.549 to 0.094; 0.164)
Fears & beliefs: quality of life
TCS treatment is complicated 106 52.2 72 35.5 25 12.3 0.136 (−0.182 to 0.454; 0.399)
TCS treatment helps me improve my quality of life 56 27.6 106 52.2 41 20.2 −0.434 (−0.749 to −0.118; 0.007*)
TCS increase my well-being 42 20.7 109 53.7 52 25.6 0.134 (−0.195 to 0.463; 0.422)
The advantages of TCS use outweigh the disadvantages 48 23.6 105 51.7 50 24.6 0.168 (−0.096 to 0.431; 0.210)

B: regression coefficient; CI: confidence interval;

*Significant at p < 0.05.

Table 4. Frequencies of respondents’ answers to questions concerning behaviors toward TCS (n = 203).

Never Sometimes Often Always B (95% CI; p value)
n % n % n % n %
Behaviors: safety
I'm afraid of applying too much cream 21 10.3 48 23.6 62 30.5 72 35.5 0.279 (0.080–0.479; 0.006*)
I’m afraid of using the cream for too long 19 9.4 32 15.8 47 23.2 105 51.7 0.238 (0.020–0.456; 0.033*)
I'm afraid of putting cream on certain zones like the eyelids, where the skin is thinner 5 2.5 13 6.4 29 14.3 156 76.8 0.281 (0.070–0.493; 0.010*)
I am careful to rub the cream in well when I apply it 116 57.1 40 19.7 22 10.8 25 12.3 0.060 (−0.095 to 0.215; 0.446)
I need reassurance about TCS 19 9.4 42 20.7 41 20.2 101 49.8 0.310 (−0.137 to 0.483; 0.001*)
Behaviors: compliance
If the doctor prescribed TCS then I would apply the prescription 8 3.9 52 25.6 53 26.1 90 44.3 −0.060 (−0.210 to 0.090; 0.431)
I wait as long as I can before treating myself 46 22.7 48 23.6 55 27.1 54 26.6 0.040 (−0.133 to 0.213; 0.650)
I stop the treatment as soon as I can 21 10.3 42 20.7 55 27.1 85 41.9 0.151 (−0.029 to 0.331; 0.100)

B: regression coefficient; CI: confidence interval;

*Significant at p < 0.05.

Table 5. Spearman’s correlation between fear of TCS, feelings toward TCS and the components of the questionnaire.

Fear of TCS Feeling toward using TCS
Efficacy score rs 0.437 0.252
p <0.001* <0.001*
n 203 203
Safety score rs 0.615 0.461
p <0.001* <0.001*
n 203 203
Quality score rs −0.313 −0.297
p <0.001* <0.001*
n 203 203
Compliance score rs 0.237 0.125
p 0.001* 0.076
n 203 203

rs: correlation coefficient;

*Significant at p < 0.05.

Figure 3. Sources of the respondents’ knowledge about TCS (n = 203).


Conclusion

TCS phobia was found widespread among patients with dermatological diseases. Most fears were related to safety issues. These fears were found to affect patients’ behaviors, and hence their compliance with treatment. Providing public awareness and health education programs addressing the adverse effects of TCS and steps to avoid or decrease their usage could play a pivotal role in reducing TCS phobia. The study recommends the dermatologists to dedicate adequate time to provide health education to their patients.


List of Abbreviations

TCSTopical corticosteroids
VASVisual analogue scale

Conflict of interest

The authors declare that there is no conflict of interest regarding the publication of this article.


Funding

None.


Consent for publication

Informed consent was obtained from all the participants.


Ethical approval

Ethical approval was obtained from the Institutional Review Board of Princess Noura Bint Abdulrahman University (Registration number: H-01-R-059).


Author details

Ibrahim Al-Omair1, Leena Emad Alghamdi2, Deema Abdulwahab AlSadoun2, Saad Altalhab3, Abdulrahman Abdullah Al-Omair4, Sara Mohamed Alkassimi5

  1. Assistant Professor and Consultant in Dermatology, Laser and Dermatologic Surgery, Department of Dermatology, College of Medicine, Al-Imam Mohammad Ibn Saud Islamic University, Riyadh, Saudi Arabia
  2. Princess Nora Bint Abdulrahman University, Riyadh, Saudi Arabia
  3. Assistant Professor and Consultant in Dermatology, Dermatologist, Department of Dermatology, College of Medicine, Al Imam Mohammad Ibn Saud Islamic University, Saudi Arabia
  4. King Saud Bin Abdulaziz University for Health Sciences, Ar Rimayah, Saudi Arabia
  5. King Abdulaziz University, Jeddah, Saudi Arabia

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How to Cite this Article
Pubmed Style

Al-Omair I, Alghamdi LE, AlSadoun DA, Altalhab S, Al-Omair AA, Alkassimi SM. Topical corticosteroid phobia among patients with dermatological diseases. IJMDC. 2019; 3(7): 570-576. doi:10.24911/IJMDC.51-1547136982


Web Style

Al-Omair I, Alghamdi LE, AlSadoun DA, Altalhab S, Al-Omair AA, Alkassimi SM. Topical corticosteroid phobia among patients with dermatological diseases. http://www.ijmdc.com/?mno=25571 [Access: May 27, 2019]. doi:10.24911/IJMDC.51-1547136982


AMA (American Medical Association) Style

Al-Omair I, Alghamdi LE, AlSadoun DA, Altalhab S, Al-Omair AA, Alkassimi SM. Topical corticosteroid phobia among patients with dermatological diseases. IJMDC. 2019; 3(7): 570-576. doi:10.24911/IJMDC.51-1547136982



Vancouver/ICMJE Style

Al-Omair I, Alghamdi LE, AlSadoun DA, Altalhab S, Al-Omair AA, Alkassimi SM. Topical corticosteroid phobia among patients with dermatological diseases. IJMDC. (2019), [cited May 27, 2019]; 3(7): 570-576. doi:10.24911/IJMDC.51-1547136982



Harvard Style

Al-Omair, I., Alghamdi, . L. E., AlSadoun, . D. A., Altalhab, . S., Al-Omair, . A. A. & Alkassimi, . S. M. (2019) Topical corticosteroid phobia among patients with dermatological diseases. IJMDC, 3 (7), 570-576. doi:10.24911/IJMDC.51-1547136982



Turabian Style

Al-Omair, Ibrahim, Leena Emad Alghamdi, Deema Abdulwahab AlSadoun, Saad Altalhab, Abdulrahman Abdullah Al-Omair, and Sara Mohamed Alkassimi. 2019. Topical corticosteroid phobia among patients with dermatological diseases. International Journal of Medicine in Developing Countries, 3 (7), 570-576. doi:10.24911/IJMDC.51-1547136982



Chicago Style

Al-Omair, Ibrahim, Leena Emad Alghamdi, Deema Abdulwahab AlSadoun, Saad Altalhab, Abdulrahman Abdullah Al-Omair, and Sara Mohamed Alkassimi. "Topical corticosteroid phobia among patients with dermatological diseases." International Journal of Medicine in Developing Countries 3 (2019), 570-576. doi:10.24911/IJMDC.51-1547136982



MLA (The Modern Language Association) Style

Al-Omair, Ibrahim, Leena Emad Alghamdi, Deema Abdulwahab AlSadoun, Saad Altalhab, Abdulrahman Abdullah Al-Omair, and Sara Mohamed Alkassimi. "Topical corticosteroid phobia among patients with dermatological diseases." International Journal of Medicine in Developing Countries 3.7 (2019), 570-576. Print. doi:10.24911/IJMDC.51-1547136982



APA (American Psychological Association) Style

Al-Omair, I., Alghamdi, . L. E., AlSadoun, . D. A., Altalhab, . S., Al-Omair, . A. A. & Alkassimi, . S. M. (2019) Topical corticosteroid phobia among patients with dermatological diseases. International Journal of Medicine in Developing Countries, 3 (7), 570-576. doi:10.24911/IJMDC.51-1547136982