Are your patients afraid of their dermatological treatments?

If your eczema patients aren’t using their topical treatments as prescribed, they may be suffering from corticosteroid phobia.Fear of treatment is not only common, but many patients start treatment late, stop early and use less than prescribed, even if they don’t have very specific concerns. Indeed, the bigger their phobia, the less they use, according to a study in Journal of the American Academy of Dermatology.These findings underline a need for better education about topical corticosteroid (TCS) treatments as well as a need for safe and effective non-steroid treatments, the researchers said.Generally, the term ‘corticosteroid phobia’ refers to “the exaggerated concerns, fears, worries, anxiety, doubts, reservations, reluctance, or skepticism regarding corticosteroid use in patients, their caregivers, or healthcare professionals,” the paper said.The issue of treatment phobia had been studied for other skin conditions such as atopic dermatitis and some studies showed that at least half of patients have corticosteroid phobia.But this study focused on patients with chronic hand eczema (CHE), affecting a relatively small part of the body, and used a population-based cohort of adult CHE patients derived from the Danish Skin Cohort. It assessed patient knowledge, beliefs, fears and behaviors about the treatment, as well as adherence. CHE was verified by dermatologists.Information taken into account included age, CHE onset, details of CHE such as skin pain, pruritus, and cracks or fissures; severity, atopic history, smoking status, treatment with TCS and knowledge, fears and behaviour regarding TCS treatment.Patients were asked questions from the Topical Corticosteroid Phobia (TOPICOP) scale and Medication Adherence Report Scale (MARS-5).A total of 927 people with CHE answered both questionnaires and were included in the study. The mean age was 55.4 years, the mean age at CHE onset was 35.9 years and most, 665 (71.7%), were women. A significant number, 589 (53.5%), had a smoking history, while 334 (36.0%) had never smoked.As for current CHE severity, 516 (55.8%) overall were clear or almost clear; 280 (30.3%) had moderate CHE, 93 (10.1%) had severe CHE, and 35 (3.8%) had very severe disease. A total of 368 (39.7%) patients reported they also had current or previous atopic dermatitis.When it came to cautions or fears about TCS, the TOPICOP results revealed that 75.5% of the respondents totally or almost agreed that TCS damage the skin; close to half, 48.9% totally or almost agreed that TCS would affect their future health, and 36.3% said they had some degree of fear of TCS even though they didn’t know of any TCS-associated risks, the study said.And what about their behaviour? Most patients, 77.9% said they always or often stop treatment as soon as possible, while 54.8% always or often wait as long as possible before starting treatment.Overall, 38.8% of the patients took less medicine than prescribed and 54.0% had stopped treatment for a while.But even people who had never used TCS were hesitant. In fact “66.6% of patients who never used TCS reported that they would always or often wait as long as possible before treating themselves with TCS and (over) 90% reported that they would always or often stop TCS treatment as soon as possible,” the researchers wrote.When it came to adherence, findings from the MARS-5 portion of study weren’t encouraging. A total of 359 (38.8%) patients said that they very often or sometimes took less medicine than prescribed. When asked if they ever stopped taking their treatment throughout a prescribed period, 501 (54.0%) patients said they did this very often, 17.0% did this often (16.5%), and 20.5% or sometimes.Even significant numbers of patients with severe CHE often applied less than instructed, and some even stopped treatments. However, 71.4% of patients with severe CHE said that they never change dose compared to 43.6% of patients with mild CHE, the study said.Not surprisingly, the patients who had higher scores from TOPICOP tended to be less adherent to their TCS treatments. “It is mainly the fear of TCS that are driving their non-adherence. This concept of fear might be based on low quality information about the actual risk with topical steroids or because patients have made negative experiences with steroid use,” the study said.While prolonged or excessive use of TCS may induce problems such as skin barrier impairment, they are considered safe and effective as long as they are used correctly.The extent of the fears seen in the study may be “a result of improper education and based on misconception, and misinformation. Multiple studies have suggested that patients may confuse side effects of TCS with side effects of oral corticosteroids,” the paper said.The authors concluded that “Physicians should address any fears or concerns their patients may have proactively and instruct them properly in TCS use and application.”The TOPICOP is a validated score that first appeared in 2013 in multiple journals and was developed by researchers in France. Previously the problem was referred to as topical corticophobia, but earlier scales were considered simplistic. There is also a simplified version of TOPICOP. The MARS-5 is also a relatively new scale.

Are your patients afraid of their dermatological treatments?

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