Dermatology: Practical and Conceptual Original Article | Dermatol Pract Concept. 2024;14(3):e2024106 1 Topical Corticophobia Among Healthcare Professionals in Saudi Arabia: A Cross-Sectional Study Abdullah Alakeel1, Abeer Alkahtani2,3, Rahaf Alshareef3,4, Norah Almajli5, Khalid Alekrish1 1 Department of Dermatology, College of Medicine, King Saud University, Riyadh, Saudi Arabia 2 Department of Dermatology, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia 3 General Directorate of Research and Studies, Ministry of Health, Riyadh, Saudi Arabia 4 Department of Dermatology, Prince Sultan Military Medical City, Riyadh, Saudi Arabia 5 College of Medicine, Princess Nourah Bint Abdulrahman University, Riyadh, Saudi Arabia Key words: corticophobia, topical steroids, physicians, dermatologists, family medicine Citation: Alakeel A, Alkahtani A, Alshareef R, Almajli N, Alekrish K. Topical Corticophobia Among Healthcare Professionals in Saudi Arabia: A Cross-Sectional Study. Dermatol Pract Concept. 2024;14(3):e2024106. DOI: https://doi.org/10.5826/dpc.1403a106 Accepted: January 16, 2024; Published: July 2024 Copyright: ©2024 Alakeel et al. This is an open-access article distributed under the terms of the Creative Commons Attribution- NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original authors and source are credited. Funding: None. Competing Interests: None. Authorship: All authors have contributed significantly to this publication. Corresponding Author: Abeer Rashid Alkahtani, Department of Dermatology, King Faisal Specialist Hospital & Research Centre, General Directorate of Research and Studies, Ministry of Health, Riyadh, Saudi Arabia. Email: Abeeralkahtani@hotmail.com Introduction: Corticophobia constitutes a complex challenge affecting patients and healthcare profes- sionals alike, resulting in suboptimal management and treatment of dermatological conditions. Objectives: This study aims to investigate corticophobia among physicians in Saudi Arabia and identify associated factors. Methods: This is a retrospective, observational, cross-sectional study that included 700 participants. The sample constituted dermatologists, pediatricians, and family medicine practitioners at differ- ent levels (consultants, fellows, and residents) in Saudi Arabia. Data were collected via an electronic survey addressing demographic information and corticophobia-related questions. Results: A total of 700 participants were included in the data analysis. Dermatologists were the most comfortable prescribing steroids (32%), followed by family medicine physicians (25%), and pedi- atricians (18%). Pediatricians were the most hesitant to prescribe steroids. Fellows were the most confident in prescribing steroids. Physicians from the northern and western regions were least likely to be hesitant in prescribing steroids. ABSTRACT 2 Original Article | Dermatol Pract Concept. 2024;14(3):e2024106 Introduction Since their introduction in the early 1950s, topical cortico- steroids (TCs) have been the mainstay treatment for various dermatological disorders. The initial evidence supported the use of TCs in managing conditions such as atopic derma- titis, localized vitiligo, psoriasis, chronic hand eczema, and localized bullous pemphigoid [1]. These medications exhibit anti-inflammatory, vasoconstrictive, and anti-proliferative properties, which contribute to their therapeutic effects. The efficacy of TCs depends on their potency. However, the extensive and improper use of TCs among a considerable segment of the population has led to systemic and localized adverse events [2]. The unfounded negative perception of corticosteroids, often termed “corticophobia,” stems from disproportionate relationship between the likelihood of medication-induced side effect and patents concerns. Studies suggest that access to scientific and online resources among patients experienc- ing corticophobia contributes to misconceptions about TC therapy, leading to non-adherence [3,4]. Bernos et al conducted research to examine parental and healthcare-provider concerns about topical corticosteroids. The study found that both parents of children with atopic dermatitis and healthcare professionals working with these children were affected by corticophobia. Interestingly, corti- cophobia impacted healthcare nurses similarly to parents [5]. Another investigation involving pediatricians, general prac- titioners, pharmacists, and dermatologists concluded that pharmacists were the most reluctant to recommend topical corticosteroid use, likely due to insufficient understanding of the medications [6]. Objectives Corticophobia constitutes a complex challenge affecting patients and healthcare professionals alike, resulting in sub- optimal management and treatment of dermatological con- ditions. Corticophobia among healthcare professionals has not received the appropriate level of attention it warrants. This study aims to investigate corticophobia among physi- cians in Saudi Arabia and identify associated factors. The findings may offer valuable insights to inform future efforts to address and mitigate corticophobia, ultimately enhancing the quality of care for patients requiring topical corticoste- roid therapy. Methods Study Design, Setting, and Participants This retrospective, observational, cross-sectional study was carried out over a duration of four months, encompassing hospitals selected through convenience sampling in the five regions of Saudi Arabia: central, northern, southern, eastern, and western. Ethical approval was obtained from the appro- priate local ethical committee prior to commencing the study. Written informed consent was acquired from each partici- pant, emphasizing that participation was entirely voluntary, and no personally identifiable information was collected. The study population consisted of consultants, fellows, and residents from three medical specialties: dermatology, pedi- atrics, and family medicine. Data Collection and Study Tool In each region, volunteers were recruited and trained to fa- cilitate data collection. The research team developed the sur- vey, which was subsequently reviewed for accuracy by two independent dermatologists. A pilot study was conducted to validate the survey. Data collection involved administering an electronic, English-language version of the questionnaire to participants. The survey was divided into two sections. The first section, focusing on demographic information, in- cluded four questions aimed at assessing participants’  de- mographic characteristics, such as age, gender,  current region, specialty, and level of training. The second section comprised questions designed to evaluate corticophobia and participants knowledge of side effects related to topical cor- ticosteroid use. Statistical Methods Data analysis was done using Rstudio. Numbers and per- centages were used to describe categorical variables. The chi-square test was used to assess the statistical significance of the categorical data. Multiple logistic regression model Conclusions: In conclusion, this study reveals that in Saudi Arabia, dermatologists were the most comfortable prescribing topical corticosteroids, with pediatricians being the most hesitant. The find- ings emphasize the importance of education in addressing corticophobia among healthcare profession- als, which could improve treatment adherence and patient outcomes. Further research and targeted educational interventions are necessary to enhance understanding and confidence in prescribing topi- cal corticosteroids among healthcare professionals. Original Article | Dermatol Pract Concept. 2024;14(3):e2024106 3 was applied to assess factors associated with hesitancy in prescribing steroids among physicians. Results A total of 700 participants were included in the data anal- ysis. The most common age category was 20-30 years (N = 417, 59.6%). Males constituted 52.6% (N = 368) of the sample. The most common region of residence for partic- ipants was the northern region (N = 241, 34.4%), followed by the western region (N = 171, 24.4%), central region (N = 140, 20%), eastern region (N = 84, 12%), and southern region (N = 64, 9.1%). The most common specialty among physicians included was family medicine (N = 338, 48.3%), followed by pediatrics (N = 240, 34.3%) and dermatology (N = 122, 17.4%). A detailed summary of the participant demographics of the sample is shown in Table 1. Dermatologists were found to be the most comfortable with prescribing steroids (32%), followed by family medicine physicians (25%), and pediatricians (18%) [p-value = 0.02]. Furthermore, for the question “When prescribing topi- cal corticosteroids for my patients, I try not to exceed five days of application,” dermatologists had the highest rate of disagreement (40%), followed by pediatricians (22%), and family medicine physicians (20%) (P < 0.001). Finally, for the question, “I advise my patients against applying topical steroids over body sites with thin skin even when the area is affected,” dermatologists had the highest rate of disagree- ment (43%), followed by pediatricians (28%), and family medicine physicians (26%) (P < 0.001). There was no sig- nificant difference among the specialties in the remaining questions (Table 2). The question “I am hesitant to prescribe topical steroids to my patients even when it is indicated” was analyzed to ex- amine factors that predict hesitance in steroid prescription. To avoid inaccurate results, physicians who chose “Unsure” as their answer to the question were excluded. It was found that pediatricians (odds ratio [OR] 2.13, 95% confidence interval [CI] 1.26-3.62, P = 0.005) were the most hesitant to prescribe steroids. For the level of education, fellows were least likely to be hesitant in prescribing steroids (OR 0.38, 95% CI 0.19-0.78, P = 0.009). For the region, physicians from the northern region (OR 0.52, 95% CI 0.31-0.87), P = 0.014) and western region (OR 0.49, 95% CI 0.28-0.85, P = 0.012) were least likely to be hesitant in prescribing ste- roids (Figure 1). Conclusions Owing to their anti-inflammatory properties, topical cortico- steroids are commonly administered in the field of dermatol- ogy for an array of conditions, encompassing autoimmune disorders and inflammatory diseases. Although the long- term safety of TCs administration has been established to be safe when utilized appropriately, the documentation and quantification of TCs phobia exhibit significant variability, posing a potential challenge to the field of dermatology [7]. Furthermore, corticosteroid phobia is regarded as one of the main factors contributing to suboptimal treatment compli- ance. Identifying the factors associated with hesitancy in the usage or prescription of topical corticosteroids is crucial for addressing this issue among healthcare professionals and their patients. By doing so, it is possible to alleviate safety concerns on both sides, ultimately improving adherence to treatment [6,8]. Corticophobia among healthcare professionals has not received the appropriate level of attention it warrants. The phenomenon of corticophobia among patients, on the other hand, has been extensively explored in numerous studies. According to various research findings, this issue among patients is primarily influenced by inaccurate information conveyed by physicians [6,9-11]. This observation is corrob- orated by a study examining general practitioners knowledge of topical corticosteroids, which found that physicians may inadvertently instill fear in patients when prescribing these Table 1. Detailed summary of the participant demographics (N = 700). Study variables Total N (%) Age, years 20 - 30 417 (59.6) 31 - 40 217 (31.0) 41 - 50 43 (6.1) 51 and more 23 (3.3) Gender Male 368 (52.6) Female 332 (47.4) Current region of practice Central region 140 (20.0) Eastern region 84 (12.0) Northern region 241 (34.4) Southern region 64 (9.1) Western region 171 (24.4) Medical specialty Dermatology 122 (17.4) Family medicine 338 (48.3) Pediatrics 240 (34.3) Level of training Consultant 86 (12.3) Fellow 186 (26.6) Resident 428 (61.1) 4 Original Article | Dermatol Pract Concept. 2024;14(3):e2024106 Table 2. Comparison between the three different specialties in terms of demographics, attitude towards topical corticosteroids and the knowledge of different side effects. Dermatology N = 122 N (%) Family medicine N = 338 N (%) Pediatrics N = 240 N (%) P Age 0.532 20 - 30 65 (53.3) 209 (61.8) 143 (59.6) 31 - 40 43 (35.2) 99 (29.3) 75 (31.2) 41 - 50 7 (5.7) 20 (5.9) 16 (6.7) 51 and more 7 (5.7) 10 (3.0) 6 (2.5) Gender, male 75 (61.5) 179 (53.0) 114 (47.5) 0.041 What is your current region 0.028 Central region 30 (24.6) 65 (19.2) 45 (18.8) Eastern region 21 (17.2) 33 (9.8) 30 (12.5) Northern region 37 (30.3) 128 (37.9) 76 (31.7) Southern region 10 (8.2) 22 (6.5) 32 (13.3) Western region 24 (19.7) 90 (26.6) 57 (23.8) Level of education (%) 0.014 Consultant 26 (21.3) 31 (9.2) 29 (12.1) Fellow 30 (24.6) 90 (26.6) 66 (27.5) Resident 66 (4.1) 217 (64.2) 145 (60.4) I generally think that topical corticosteroids have more of a negative effect than positive on the skin (%) 0.609 Agree 51 (41.8) 135 (39.9) 87 (36.2) Disagree 55 (45.1) 156 (46.2) 110 (45.8) Unsure 16 (13.1) 47 (13.9) 43 (17.9) I am hesitant to prescribe topical steroids to my patients even when it is indicated (%) 0.738 Agree 48 (39.3) 124 (36.7) 80 (33.3) Disagree 61 (50.0) 171 (50.6) 125 (52.1) Unsure 13 ( 0.7) 43 (12.7) 35 (14.6) I feel comfortable prescribing high potency topical corticosteroids. (%) 0.02 Agree 39 (32.0) 86 (25.4) 43 (17.9) Disagree 64 (52.5) 176 (52.1) 148 (61.7) Unsure 19 (15.6) 76 (22.5) 49 (20.4) I advise my patients against applying topical steroids over body sites with thin skin even when the area is affected (%) 0.001 Agree 54 (44.3) 151 (44.7) 111 (46.2) Disagree 52 (42.6) 88 (26.0) 66 (27.5) Unsure 16 (13.1) 99 (29.3) 63 (26.2) When prescribing topical corticosteroids for my patients I try not to exceed five days of application (%) <0.001 Agree 55 (45.1) 199 (58.9) 143 (59.6) Disagree 49 (40.2) 69 (20.4) 52 (21.7) Unsure 18 (14.8) 70 (20.7) 45 (18.8) Original Article | Dermatol Pract Concept. 2024;14(3):e2024106 5 could potentially be attributed to dermatologists’ more comprehensive knowledge of  topical corticosteroids, given their increased exposure to skin diseases. These findings align with a  Saudi study, which demonstrated that physi- cians reporting exposure to fewer than 10% of skin-related visits had the lowest  knowledge scores  regarding topical corticosteroids. Furthermore, the Saudi study revealed that primary care physicians possessed less knowledge about medications [12]. Further attention should be directed to- ward this topic, as it may result in undesirable consequences such as noncompliance, treatment failure, and the utilization of alternative systemic treatments potentially accompanied by increased side effects and unwarranted costs [6]. In this study, as well as in others, it has been observed that dermatologists exhibit the highest level of comfort when prescribing high-potency topical corticosteroids. This Dermatology N = 122 N (%) Family medicine N = 338 N (%) Pediatrics N = 240 N (%) P Topical corticosteroids can be absorbed from the skin to the bloodstream (%) 0.185 Agree 56 (45.9) 141 (41.7) 83 (34.6) Disagree 40 (32.8) 115 (34.0) 100 (41.7) Unsure 26 (21.3) 82 (24.3) 57 (23.8) Which of the following is a side effect of topical corticosteroids Skin infection 83 (68.03) 279 (82.54) 202 (84.17) <0.001 Increase in body weight 60 (49.18) 200 (59.17) 149 (62.08) <0.001 Bronchial asthma 31 (25.4) 73 (21.6) 48 (20) 0.145 Skin stria 77 (63.11) 245 (72.49) 154 (64.1) <0.001 Glaucoma 53 (43.44) 161 (47.63) 119 (49.58) 0.002 Cataract 54 (44.26) 151 (44.67) 119 (49.58) <0.001 Skin Cancer 36 (29.50) 128 (37.87) 100 (41.6) <0.001 Infertility 31 (25.41) 110 (32.54) 83 (34.58) <0.001 Coronary artery disease 14 (11.47) 44 (13.02) 31 (12.92) <0.001 Figure 1. Factors associated with hesitancy when prescribing steroids. 6 Original Article | Dermatol Pract Concept. 2024;14(3):e2024106 topical corticosteroid potency classifications, in contrast to dermatologists, who demonstrated greater awareness of the potency rankings of commonly prescribed topical corticosteroids [13]. This study highlights that dermatologists demonstrated relative confidence in prescribing topical corticosteroids for affected body areas with thin skin. This finding con- trasts with the results of a study investigating corticopho- bia among healthcare professionals, which concluded that both healthcare professionals and patients exhibited the greatest apprehension regarding the application of topi- cal corticosteroids on areas with thin skin, such as the eyelids [6]. The findings of this study are consistent with those of a prior prospective study, which determined that the prevalence of corticophobia is similar among healthcare professionals in general, but lower among dermatologists [6]. The solution to topical corticosteroid phobia appears to be with education and increasing the knowledge regarding these medications, as demonstrated by an Australian study, has also supports that the fear of steroids can be influenced by the education about the use, mode of action and the side effects of TCS. A potential solution to topical corticosteroid phobia may lie in education and enhancing knowledge surround- ing these medications. As evidenced by an Australian study, it has been suggested that apprehension regarding steroids could be mitigated through increased understanding of their usage, mode of action, and potential side effects asso- ciated with TCS [14]. In light of the findings, it is recommended that further education and training be provided to healthcare profession- als, to enhance their understanding of topical corticosteroid usage, potency, and safety. This could help address cortico- phobia, ultimately improving treatment adherence and pa- tient outcomes. In conclusion, this study reveals that in Saudi Arabia, dermatologists were the most comfortable prescribing top- ical corticosteroids, with pediatricians being the most hes- itant. The findings emphasize the importance of education in addressing corticophobia among healthcare professionals, which could improve treatment adherence and patient out- comes. Further research and targeted educational interven- tions are necessary to enhance understanding and confidence in prescribing topical corticosteroids among healthcare professionals. References 1. Das A, Panda S. Use of Topical Corticosteroids in Dermatology: An Evidence-based Approach. Indian J Dermatol. 2017;62(3): 237-250. 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