Oct. 19, 2017
“I don’t want to use steroids on my baby! I’m really afraid of the side effects! I see what they’ve done to athletes. Can’t you prescribe something natural?”
I am amazed people think that applying 2.5% hydrocortisone cream can pump up their children into Hans and Franz.
Topical corticosteroid phobia (TCP, aka “corticosteroid phobia”, “corticophobia”) describes exaggerated concerns, fears, worries, anxiety, doubts, reservations, reluctance or skepticism regarding corticosteroid use in patients, their caregivers, or health care professionals. Corticophobia does not just present to dermatologists, but is an issue for allergists, pulmonologists, rheumatologists, and pediatricians. (1)
Sixty-five years ago, Sulzberger and Witten revolutionized dermatologic therapeutics by applying compound F (17-hydroxycortisosterone-21-acetate, 25 mg per gram of base [lanolin 15%, liquid petrolatum 10%, and white petrolatum qs]) to 19 patients, 8 of them with atopic dermatitis. They compared compound F to one side and the base alone to the other. In their words: “It is of interest to note that in six of the eight cases of proved or presumptive atopic dermatitis, the compound F ointment produced greater improvement than did the base alone.” (2) Dermatology has never been the same since.
It takes great knowledge and skill to use steroids properly — choosing the appropriate strength (groups 1 through 7) and optimal vehicle for the affected site is not a random process. Incorrect choices may lead to adverse reactions, both local and systemic. The most common local side effects include atrophy, striae, rosacea, perioral dermatitis, acne, purpura, hypertrichosis, and hypopigmentation. Systemic adverse reactions are more likely to develop when high potency topical steroids are used for prolonged periods on thin skin, or those with altered barrier function. Hypothalamic-pituitary adrenal axis suppression may occur with all topical steroids, but is more likely with more potent steroids applied over large surface areas. (3)
What concerns our patients and where do they get their (mis)information?
According to Smith et al, “The most common belief that parents offer regarding perceived risk associated with the use of TCS [topical corticosteroids] is that it will thin the skin irreversibly. However, especially in the pediatric population, many parents also voice concerns about immune suppression and growth failure. Patients and parents cite a range of sources for their information on the safety and efficacy of TCS in AD. In particular, they clearly identify there is a significant role of family/friends and the Internet as an information resource.” (4) This fear is real. In a study of 300 patients with atopic dermatitis, 81% of parents believed that the advantages of topical corticosteroids do not outweigh the disadvantages. Parents were also worried about applying too much cream. (5)
In a systematic review of 16 articles, Li et al demonstrated that topical corticosteroid phobia pranged from 21% to 83.7%. Compared to patients without corticophobia, phobic patients had higher nonadherence rates. This is a cross-cultural phenomenon. (6)
While there may be workarounds for the steroid phobic, such as topical immunomodulators (disregarding the notorious black box warning) or crisaborole, topical corticosteroids remain the cornerstone of treatment for the majority of dermatitic patients. A patient not adhering to treatment, because of myths and misconceptions, is a travesty. Education is the key.
I have found that it is best to ask the patient (parent or guardian) what concerns them the most and address those concerns to the best of my ability. I tell them that I respect their opinion, and I will abide by their decisions, but it is my duty to give them my perspective, and allay any fears, if possible.
Whatever your opinion is of Dr. Albert Kligman’s legacy, most would agree that he was a compelling, provocative, entertaining voice when he held court at the Duhring Conference at the University of Pennsylvania. The concept of corticophobia is not new. Decades ago, Dr. Kligman said that when patients only want something “natural,” he would reply, “Nothing is more natural than water — even that can kill you when it’s over your head and you can’t breathe.” People get the point.
1. Mueller SM, et al. Assessment of “corticophobia” as an indicator of non-adherence to topical steroids: A pilot study. J Dermatolog Treat 2017; 28: 104-11.
2. Sulzberger MB, Witten VH. The effect of topically applied compound F in selected dermatoses. J Invest Dermatol 1952; 19: 101-2.
3. Coondoo A, et al. Side-effects of topical steroids: A long overdue revisit. Indian Dermatol Online J 2014; 5: 416-25.
4. Smith SD, et al. Evaluation of the influence of family and friends, and the internet on patient perceptions of long-term topical corticosteroid use. J Dermatolog Treat 2017; Apr [Epub ahead of print].
5. El Hachem M, et al. Topical corticosteroid phobia in parents of pediatric patients with atopic dermatitis: A multicentre study. Ital J Pediatr 2017; 43: 22.
6. Li AW, et al. Topical corticosteroid phobia in atopic dermatitis. JAMA Dermatol 2017; 153: 1036-42.
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