An AD treatment phobia that is a “phenomenon”

A review of topical corticosteroid use in atopic dermatitis patients reveals a treatment “phobia” affecting up to 83% percent of patients. The phobia is so strong that it impairs treatment adherence.

The review, by Richard Antaya M.D., of Yale University School of Medicine, and colleagues, appears in the July 19 issue of JAMA Dermatology. Dr. Antaya spoke with Dermatology Times for this article.

“The analogy I provide for parents is comparing this to a child with an ear infection. If insufficient antibiotics are prescribed, the bacteria will not be killed and the ear infection will not improve,” explains Dr. Antaya. “Steroids seem to work in the same way. You have to use enough for them to work.”

This systemic review includes 490 studies with only 16 cross-sectional studies meeting the eligibility criteria. The review is based on a search of MEDLINE, Embase, PubMed and Web of Science databases for articles published between Jan. 1, 1946 and Oct. 31, 2016. Their analysis shows a prevalence of topical corticosteroid phobias ranging from 21% to (95% CI, 15.8%-26.2%) to 83.7% (95% CI, 81.9%-85.5%) with phobias ranging from "concern" to "irrational fear."

Two studies compared non-adherence between a phobia group and a non-phobia group. Patients in both groups were found to have a significantly higher rate of non-adherence (49.4% vs 14.1% and 29.3% vs 9.8%). The phobias were derived from a combination of information from  physicians, friends, relatives, broadcast media, print media and the internet.

“Patients and caregivers need to know that the short-term use of topical steroids is safe and effective treatment for atopic dermatitis,” said Alvin Li, a medical student and first author of the review.

The authors suggest that physicians and pharmacists could benefit from continuing education sessions and updated treatment guidelines that address the safe use of corticosteroids for atopic dermatitis.

Two of the studies included in the review examined the impact of phobias on adherence to therapy by comparing a group of patients with phobia to a group without phobia. Investigators found that patients in the phobia groups were more likely to abstain from applying topical corticosteroids to affected areas (49.4% vs. 14.1% and 29.3% vs. 9.8%). “Topical corticosteroid phobia very likely plays a significant role in the treatment effect,” Dr. Antaya said.

Another study found that primary care clinicians and pharmacists had inconsistent opinions and inadequate information about topical steroids leading to anxiety and confusion among patients.³

Inform and educate

Some general practitioners avoid treating atopic dermatitis patients due to concerns about corticosteriod use and instead, refer patients to dermatologists, Dr. Antaya said. For this reason, non-specialists should be exposed to continuing education or information sources for treatment guidance. More informed clinicians are better suited to communicate information about side effects. And, the same is true of patients. Patient education can address and possibly resolve phobia issues, he said citing one study that found a brief educational session produced a 43.2% reduction in a patient phobia index score.4

Long-term corticosteroid use is associated with complications and patients should be informed accordingly. Adverse events such as hypothalamic-pituitary-adrenal axis suppression, thinning of the skin and stretch marks can develop with steroid use of mid-strength to potent strength are used for prolonged periods of time.

“If topical steroids are used continuously and without interruption, problems are more likely. Intermittent use is what we recommend. When patients are using topical corticosteroids too frequently, we recommend using topical calcineurin inhibitors or other alternative treatments,” he said.

Dr. Antaya points to the need for studies to examine the prevalence of treatment phobias and to examine interventions designed to reduce phobias to improve treatment outcomes.

This study had some limitations, including the significant variation among the 16 articles in defining phobias. There were questionnaires of one to 69 questions, but there appeared to be no standardization for defining a topical corticosteroid phobias. “We need a standardized measure to clearly define and study topical corticosteroid phobias,” Dr. Antaya said.

The authors have proposed adopting the use of a 12-item questionnaire called TOPICOP as a standardized assessment tool. The scale would characterize the phobia and guide researchers in determining which phobia features impacts compliance the most, Dr. Antaya said.

Disclosures

Dr. Antaya has been a paid consultant or performed research for Promius.

References

1. NEJM, July 19, reasons for corticosteroid phobias:  Alvin W. Li, BS; Emily S. Yin, BS; Richard J. Antaya, MD. “Topical Corticosteroid Phobia in Atopic Dermatitis: A Systematic Review,” NEJM. July 19, 2017. DOI: 10.1001/jamadermatol.2017.2437 http://jamanetwork.com/journals/jamadermatology/article-abstract/2643740?resultClick=1

2. NEJM, July 19, reasons for corticosteroid phobias:  Moret L, Anthoine E, Aubert-Wastiaux H, et al. “TOPICOP^©: a new scale evaluating topical corticosteroid phobia among atopic dermatitis outpatients and their patients,” PLoS One. Oct 16, 2013. DOI: 10.1371/journal.pone.00776493 http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0076493

3. NEJM, July 19, reasons for corticosteroid phobias:  Smith SD, Stephens AM, Werren JC, Fischer GO. “Treatment Failure in Atopic Dermatitis as a Result of Parental Health Belief,” Med J Aust. Oct 7, 2013.

4. NEJM, July 19, reasons for corticosteroid phobias:  Lee JY, Her Y, Kim CW, Kim SS. “Topical Corticosteroid Phobia among Parents of Children with Atopic Eczema in Korea.” in Atopic Dermatitis: A Systematic Review,” Ann Dermatol. October 2015. DOI:10.5021/ad.2015.27.5.499 https://anndermatol.org/DOIx.php?id=10.5021/ad.2015.27.5.499