Corticosteroid Phobia: Fear of Corticosteroid Side Effects

Learn what corticosteroid phobia is, why it occurs and how fear of corticosteroid side effects can affect the treatment of atopic dermatitis.

Although corticosteroids are well-established treatments for children with atopic dermatitis and many other inflammatory skin conditions, dermatologists frequently encounter reluctance among parents to use topical corticosteroids in young children because of concerns about possible side effects.

Corticosteroid phobia, or more specifically topical corticosteroid phobia, refers to excessive concern, fear or reluctance regarding the use of corticosteroid creams and ointments. Studies have reported widely varying rates of concern among patients and families, depending on the population studied and the way corticosteroid phobia is defined and measured. Concerns may be particularly pronounced when treatment is prescribed for young children.

Uncertainty about topical corticosteroids is not limited to patients and parents. Healthcare professionals who use these medicines less frequently may also have concerns, particularly in paediatric patients.

However, topical corticosteroids remain a cornerstone of treatment for inflammatory flares of atopic dermatitis and are also widely used in other inflammatory skin diseases, including psoriasis and different forms of eczema.

Why are people afraid of corticosteroids?

Corticosteroid phobia is partly related to misconceptions or overgeneralisation about their possible side effects.

When corticosteroids are administered systemically, for example orally or by injection, particularly at high doses and for prolonged periods, they can cause adverse effects such as fluid retention, weight gain, effects on growth and metabolic or cardiovascular complications.

Topical corticosteroids are different. They are applied directly to affected areas of skin and, when appropriately selected and used as prescribed, systemic exposure is generally much lower than with oral or injectable corticosteroids. However, absorption is not completely absent and depends on factors including the potency of the corticosteroid, the area and condition of the skin being treated, the amount applied, duration of treatment, use under occlusion and the age of the patient.

Topical corticosteroids have been used for decades and have a well-established safety and efficacy profile when the correct product, strength and treatment schedule are selected.

As with any medicine, however, they can cause adverse effects, particularly when used excessively, for too long or inappropriately.

Possible local adverse effects include: skin atrophy, in which the skin becomes thinner and more fragile; stretch marks; telangiectasia, or visible superficial blood vessels; acneiform eruptions; changes in pigmentation; and hypertrichosis, or increased hair growth in the treated area. The risk varies according to factors such as corticosteroid potency, duration of treatment, body site and patient age.

Consequences of corticosteroid phobia in the treatment of atopic dermatitis

Fear of topical corticosteroids may lead some parents to undertreat their child’s eczema, avoid prescribed medication altogether or apply it inconsistently. One problem frequently seen in clinical practice is delaying treatment until the eczema has become considerably more inflamed.

This may prolong discomfort, itching and sleep disturbance and may allow the affected area to become more extensive or difficult to control. More severe itching can also lead to repeated scratching, which damages the skin barrier and may result in excoriations, crusting and secondary infection.

Poorly controlled atopic dermatitis can have a substantial impact on quality of life. Persistent itching and disturbed sleep may affect mood, concentration, school performance and the wellbeing of both the child and their family.

Research has also explored the relationship between atopic dermatitis, stress and immune function. However, these interactions are complex, and it should not be assumed that topical corticosteroid treatment alone directly normalises immune responses or prevents other diseases.

The term atopic march describes the observation that some children with atopic dermatitis subsequently develop other allergic conditions, such as food allergy, asthma or allergic rhinitis. Atopic dermatitis — particularly when it is early-onset or more severe — is associated with an increased likelihood of developing some of these conditions.

However, this does not mean that every child will follow this sequence, nor is it established that undertreating eczema directly causes the atopic march. Current management therefore focuses on controlling the skin disease effectively, restoring the skin barrier and monitoring the child for associated allergic conditions when clinically appropriate.

Our approach to topical corticosteroids

Based on the available evidence and our clinical experience as dermatologists expert in atopic dermatitis, topical corticosteroids remain one of the main treatments for inflammatory flares of atopic dermatitis and many other inflammatory skin conditions. Their use should be individualised. The appropriate corticosteroid depends on factors such as the patient’s age, the area of the body being treated, the severity of the inflammation, the potency of the medicine and how long it needs to be used.

For this reason, treatment decisions should not be based on myths, information from non-specialist websites or recommendations from friends and relatives whose skin condition may appear similar.

When a topical corticosteroid is prescribed for the appropriate indication and used correctly in terms of potency, quantity, frequency and duration, the risk of clinically significant adverse effects is generally low. At the same time, using too little treatment because of fear can leave inflammatory disease inadequately controlled. The aim is therefore not to use corticosteroids indiscriminately, but to use them appropriately, for the right indication and under medical guidance, balancing their potential benefits and risks for each patient.

We invite you to share this article about corticosteroid phobia and concerns surrounding corticosteroid side effects with family and friends who may find it useful.