Topical Corticosteroid Phobia in Tunisia: A Pilot Study in Atopic Dermatitis Patients and Healthcare Professionals

Abstract

Topical corticosteroids remain the gold standard for treating flares of atopic dermatitis (AD). Topical corticosteroid phobia (TCP) often leads to poor treatment adherence and therapeutic failure. While TCP has been largely studied in Europe and Asia, data from North Africa remain poor. We conducted a cross-sectional study at the Charles Nicolle Hospital in Tunis over a six-month period to evaluate TCP and its determinants among Tunisian patients and the healthcare professionals (HCPs) managing them. Our study included 50 participants, consisting of 43 parents of children with AD and 7 adult patients (patient group) and 92 HCPs (dermatologists (n = 28), residents in dermatology (n = 26), pediatricians (n = 9), pharmacists (n = 11), and nurses (n = 18)). TCP was quantified using the validated 12-item TOPICOP score, which assesses two dimensions: “beliefs” and “fears and concerns.” [1] AD severity was measured using the Patient-Oriented Eczema Measure (POEM) [2]. The TOPICOP score has no established cutoff value; however, the mean score in dermatologists was considered the reference value. Statistical analyses were performed using Student's t-test or Mann–Whitney U test, chi-squared or Fisher's exact test, ANOVA test, and Spearman's correlation as appropriate. A p-value < 0.05 was considered significant. The mean global TOPICOP score was 38.9% ± 22.4% in the patient group. Regarding HCPs, nurses (56.3% ± 17.3%), pediatricians (56.2% ± 17%), and pharmacists (54.8% ± 12.4%) showed numerically higher TOPICOP scores. In contrast, dermatologists (43.2% ± 17.3%) and dermatology residents (44.8% ± 10.5%) showed the lowest scores (Table 1). A positive correlation was found between a higher educational level and higher TOPICOP scores (r = 0.323, p = 0.025) in the patient group. No association was found between TOPICOP scores and AD severity, age, or previous history of side effects. Our study, the first of its kind in Africa, highlighted a relatively lower mean TOPICOP scores in the patients group compared with European cohorts [1, 3], suggesting distinct sociocultural factors. This trend is even observed in our daily clinical practice in Africa, where patients occasionally tend to overuse topical corticosteroids for many indications, including irritant dermatitis or even for skin-bleaching properties. On the other hand, those with higher educational status tend to have higher TOPICOP scores. We hypothesize that this finding may reflect a greater exposure to European information through social media and press, where concerns regarding topical corticosteroids are more frequently debated. However, further qualitative research is needed to better understand the socio-cultural determinants of treatment perceptions in our population. Our study showed high mean TOPICOP scores among some HCP like pediatricians, pharmacists, and nurses. This is particularly relevant as these professionals often serve as the primary point of contact for patients and their families. Pediatricians may be the first to diagnose AD and initiate treatment, while pharmacists and nurses play a role in drug dispensing and counseling. These groups may benefit from targeted therapeutic education [4, 5]. The primary limitation of this study is the lack of a validated cutoff value for the TOPICOP score, which prevents the diagnosis of TCP at the individual level. Additionally, the small sample size in certain healthcare professional subgroups may limit the generalizability of our findings. Besides, the ‘patient group’ included both patients and parents. These two subgroups were not analyzed separately limiting the interpretation of specific concerns unique to each respondent type. In conclusion, our study demonstrates that TCP scores are slightly lower than those reported in the European studies, reflecting social and educational differences. Nevertheless, it highlights the importance of therapeutic education and the dissemination of accurate information to both patients and HCPs. The authors have nothing to report. The authors declare no conflicts of interest. The data that support the findings of this study are available from the corresponding author upon reasonable request.