Chronic Hand Eczema and the Impact of Corticosteroid Fear

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Hand eczema (HE), which affects up to 15% of adults over their lifetime, can cause itch, burning sensations, and pain.¹ Consequently, this can have a negative impact on patients’ quality of life (QoL).² Chronic HE (CHE) is the most common occupational disease and patients may have to either modify work routines or change occupation.³

The main treatment for acute HE or flare-ups involves avoiding triggers, using emollients daily, and applying topical corticosteroids (TCS) or topical calcineurin inhibitors. However, prolonged use of TCS can lead to side effects like skin thinning, fissures, pain, and impaired skin barrier, and may even cause allergic contact dermatitis.^4-5

Corticosteroid phobiacan lead to poor adherence to treatment and reliance on alternative therapies.⁶ While previous research has shown that 51% of patients with various skin diseases experience corticosteroid phobia, there is limited data on this issue in patients with CHE.⁷ A recent study aimed to explore patient knowledge, beliefs, fears, and behaviors regarding TCS, as well as treatment adherence, in a Danish population of adult patients with CHE.⁸

“We found significant inverse associations between level of corticosteroid phobia and treatment adherence, highlighting the clinical impact of patients fears towards TCS use,” researchers wrote.

Methods

The study involved patients with CHE from the Danish Skin Cohort, a nationwide prospective cohort.Researchers gathered data on patients' age, onset and specifics of CHE (such as pain, itching, and fissures), atopic history, smoking status, CHE severity, and treatment with TCS. Patients' knowledge, beliefs, fears, and behaviors regarding TCS were assessed using the Topical Corticosteroid Phobia (TOPICOP) scale, and medication adherence was measured with the 5-item Medication Adherence Report Scale (MARS-5).

The TOPICOP scale, a validated 12-item tool, evaluates beliefs and fears about TCS use, with scores ranging from 0-36, while MARS-5 measures adherence with scores indicating levels of compliance. Only patients who completed both the TOPICOP and MARS-5 questionnaires were included in the study.

Demographics

The study included 1,340 patients with CHE, with 927 completing both the TOPICOP and MARS-5 surveys. The majority of participants were women (71.7%), with an average age of 55.4 years and an average age of CHE onset at 35.9 years. Researchers found a significant portion had a smoking history (53.5%); 36% had never smoked. The study stated55.8% of participants had clear or almost clearCHE severity distribution, 30.3% were moderate, 10.1% severe, and 3.8% very severe. Out of those who completed both surveys 39.7% had a history of atopic dermatitis. 37.2% of participants were current TCS users, 27.1% had used them in the last 3-12 months, 28.8% used them over a year ago, and 4.1% had never used them.

TOPICOP Findings

Knowledge and Beliefs:

• Many patients believed TCS enter the bloodstream (66.7%) and damage the skin (75.5%)
• Concerns about long-term health effects of TCS were reported by 48.9% of patients
• Beliefs varied by CHE severity and TCS use, with those using TCS less likely to fear long-term effects but more likely to believe TCS damage skin

Fears:

• 53.1% of patients feared applying TCS to sensitive areas like eyelids, and 64.1% were afraid of applying too much
• Fears of side effects were prevalent, especially among those who had never used TCS

Behaviors:

• Many patients (47.4%) often or always stop treatment as soon as possible
• 28.1% wait as long as possible before starting TCS
• 36.4% required reassurance about TCS use
• Patients with severe CHE were less likely to stop treatment promptly compared to those with mild CHE

MARS-5 Findings

• 38.8% of patients often or sometimes took less medicine than prescribed, and 54.0% frequently or sometimes stopped treatment early
• Patients with severe CHE were more likely to adhere to prescribed doses compared to those with mild CHE
• Higher TOPICOP scores (indicating more concerns and fears about TCS) were associated with lower medication adherence

Conclusion

This study highlights that topical corticosteroid phobia is prevalent among patients with CHE and is negatively associated with treatment adherence. Limitations of the study included the lack of a clear definition and standardization of corticosteroid phobia, and the absence of validated cut-off values for the TOPICOP scale in patients with CHE. The study also notes that the MARS-5, while useful for measuring adherence, is not specifically designed for TCS. Researchers stated these findings underscore the urgent need for improved education about TCS for both patients and healthcare professionals, and the importance of developing safe and effective non-steroidal treatment options for those with CHE.

References

1. Christensen MO, Sieborg J, Nymand LK, et al. Prevalence and clinical impact of topical corticosteroid phobia among patients with chronic hand eczema – findings from the Danish skin cohort. JAAD. August 2024. doi:10.1016/j.jaad.2024.07.1503
2. Agner T, Andersen KE, Brandao FM, et al. Hand eczema severity and quality of life: a cross-sectional, multicentre study of hand eczema patients. Contact Dermatitis. 2008;59(1):43-47. doi:10.1111/j.1600-0536.2008.01362.x
3. Cvetkovski RS, Zachariae R, Jensen H, et al. Prognosis of occupational hand eczema: a follow-up study. Arch Dermatol. 2006;142(3):305-311. doi:10.1001/archderm.142.3.305
4. Thyssen JP, Schuttelaar MLA, Alfonso JH, et al. Guidelines for diagnosis, prevention, and treatment of hand eczema. Contact Dermatitis. 2022;86(5):357-378. doi:10.1111/cod.14035
5. Baeck M, Goossens A. Immediate and delayed allergic hypersensitivity to corticosteroids: practical guidelines. Contact Dermatitis. 2012;66(1):38-45. doi:10.1111/j.1600-0536.2011.01967.x
6. Countering corticophobia. AAD. Accessed August 29, 2024. https://www.aad.org/dw/dw-insights-and414 inquiries/pediatric-dermatology/countering-corticophobia
7. Contento M, Cline A, Russo M. Steroid phobia: A review of prevalence, risk factors, and interventions. Am J Clin Dermatol. 2021;22(6):837-851. doi:10.1007/s40257-021-00623-6
8. Christensen MO, Sieborg J, Nymand LK, et al. Prevalence and clinical impact of topical corticosteroid phobia among patients with chronic hand eczema – findings from the Danish skin cohort. JAAD. 2024; doi:10.1016/j.jaad.2024.07.1503