Abstract
Introduction
Various healthcare professionals (HCPs) deliver care for patients with atopic dermatitis (AD). Although pivotal, management strategies and the relation with corticophobia among HCPs have not been investigated. This study aimed to investigate management strategies for AD and its relation with corticophobia among HCPs.
Methods
Dutch general practitioners (GPs), youth healthcare physicians (YHPs), pediatricians, dermatologists, pharmacists, and pharmacy assistants participated in a survey on management strategies and corticophobia. The Topical Corticosteroid Phobia questionnaire for professionals (TOPICOP-P) was used to measure attitudes toward topical corticosteroids (TCSs). Higher scores reflect a more negative attitude.
Results
A total of 407 HCPs (124 GPs, 33 YHPs, 51 pediatricians, 56 dermatologists, 58 pharmacists, and 85 pharmacy assistants) participated. Compared to dermatologists, other HCPs showed greater reluctance to TCS. This difference was highlighted by the finding that half of GPs reported to prescribed only TCS of mild potency for infants with severe AD, while few dermatologists (9%) reported a similar approach. Dermatologists had lowest TOPICOP-P scores (median: 19, IQR: 12–28). GPs and pharmacy assistants had highest scores (GPs median: 36, IQR: 31–44, pharmacy assistants: median: 36, IQR: 31–42). More corticophobia was significantly associated with prescription of a lower TC potency class in prescribing HCPs (B −0.04, 95% CI: −0.07 to 0.01, p = 0.01), and a trend was found between more corticophobia and longer perceived durability of one TCS tube.
Conclusions
This study shows the differences in management of AD and reluctance toward TCS in HCPs. Furthermore, corticophobia among HCPs and its influence on the selection of TCS potency class and recommendations were demonstrated. To reduce corticophobia and improve care for AD, more education is needed.
Keywords: Atopic dermatitis, Health personnel, Disease management, Patient education, Corticophobia
Introduction
Atopic dermatitis (AD) is a common chronic inflammatory skin disease with a prevalence up to 20% in children and 10% in adults [1]. Of all skin diseases, AD has the highest global disease burden [2]. Hallmark features of AD include intense pruritus and skin rash affecting the quality of life of patients and their family members [3]. Although no cure for AD is available, symptoms can be treated effectively in most patients [4, 5]. The basic treatment includes daily application of emollients to improve skin hydration and protection from allergens and irritants. The next step consists of treatment with topical anti-inflammatory therapies. Topical corticosteroids (TCSs) are the first-line anti-inflammatory treatment and their effectiveness and safety have been well documented [6]. Most patients with AD can be treated effectively with a combination of TCS and emollients [7]. Although effective, success of TCS treatment depends on three principles: sufficient potency, sufficient dosage, and correct application. Unfortunately, TCSs are often incorrectly used and adherence is low [8].
Conflicting information of healthcare professionals (HCPs) on TCS and AD management is an important source of nonadherence [9]. Besides conflicting information, the widespread presence of incorrect information on social media and the internet may lead to confusion and low adherence [10]. To improve adherence and overall treatment success, all HCPs should provide similar instructions on TCS and hold a similar approach to managing AD with TCS. Therefore, it is vital to gain insight into the management strategies used by HCPs. This includes the treatment and instructions a HCP would recommend for patients.
Besides conflicting information, anxiety for TCS, also known as “corticophobia,” is an important cause of nonadherence [11, 12]. In addition to patients, HCPs themselves may also experience anxiety for TCS [13, 14]. Compared to dermatologists, general practitioners (GPs), pediatricians, and pharmacists experience more anxiety for TCS [14]. Negative views on TCS among HCPs may affect management decisions and patient adherence [15, 16]. Although pivotal, corticophobia among HCPs and its relation to the management of patients (e.g., choice for TCS potency or recommendations on its usage) has not been investigated. Since patients’ views are shaped by the overall care they receive, it is crucial to investigate corticophobia among all HCPs.
Materials and Methods
Setting
In the Netherlands, the majority of patients with AD receive treatment from their GP [17]. In addition to managing AD, GPs function as gatekeepers to secondary care. Most children with AD requiring specialized care from a pediatrician or dermatologist are referred back to primary care after achieving disease control. In addition to patient education provided by physicians, caregivers receive education on the use of medication from pharmacy personnel. Finally, youth healthcare physicians (YHPs) have an important role in the primary detection of AD and provide additional education during developmental checkups [18].
Study Design
We conducted an electronic survey among consulting GPs, YHPs, pediatricians, dermatologists, pharmacists, and pharmacy assistants. GPs were invited to participate by the Department of General Practice of the Erasmus MC University Medical Center, Rotterdam (N = 391). All Dutch pediatricians, dermatologists, and pharmacy assistants received an invitation to participate via newsletters of their respective national associations (Dutch Society of Pediatrics, Dutch Society for Dermatology and Venereology, and Optima Farma). Pharmacists were invited by the Pharmacists Association Rijnmond (representing 148 pharmacies). Finally, YHPs of the Youth Healthcare Physicians Netherlands were invited to participate prior a scientific meeting of their organization.
Survey
A panel of experts consisting of two dermatologists, a GP, a pediatrician, pharmacist, psychologist, and two PhD candidates in AD was formed (online suppl. Table S1; for all online suppl. material, see https://doi.org/10.1159/000542421). During several meetings, a survey was designed to investigate management strategies, patient education, and corticophobia. After development, the initial survey was sent to independent GPs, pediatricians, dermatologists, pharmacists, and the national patient organization for AD to check the relevance, comprehensiveness, and comprehensibility. After their input, a final version of the survey was established.
The survey consisted of 4 parts: background characteristics, medical casuistry, TCS, and the Topical Corticosteroid Phobia questionnaire for professionals (TOPICOP-P) questionnaire (online suppl. S2) [14]. The medical casuistry contained two cases: an infant with severe AD and a toddler with mild AD (Table 1). The first case was also questioned with the infant’s age changing to the age of an adolescent. Treatment strategies were only asked of GPs, dermatologists, and pediatricians since HCPs do not prescribe medication. Patient education strategies were asked of all HCPs, and handling of prescriptions was only asked of pharmacists/pharmacy assistants. After medical casuistry, all HCPs were asked to estimate the prevalence of nonadherence caused by corticophobia in patients. Finally, beliefs on TCS and corticophobia were investigated using the TOPICOP-P [14]. The TOPICOP was initially developed for patients with AD but has been modified for HCPs (TOPICOP-P) [14, 19]. The questionnaire consists of 12 statements on TCS and can be divided into a “worries” (6 items) and “beliefs” (6 items) subscale. For each statement, HCPs reported the degree to which they agreed on a 4-point scale (ranging from totally disagree to not really agree; almost agree or totally agree; or for other statements from never to sometimes, often, or always). Based on these outcomes, a score ranging from 0% to 100% was calculated for each subscale and the total score, with higher scores reflecting more corticophobia.
Table 1.
Overview of cases in our survey
| Case 1: 1-year-old infant/14-year-old adolescent with severe AD | |
| Symptoms | Intense pruritic rash causing severe sleep disturbance |
| Age – infant/adolescent | 13 months/14 years |
| Sex | Male |
| Clinical findings | Erythematosquamous plaques and excoriations over 50% of his body |
| EASI/TIS | 23.6/9 |
| Case 2: 3-year-old toddler with mild to moderate AD | |
| Symptoms | Pruritic rash |
| Age | 3 years |
| Sex | Female |
| Clinical findings | Erythematosquamous plaques in cubital and popliteal fossae |
| EASI/TIS | 6.4/4 |
EASI is a tool developed to measure the extent and severity of AD. EASI scores range from 0 to 72 with higher scores reflecting more severe AD. EASI scores between 0.1 and 5.9 reflect mild AD; 6.0–22.9, moderate; and 23.0–72.0, severe AD [20]. The EASI is commonly used in clinical trials and practice by dermatologists [21]. The TIS score is developed as a simple tool to assess AD severity based on extent and severity signs. TIS scores range from 0 to 9 with higher scores reflecting more severe AD. TIS scores ≤2 reflect mild AD; 3–5, moderate; and ≥6, severe AD. The TIS score is endorsed by Dutch guidelines as a tool to measure AD severity in primary care [22].
Statistical Analysis
Descriptive statistics were used to describe the results of our survey. Three separate ordinal logistic regression analyses were conducted to assess the impact of several factors on the choice of TCS potency prescription among HCPs for each presented case (infant and adolescent with severe AD and toddler with mild AD). Each model contained five independent variables (HCP sex, HCP years of experience, HCP prescription frequency, healthcare profession, and TOPICOP-P score). All data handling and analyses were performed in SPSS (version 26; IBM).
Ethical Approval
This study was exempt from the Dutch Medical Research Involving Human Subjects Act according to the Institutional Review Board of Erasmus MC (MEC-2020-0697).
Results
Participant Characteristics and Thoughts on Corticophobia
A total of 407 HCPs participated in the survey (Table 2). GPs comprised the largest group of participants (n = 124), followed by pharmacy assistants (n = 85). The majority of HCPs reported to provide care for patients with AD on a daily or weekly basis. Corticophobia in caregivers of patients with AD was seen as an important source of nonadherence by all professionals. More than half of prescribing HCPs estimated that corticophobia-related nonadherence is present in more than a quarter of all patients. Pharmacists and pharmacy assistants had the lowest estimates of corticophobia-related nonadherence.
Table 2.
Participant characteristics and thoughts on corticophobia
| Item | GPs (n = 124) | YHPs (n = 33) | Pediatricians (n = 51) | Dermatologists (n = 56) | Pharmacists (n = 58) | Pharmacy assistants (n = 85) |
|---|---|---|---|---|---|---|
| Age, mean (SD), years | 49.3 (11.2) | 48.7 (11.4) | 49.5 (8.9) | 43.2 (10.8) | 40.9 (12.2) | 44.5 (11.2) |
| Female, n (%) | 60 (49) | 32 (97) | 38.0 (75) | 44.0 (79) | 40.0 (69) | 82 (97) |
| Years of experience, mean (SD) | 17.9 (10) | 14.3 (9) | 15.5 (9) | 10.7 (9) | 14.9 (12) | 19.7 (12) |
| Prescription/education frequency, n (%) | ||||||
| Daily | 23 (19) | 8 (24) | 6 (12) | 43 (77) | 7 (12) | 28 (33) |
| Weekly | 71 (58) | 17 (52) | 26 (51) | 10 (18) | 33 (57) | 33 (39) |
| Monthly | 28 (23) | 3 (9) | 15 (29) | 2 (4) | 10 (17) | 7 (8) |
| Yearly | 0 (0) | 1 (3) | 3 (6) | 1 (2) | 2 (3) | 3 (4) |
| Never | 1 (1) | 0 (0) | 1 (2) | 0 (0) | 6 (10) | 14 (17) |
| Estimated prevalence of corticophobia in caregivers of patients with AD leading to nonadherence, n (%) | ||||||
| (n = 101) | (n = 28) | (n = 45) | (n = 51) | (n = 39) | (n = 65) | |
| 0% | 0 (0) | 0 (0) | 0 (0) | 0 (0) | 0 (0) | 1 (2) |
| <10% | 16 (16) | 1 (4) | 1 (2) | 8 (16) | 7 (18) | 11 (17) |
| 10–25% | 35 (35) | 5 (18) | 3 (7) | 8 (16) | 15 (39) | 26 (40) |
| 25–50% | 36 (36) | 10 (36) | 17 (38) | 18 (35) | 14 (36) | 14 (22) |
| >50% | 14 (14) | 12 (43) | 24 (53) | 17 (33) | 0 (0) | 7 (11) |
Numbers and percentages may not add up due to missing values.
SD, standard deviation.
Treatment of AD
HCPs chose a variety of different management strategies for all cases (Table 3). Compared to dermatologists, GPs (p < 0.01) and pediatricians (p = 0.1) were more reluctant to prescribe TCS for the infant with mild AD. Dermatologists were almost the only group that prescribed topical calcineurine inhibitors (p < 0.01). Compared to pediatricians and dermatologists, GPs were more reluctant to prescribe more potent TCS in all situations but especially in young children with severe AD (p < 0.01). Additionally, in contrast to other HCPs, most dermatologists (range: 92–98%) refrained from prescribing TCS of mild potency in all cases. When investigating management strategies for children with severe AD and frequent flares, GPs more often (p < 0.01) reported to refer infants (31%) than adolescents (11%).
Table 3.
Treatment strategies in AD proposed by HCPs
| Item | GPs (n = 116) | Pediatricians (n = 49) | Dermatologists (n = 54) |
|---|---|---|---|
| Treatment for a 1-year-old infant with severe AD | |||
| Emollients | 116 (100) a | 49 (100) a | 53 (98) a |
| TCS | 111 (96) a | 49 (100) a | 54 (100) a |
| TCI | 3 (3)b | 2 (4)b | 6 (11)b |
| Antihistamine | 26 (22)c | 16 (33)b | 9 (17)b |
| Sedative antihistamine | 9 (8)d | 9 (18)d | 18 (33)d |
| Oral corticosteroid | 2 (2)c | 0 (0)d | 2 (4)d |
| Treatment for a 3-year-old toddler with mild AD | |||
| Emollients | 102 (99) a | 45 (100) a | 50 (98) a |
| TCS | 86 (84) a | 40 (89) a | 50 (98) a |
| TCI | 0 (0)b | 1 (2)d | 12 (24)d |
| Antihistamine | 3 (3)c | 4 (9)b | 3 (6)b |
| Sedative antihistamine | 1 (1)b | 0 (0)b | 2 (4)b |
| Oral corticosteroid | 0 (0)c | 0 (0)c | 2 (4)c |
| TCS potency class for a 1-year-old infant with severe AD | |||
| I, mild | 58 (50)b | 8 (16)b | 5 (9)b |
| II, moderate | 51 (44)d | 34 (69)d | 30 (56)d |
| III, potent | 7 (6) a | 7 (14) a | 19 (35) a |
| IV, very potent | 0 (0)b | 0 (0)b | 0 (0)b |
| TCS potency class for a 14-year-old adolescent with severe AD | |||
| I, mild | 12 (10)b | 4 (8)b | 1 (2)b |
| II, moderate | 59 (51)b | 25 (51)b | 6 (11)b |
| III, potent | 41 (35) a | 20 (40) a | 45 (83) a |
| IV, very potent | 4 (3)b | 0 (0)b | 2 (4)b |
| TCS potency class for a 3-year-old toddler with mild AD | |||
| I, mild | 58 (56)b | 19 (42)b | 4 (8)b |
| II, moderate | 41 (40) a | 23 (51) a | 36 (71) a |
| III, potent | 4 (4)b | 3 (7) a | 11 (22) a |
| IV, very potent | 0 (0)b | 0 (0)b | 0 (0)b |
| Treatment plan for a 24-month-old infant with severe and frequent AD flares, n (%) | |||
| Restart TCS after flare-up | 27 (26)b | 7 (16)b | 1 (2)b |
| Pulse therapy (continuous maintenance treatment with intermittent TCS) | 45 (43) a | 18 (40) a | 29 (57) a |
| Combination of TCS and TCI | 1 (1)b | 2 (4) a | 21 (41) a |
| Referring patient to a specialist | 33 (31)a | 18 (40)a | 0 (0)a |
| Treatment plan for a 14-year-old adolescent with severe and frequent AD flares, n (%) | |||
| Restart TCS after flare-up | 27 (26)b | 5 (11)b | 1 (2)b |
| Pulse therapy (continuous maintenance treatment with intermittent TCS) | 59 (56) a | 18 (40) a | 25 (49) a |
| Combination of TCS and TCI | 8 (8)b | 7 (16) a | 25 (49) a |
| Referring patient to a specialist | 12 (11) a | 15 (33) a | 0 (0) a |
TCSs, topical corticosteroids; TCI, topical calcineurine inhibitor.
bNot according to relevant clinical guideline.
cNot mentioned in clinical guideline.
dMentioned as optional in clinical guideline. Responses in line with clinical guideline recommendations are also marked in bold.
Patient Education
An overview of reported patient education is provided in Table 4. Most HCPs reported instructing patients to use emollients once or twice daily, while a third of pharmacy personnel reported instructing patients to use emollients as necessary. Reported TCS starting instructions (starting with [twice-]daily application of TCS) followed clinical guidelines among almost all HCPs. Continuation instructions varied among HCPs. Most dermatologists (59%) and pediatricians (85%) instructed patients to continue to use TCS as long as AD remains active, compared to the majority of GPs (79%) and significant portion of pharmacists (24%) and pharmacy assistants (44%) that would limit the duration of TCS treatment (i.e., limit the maximum duration that TCS can be used in any regimen to a maximum of 4 weeks). With regards to TCS stop instructions, most HCPs recommend tapering schemes, except for a proportion (24%) of GPs that would instruct to stop TCS directly. For application of TCS, most HCPs instructed their patients to use the fingertip unit method. However, a large proportion of GPs (39%), YHPs (24%), pharmacy personnel (14–16%) would instruct to apply TCS thinly. Finally, with regards to instructions on the expected duration of use of a tube TCS of 30 g, except for dermatologists, most HCPs tend to overestimate the duration of use compared to the recommended duration based on body surface area and fingertip unit, especially in older children.
Table 4.
Patient education in AD across HCPs
| Item | GPs (n = 111) | YHPs (n = 25) | Pediatricians (n = 46) | Dermatologists (n = 53) | Pharmacists (n = 42) | Pharmacy assistants (n = 70) |
|---|---|---|---|---|---|---|
| Emollients, n (%) | ||||||
| No instructions | 0 (0) | 0 (0) | 0 (0) | 1 (2) | 0 (0) | 2 (3) |
| Apply if necessary | 2 (2) | 1 (4) | 5 (11) | 1 (2) | 15 (36) | 22 (31) |
| Once or twice dailya | 109 (98) | 18 (72) | 41 (89) | 51 (96) | 26 (62) | 42 (60) |
| Check with prescriberb | – | 6 (24) | – | – | 1 (2) | 2 (3) |
| TCS start instructions, n (%) | ||||||
| No instructions | 0 (0) | 0 (0) | 0 (0) | 1 (2) | 0 (0) | 2 (3) |
| Every other day | 0 (0) | 0 (0) | 0 (0) | 1 (2) | 0 (0) | 0 (0) |
| Maximum of 5 days | 5 (5) | 2 (8) | 0 (0) | 3 (6) | 0 (0) | 0 (0) |
| Once a daya | 32 (29) | 3 (12) | 11 (24) | 30 (57) | 9 (21) | 7 (10) |
| Twice a daya | 74 (67) | 4 (16) | 35 (76) | 18 (34) | 8 (19) | 22 (31) |
| Check with patient | – | 0 (0) | – | – | 18 (43) | 29 (41) |
| Check with prescriberb | – | 16 (64) | – | – | 7 (17) | 8 (11) |
| TCS continuation instructions, n (%) | ||||||
| No instructions | 0 (0) | 1 (4) | 0 (0) | 1 (2) | 0 (0) | 3 (4) |
| 1 week | 18 (16) | 2 (8) | 1 (2) | 2 (4) | 2 (5) | 5 (7) |
| Up to 4 weeks | 70 (63) | 4 (16) | 6 (13) | 19 (36) | 9 (21) | 27 (39) |
| Until eczema is gonea | 23 (21) | 5 (20) | 39 (85) | 31 (59) | 8 (19) | 5 (7) |
| Check with patient | – | 0 (0) | – | – | 20 (48) | 27 (39) |
| Check with prescriberb | – | 13 (52) | – | – | 3 (7) | 1 (1) |
| TCS stop instructions, n (%) | ||||||
| No instructions | 2 (2) | 1 (4) | 0 (0) | 1 (2) | 0 (0) | 2 (3) |
| Stop directly | 27 (24) | 1 (4) | 3 (7) | 1 (2) | 2 (5) | 2 (3) |
| Tapering schemea | 52 (47) | 15 (60) | 43 (94) | 51 (96) | 27 (64) | 53 (76) |
| Check with patient | – | 0 (0) | – | – | 11 (26) | 8 (11) |
| Check with prescriberb | – | 8 (32) | – | – | 2 (5) | 3 (4) |
| TCS application instructions, n (%) | ||||||
| No instructions | 6 (5) | 4 (16) | 1 (2) | 1 (2) | 0 (0) | 2 (3) |
| Thin | 43 (39) | 6 (24) | 4 (9) | 3 (6) | 6 (14) | 11 (16) |
| FTUa | 61 (55) | 9 (36) | 40 (87) | 47 (89) | 36 (86) | 55 (79) |
| Thick | 0 (0) | 0 (0) | 1 (2) | 2 (4) | 0 (0) | 0 (0) |
| Check with prescriberb | – | 6 (24) | – | – | 0 (0) | 0 (0) |
| Estimated duration of applying one tube of 30 grams for a 1-year-old infant with severe AD (BSA 50%), n (%) | ||||||
| 1–2 days | 0 (0) | 0 (0) | 0 (0) | 1 (2) | 0 (0) | 2 (3) |
| 3–5 days | 8 (7) | 0 (0) | 2 (4) | 7 (13) | 2 (5) | 11 (16) |
| 4 weeksa | 44 (40) | 7 (28) | 20 (44) | 27 (51) | 19 (45) | 22 (31) |
| 2 weeks | 42 (38) | 9 (36) | 20 (44) | 15 (28) | 16 (38) | 23 (33) |
| 1 month | 15 (14) | 8 (32) | 3 (7) | 3 (6) | 5 (12) | 5 (7) |
| >2 months | 1 (1) | 1 (4) | 0 (0) | 0 (0) | 0 (0) | 4 (6) |
| Estimated duration of applying one tube of 30 grams for a 14-year-old adolescent with severe AD (BSA 50%), n (%) | ||||||
| 1–2 days | 15 (14) | 4 (16) | 7 (15) | 14 (26) | 8 (19) | 21 (30) |
| 3–5 daysa | 28 (25) | 7 (28) | 20 (44) | 26 (49) | 22 (52) | 16 (23) |
| 1 week | 44 (40) | 2 (8) | 14 (30) | 8 (16) | 5 (12) | 9 (13) |
| 2 weeks | 16 (14) | 10 (40) | 3 (7) | 3 (6) | 5 (12) | 13 (19) |
| 1 month | 5 (5) | 2 (8) | 1 (2) | 1 (2) | 2 (5) | 6 (9) |
| >2 months | 2 (2) | 0 (0) | 0 (0) | 0 (0) | 0 (0) | 2 (3) |
TCS, topical corticosteroids; TCI, topical calcineurine inhibitor; FTU, fingertip unit.
bCheck with prescriber implies that a YHP, pharmacist, or pharmacy assistant would consult the prescriber before providing any recommendations. In the case of YHPs, treatment may have been prescribed by another physician.
Handling of Prescriptions
Pharmacy personnel reported varying actions when handling prescriptions depending on their profession and TC potency (online suppl. Table S3). Most pharmacists (range: 90–98%) and pharmacy assistants (range: 82–89%) reported to provide a maximum of two tubes of TCS, even if the prescriber advised an amount of 5 tubes for a 3 year old. Furthermore, the majority of pharmacists (62%) reported occasionally or often providing other TCS than prescribed (could also be another vehicle) without consultation of the prescriber, compared to a quarter of pharmacy assistants (23%). A fifth of pharmacy personnel (20–29%) reported changing TCS prescription without consulting the prescriber in case of TCS shortages.
Corticophobia among HCPs
An overview of TOPICOP-P scores is presented in Table 5. Dermatologists had the lowest TOPICOP-P scores (median: 19.4%, IQR: 11.8–27.8%) followed by pediatricians (median: 25.6%, IQR: 16.7–33.3%). GPs and pharmacy assistants had the highest scores (GPs median: 36.1%, IQR: 30.6–44.4%; pharmacy assistants: median: 36.1%, IQR: 30.6–41.7%). In all HCP groups, corticophobia scores for the beliefs scale were higher than for the worries scale. Investigation of the individual items of the TOPICOP-P questionnaire showed that HCPs most frequently agreed “almost agree” or “totally agree” that TCS pass into the bloodstream (56.6%) when following treatment guidelines, followed by agreeing that it should be discouraged to apply TCS on sensitive skin, i.e., eyelids (52.6%), and that TCS can lead to infections (37.4%) (online suppl. Table S4).
Table 5.
TOPICOP-P scores of HCPs
| Item | GPs (n = 100) | YHPs (n = 24) | Pediatricians (n = 48) | Dermatologists (n = 48) | Pharmacists (n = 37) | Pharmacy assistants (n = 61) |
|---|---|---|---|---|---|---|
| Overall TOPICOP-P score, median (IQR), % | 36.1 (30.6–44.4) | 30.6 (25.0–38.9) | 25.6 (16.7–33.3) | 19.4 (11.8–27.8) | 33.3 (27.8–43.1) | 36.1 (30.6–41.7) |
| Beliefs – score, median (IQR), % | 38.9 (29.2–44.4) | 36.1 (23.6–44.4) | 33.3 (22.2–38.9) | 27.8 (16.7–37.5) | 38.9 (33.3–50.0) | 44.4 (33.3–47.2) |
| Worries – score, median (IQR), % | 33.3 (27.8–44.4) | 27.8 (16.7–37.5) | 22.2 (33.3–45.8) | 11.1 (5.6–16.7) | 27.8 (22.2–36.1) | 33.3 (22.2–38.9) |
TOPICOP-P scores can range from 0 to 100%, with higher scores reflecting more corticophobia.
TOPICOP-P, Topical Corticosteroid Phobia questionnaire for professionals.
Corticophobia, TCS Prescription, and Instructions
The relation between HCP-reported choice for TCS potency and corticophobia among HCPs is visualized for all cases in Figure 1. HCP-reported selection of TC potency class for infants with severe AD was significantly associated with TOPICOP-P scores (B −0.04, 95% CI: −0.07 to 0.01, p = 0.01) and being a GP (B −1.9, 95% CI: −2.98 to 0.89, p = 0.00). This implies that an increase of 25 points (out of 100) is associated with the prescription of TC from a lower potency class and being a GP is associated with prescription of TCS of 2 potency classes lower than dermatologists (online suppl. Table S5). In our population, 21% of GPs have TOPICOP-P scores at least 25 points higher than the median score of dermatologists. Comparable results were found for the selection of TC potency for infants with mild and adolescents with severe AD, in which being a GP and pediatrician was associated with prescription of lower TC potency, and a clear trend was found for TOPICOP-P scores (−0.03, 95% CI: −0.06 to 0.00, p = 0.05, in infants with mild AD and −0.02, 95% CI: −0.05 to 0.01, p = 0.12, in adolescents with severe AD). All three models explained almost a third of the variance in TC potency (range: 28–31%). A similar visualization is presented for the estimated duration for which HCPs would advise to use a tube of TCS in relation to their TOPICOP-P scores (Fig. 2). This figure shows a trend in which HCPs with higher TOPICOP-P scores would advise a longer duration of use for a single tube of TCS.
Fig. 1.
Corticophobia score of HCPs in relation to prescribed TCS potency class. The boxes represent the interquartile range which represents the 25th to the 75th percentile of TOPICOP-P scores of HCPs; the line in the box represents the median. a Corticophobia scores of HCPs in relation to potency class prescribed for an infant with severe AD. b Corticophobia of HCPs in relation to potency class prescribed for an adolescent with severe AD. c Corticophobia of HCPs in relation to potency class prescribed for an infant with mild AD. TCSs, topical corticosteroids.
Fig. 2.
Corticophobia score of HCPs in relation to estimated duration of use of one tube of TCS. The boxes represent the interquartile range which represents the 75th minus the 25th percentile of TOPICOP-P scores of HCPs; the line in the box represents the median. a Corticophobia scores of HCPs in relation to the estimated duration of use of a standardized tube of 30 g of TCS for an infant with severe AD with severe AD affecting approximately 50% of the body surface area. b Corticophobia of HCPs in relation to potency class prescribed for an adolescent with severe AD affecting approximately 50% of the body surface area.
Discussion
In this study, we investigated management strategies, patient education, and corticophobia among HCPs involved in AD. First, we found that GPs and pediatricians prescribe less potent TCS than dermatologists. In addition, we found large differences in TCS application instructions and the amount of TCS perceived as necessary for treatment. Second, we found handling of TCS prescriptions in pharmacies may result in provision of less TCS than prescribed and in some cases other TCS than prescribed. Third, we found more corticophobia among GPs, YHPs, and pharmacy personnel as compared to dermatologists. Finally, we found that higher corticophobia scores are associated with prescription of less potent TCS and longer perceived durability of a TCS tube.
Differences in management strategies may be partially explained by differences in the setting in which HCPs operate. For example, GPs see fewer patients with severe AD than dermatologists and are generally used to operating based on a “step-up approach” (start with less intensive treatment and raise intensity after reevaluation). In a qualitative study, GPs reported uncertainty about quantities of topical treatments and lack of confidence to prescribe potent TCS [28]. This uncertainty may be reflected in our findings that showed that management strategies and patient education of HCP groups seem to differ from their respective clinical guidelines, especially among HCPs other than dermatologists. Although guidelines for AD management have become available for all HCPs, certain barriers (i.e., lack of familiarity with guideline recommendations or lack of self-efficacy) may refrain some HCPs from adhering to these recommendations. Unfortunately, adherence and barriers to guideline adherence for dermatological guidelines have only been investigated to a limited extent. A study using a previously developed framework could further help explore which barriers explain why some HCPs do not adhere to guidelines [29].
According to our study, HCPs were more reluctant with TC potency and TC amount in young children and children with severe AD than in older children with mild AD. More anxiety about side effects may be present due to fear of percutaneous absorption when using potent TCS [30]. To gain better insights, we investigated corticophobia among HCPs and found more anxiety for TCS among other HCPs than dermatologists, confirming previous findings [13, 14, 31]. Next, we found that corticophobia was associated with prescription of less and less potent TCS. These findings suggest that corticophobia may lead to undertreatment. Given that the majority of patients are treated in primary care settings, improving care at this level is essential to reduce the overall burden of AD on society [7]. Similarly negative messages on TCS in pharmacies could influence adherence and thereby the effectiveness of treatment. Fortunately, studies have shown that additional education may lower corticophobia among HCPs [31, 32]. Another proven effective approach to combat undertreatment in more severe patients would be to invest in structured educational programs that improve (self-)management of patients with AD [33]. In any case, investment in patients and professionals is needed to improve the overall care in AD.
Strengths and Limitations
This is the first study to assess management strategies, patient education, and its relation with corticophobia among HCPs groups involved in management of AD, offering an overview of their practices and care patients with AD receive. A limitation was the questionnaire-based nature of this study which could have led to professional desirability bias. Additionally, selection bias may have occurred as HCPs with a specific interest in AD may have participated. Furthermore, the amount of HCPs in some groups was relatively low. Next, although we received the TOPICOP questionnaire directly from Lambrechts et al. [14], this version of the questionnaire has not been extensively validated. Some caution when interpreting the results may be needed. Finally, the generalizability of our results may be reduced due to differences in healthcare systems or specific content of the Dutch AD guideline. However, in our study, we evaluated internationally accepted concepts of care for AD, and differences in the Dutch healthcare system may be modest compared to other developed countries [34–36].
Conclusion
This study reveals the differences in management strategies and patient education HCPs provide for patients with AD. In general, GPs and pediatricians were more reluctant with TCS compared to dermatologists. Furthermore, this study confirmed the presence of corticophobia among HCPs and impact of corticophobia on management strategies of HCPs. These findings emphasize the need for medical education in HCPs involved in the care for AD.
Key Message
Management strategies between healthcare professional groups in atopic dermatitis vary and are influenced by corticophobia.
Acknowledgment
We thank all participating and supporting healthcare professionals.
Statement of Ethics
This study was exempt from the Dutch Medical Research Involving Human Subjects Act according to the Institutional Review Board of Erasmus MC (MEC-2020-0697). Written informed consent to participate was not directly obtained but inferred by participation in the survey.
Conflict of Interest Statement
The authors have no conflicts of interest to declare.
Funding Sources
No funding for this study was received.
Author Contributions
A.R., K.F.H., R.S., G.E., M.L.A.S., and S.G.M.A.P. designed the study. All the authors contributed to the finalization of the survey and the data collection. A.R. and R.S. analyzed the data. A.R. wrote the original draft of the manuscript with support of K.F.H., W.C.A.M.W., and R.S. All the authors discussed the results and contributed to the final manuscript. N.J.T.A., J.H., A.M.B., R.S., G.E., M.L.A.S., and S.G.M.A.P. supervised the project.
Funding Statement
No funding for this study was received.
Data Availability Statement
The data that support the findings of this study are not publicly available due to privacy reasons but are available from the corresponding author (S.G.M.A.P.) upon reasonable request.
Supplementary Material.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
The data that support the findings of this study are not publicly available due to privacy reasons but are available from the corresponding author (S.G.M.A.P.) upon reasonable request.