Awareness, knowledge, attitude, and behaviors related to topical corticosteroid use among population in Hail, Saudi Arabia: A cross-sectional study

ABSTRACT

Background:

Corticosteroids are widely used for inflammatory conditions, yet misuse and limited public awareness can cause preventable harm. In Hail, Saudi Arabia, community knowledge appears limited, warranting targeted assessment.

Objective:

To assess knowledge, awareness, attitudes, and use patterns of topical corticosteroids (TCSs) among adults in Hail, Saudi Arabia.

Methods:

We conducted a cross-sectional online survey (October 2024–March 2025) among adults aged ≥18 years. Of 535 respondents, 419 (78.0%) reported prior TCS use and were included in behavioral analyses, while 116 (21.0%) were non-users. Descriptive statistics summarized patterns, and bivariate analyses examined associations between awareness and behaviors.

Results:

Prescription use was more common than self-medication (58.9% vs 41.1%), and most users applied corticosteroids once daily (60.6%). Mometasone was the most frequently reported agent (33.9%), although 36.8% could not name the product; acne, melasma, and tinea were common indications. Awareness was moderate: 62.8% recognized potency categories, and 55.4% were aware of adverse effects. Overall, 45.0% reported ≥1 adverse effect, most often mood changes, pruritus, increased thirst/urination, or skin thinning. Most had discontinued at least once (79.5%); tapering was more frequent than abrupt cessation (58.9% vs 41.1%), and relapse occurred in 23.7%, often within a week. Awareness aligned with safer practice: aware users were more likely to have a prescription (65.0% vs 48.7%) and to recognize adverse effects (73.8% vs 24.4%); prescribed users also tapered more often than they stopped abruptly (67.6% vs 43.9%).

Conclusion:

TCS use is prevalent in Hail and is accompanied by self-medication and important knowledge deficits. Strengthening pharmacist counseling, improving labeling, regulating access to higher-potency agents, and implementing community education initiatives may enhance safety and reduce avoidable adverse outcomes.

Introduction

Corticosteroids are a class of medications that mimic the effects of hormones naturally produced by the adrenal glands.[1] They are widely recognized as a standard treatment for reducing inflammation and modulating immune responses in a range of acute and chronic inflammatory disorders.[2] These medications can be administered orally, topically, or through injections, depending on the clinical indication.[1] However, corticosteroid use is not without risks. The adverse effects of glucocorticoids can vary significantly, ranging from mild to severe, depending on the dosage, duration of therapy, and individual patient susceptibility.[2,3] With careful monitoring and appropriate preventive measures, the benefit-to-risk ratio of glucocorticoid therapy can be optimized to ensure safer use.[4] While short-term corticosteroid use is generally associated with mild and reversible side effects, long-term therapy can lead to severe, potentially irreversible complications involving multiple organ systems, including osteoporosis, adrenal suppression, hyperglycemia, hypertension, and increased susceptibility to infections.[1,3] Despite extensive corticosteroids use in Saudi Arabia, studies have reported gaps in public awareness and misconceptions about proper use and adverse effects.[5,6] This knowledge gap can have critical implications for patient safety, treatment adherence, and overall health outcomes. Many patients are not fully aware of the indications, side effects, and precautions associated with the corticosteroids they use, increasing the risk of improper use and serious adverse effects.[7,8] In addition, studies from different regions of Saudi Arabia have reported widespread self-medication and inappropriate patterns of topical corticosteroid (TCS) use among the public.[5,9] Moreover, cultural misconceptions, misinformation, and fears surrounding corticosteroid therapy, such as concerns about “skin thinning,” dependency, or long-term harm, may exacerbate non-compliance, reluctance to initiate treatment, or premature discontinuation, thereby compromising therapeutic efficacy.[5,6] A better understanding of how the general population in Hail uses TCSs, and what they know and believe about them, can help dermatologists, general practitioners, and pharmacists identify common misconceptions, target high-risk behaviors, and tailor patient education and counseling strategies more effectively.[9,10] For patients and the wider community, such data can support the development of focused awareness campaigns and regulatory measures aimed at reducing inappropriate self-medication, minimizing preventable adverse effects, and improving treatment outcomes and quality of life.[5,6] Given these concerns, this study aims to assess the knowledge, awareness, attitudes, and behaviors of the Hail population regarding TCS use and its potential side effects. Identifying local knowledge gaps and unsafe TCS practices can help dermatologists, primary care physicians, and pharmacists optimize potency/duration choices and strengthen counseling to reduce preventable harm.[11] For patients, targeted education addressing misconceptions and corticosteroid-related fears may improve adherence and appropriate use, supporting better outcomes in chronic inflammatory dermatoses.[12]

Objective

To assess the knowledge, awareness, and attitude regarding corticosteroid use among the Hail population, Saudi Arabia.

Methods

Study design and setting

This was an observational cross-sectional study conducted between Oct 2024 andMar 2025 in Hail region, a city in north-western Saudi Arabia. An online questionnaire was distributed through social media applications (WhatsApp, X, Facebook, etc.) to invite participants from the Hail region, Saudi Arabia, to participate in the study.

Subject: Participants, recruitment, and sampling procedure

The study’s population consisted of adults over the age of 18 of both sexes in the Hail region in Saudi Arabia. Participants were recruited by a convenience sampling technique and were requested to sign the informed consent. The study’s goals were presented to the participant, and informed consent was obtained.

Sample size

The calculation of sample size was done to ensure the minimum number of respondents needed to be a representative sample of the whole population. The sample size was determined using Epi Info software, version 7.2.2.6. Keeping an indicator percentage of 0.50, a margin of error of 5%, a confidence interval (CI) of 95%, a power of 80%, and an expected frequency of 50%. The estimated sample size is 384.

Inclusion and exclusion criteria

The inclusion criteria for this study were as follows:

Residents of the Hail region, Saudi Arabia, both Saudi and non-Saudi Residents, aged above 18 years old, both sexes, females and males, and who agreed to participate in our study.

People younger than 18 years old, outside of Hail city, who disagreed to participate or hadn’t completed the questionnaire were excluded from this study.

Method for data collection, instrument, and score system

A structured questionnaire (in English and Arabic) was used as a study tool. This tool was developed after consulting relevant studies conducted in Saudi Arabia and elsewhere.[9,10,13] The final version of the questionnaire consisted of 23 questions. Three sections were included as follows: socio-demographic data, knowledge and awareness about topical steroids, participants’ practice toward topical steroids. The questionnaire was distributed via social media applications to the sample.

Scoring system

Data scoring involved assessing and quantifying participants’ responses on their knowledge, attitudes, and awareness of TCSs. This process included assigning numerical values or codes to different responses or categories within the survey. Participants’ answers were then converted into numerical scores, which allowed for statistical analysis to identify patterns, trends, and correlations. The methodology utilized Likert scales for rating awareness levels. Analyzing these scores offered a detailed insight into the awareness of topical steroid use among the Hail population, leading to informed conclusions and potential recommendations for improving awareness and education on this healthcare topic.

Pilot test

The questionnaire was distributed to 20 individuals, and they were asked to fill it out. This was done to test the simplicity of the questionnaire and the feasibility of the study. Data of the pilot study was excluded from the final data of the study.

Data entry and statistical analysis

Data was entered on the computer using the “Microsoft Office Excel Software” program (2016) for Windows. Data was then transferred to the Statistical Package of Social Science Software (SPSS) program, version 20 (IBM SPSS Statistics for Windows, Version 20.0. Armonk, NY: IBM Corp.) to be statistically analyzed.

Ethical consideration

Ethical approval was obtained from the Research Ethics Committee at Hail Health. (Ethical approval number: H-2025-798). Participants were informed that their participation was voluntary and that filling out the questionnaire indicates their consent to participate.

Results

Demographic characteristics are summarized in Table 1. Most participants were Saudi (97.9%) and female (85.4%), with the largest age group being 21–39 years (46.8%). Most had a bachelor’s degree (73.3%), and nearly half were students (48.7%).

Table 1.

Demographic characteristics of topical corticosteroid users (n=419)

Parameters	Characteristics	Frequency	Percentage
Nationality	Saudi	410	97.9
	Non-Saudi	9	2.1
Age	18–20 years	130	31.0
	21–39 years	196	46.8
	40–59 years	86	20.5
	≥60 years	7	1.7
Gender	Male	61	14.6
	Female	358	85.4
Social status	Single	246	58.7
	Married	150	35.8
	Separate	18	4.3
	Widow	5	1.2
Educational level	High school	77	18.4
	Bachelor’s degree	307	73.3
	Postgraduate	35	8.4
Occupation	Student	204	48.7
	Employee	122	29.1
	Retired	10	2.4
	Unemployed	83	19.8

Patterns of TCS use, including knowledge, attitudes, and practices, are presented in Table 2. Among corticosteroid users (n = 419), 247 (58.9%) reported using TCSs as prescribed, whereas 172 (41.1%) used them without medical advice. Mometasone was the most commonly reported agent (33.9%), and 36.8% of participants were unable to identify the product used. Most participants applied corticosteroids once daily (60.6%), and moderate-potency preparations were the most frequently reported (38.4%). Awareness of potency categories was reported by 62.8% of users, and 55.4% reported knowledge of potential side effects.

Table 2.

Awareness, knowledge, attitude, and behaviors related to topical corticosteroids use among population in Hail, Saudi Arabia

Statements	Characteristics	Frequency	Percentage
Did you use corticosteroids?	Yes	419	78.0
	No	116	21.0
The recommendation to use corticosteroids was Prescribed/Not	Yes	247	58.9
	No	172	41.1
Duration of use of cortisone	Less than a week	213	50.8
	Week to month	126	30.1
	More than 1 to 3 months	39	9.3
	More than 3 months to 6 months	19	4.5
	More than 6 months to a year	8	1.9
	More than a year	14	3.3
Most commonly used steroids	Betamethasone	50	11.9
	mixed combination	37	8.8
	Clobetasol	13	3.1
	Mometasone	142	33.9
	Beclomethasone	8	1.9
	I don’t know	154	36.8
	Others	15	3.6
Distribution of indications for the use of topical steroids	Betamethasone	27	6.4
	Tinea	59	14.1
	General purpose/fairness creams	14	3.3
	Unsure diagnosis	18	4.3
	Melasma	75	17.9
	Acne	84	20.0
	Eczema	6	1.4
	Psoriasis	10	2.4
	Lichen planus	35	8.4
	Miscellaneous (keloids, insect bites, etc.)	91	21.7
	Others	27	6.4
How many times a day is cortisone used?	Only once a day	254	60.6
	Twice a day	135	32.2
	3 times a day	20	4.8
	More than three times	10	2.4
What is the potency of corticosteroids that used?	Low potency	64	15.3
	Moderate potency	161	38.4
	High potency	88	21.0
	Ultra-high potency	106	25.3
Are you aware of the various potencies of topical steroid?	No	156	37.2
	Yes	263	62.8
Do you know about the various side effects of topical steroid?	No	187	44.6
	Yes	232	55.4
Have you stopped using cortisone treatment?	No	86	20.5
	Yes	333	79.5
If your answer is yes, did you stop using cortisone? (n=333)	Gradually	196	58.9
	Suddenly	137	41.1
What was the reason for stopping the use of cortisone? (n=333)	Symptoms disappear	240	72.1
	Symptoms got worse	28	8.4
	No improvement	65	19.5
Relapse of the disease after stopping the cortisone treatment (n=333)	No	254	76.3
	Yes	79	23.7
If yes, the disease has increased after stopping the use of cortisone during? (n=79)	Less than a week	32	40.5
	A week	28	35.4
	More than a week	19	24.1

Regarding discontinuation behaviors, 79.5% reported stopping TCSs at some point; among those, 58.9% discontinued gradually and 41.1% stopped abruptly. Relapse after discontinuation was reported by 23.7% of users. Detailed distributions of duration of use, indications, and reasons for discontinuation are provided in Table 2.

Reported adverse effects among users are summarized in Figure 1. More than half of the participants (55.0%) reported no side effects after using corticosteroids. Among those reporting adverse effects, mood changes (7.5%), itching (6.6%), and increased thirst/urination (6.3%) were most common, followed by skin discoloration (4.2%), skin thinning (4.2%), and acne (4.1%). Other reported effects included central obesity (3.2%), increased blood pressure (2.5%), menstrual irregularity (2.4%), peptic ulcer (2.2%), and voice changes (1.7%). Reported adverse effects by TCS type are presented in Figure 2, demonstrating variation in the proportion of users reporting ≥1 adverse effect across corticosteroid types. Awareness of TCS potency was further examined across demographic subgroups in Table 3. No significant differences were observed by educational level (χ² =0.497, P = 0.78) or gender (χ² =0.604, P = 0.437). While demographic variables were not associated with potency awareness, potency awareness showed significant associations with key use-related behaviors and knowledge in Table 4. Participants aware of potency categories were more likely to have been prescribed corticosteroids (65.0% vs 48.7%; χ² =10.752, P = 0.001). Prescribed users were more likely to discontinue gradually (67.6% vs 43.9%), whereas non-prescribed users more often stopped suddenly (56.1%) (χ² =18.018, P = 0.001). Awareness/knowledge of potential adverse effects was higher among those aware of potency categories (73.8% vs 24.4%; χ² =96.719, P = 0.001). Overall, potency awareness was associated with prescription use, gradual discontinuation, and better recognition of potential adverse effects.

Figure 1.

Side effects reported after corticosteroid use among users (percentage of respondents). (Multiple responses allowed.)

Figure 2.

Reported adverse effects by topical corticosteroid type. Bars indicate the percentage reporting ≥1 adverse effect within each category; n indicates the sample size (Betamethasone, n = 41; Mixed/combination, n = 33; Mometasone [Elica/Elocom], n = 139; Unknown, n = 115)

Table 3.

Association between participants’ demographic characteristics and awareness of various potencies of topical steroids

Variables	Characteristics	Awareness of various potencies of topical steroids		χ 2	P
		No n (%)	Yes n (%)
Educational level	High school	26 (33.8%)	51 (66.2%)	0.497	0.78
	Bachelor’s degree	117 (38.1%)	190 (61.9%)
	Postgraduate	13 (37.1%)	22 (62.9%)
Gender	Male	20 (32.8%)	41 (67.2%)	0.604	0.437
	Female	136 (38.0%)	222 (62.0%)

Table 4.

Association between awareness, prescription recommendation, and knowledge of corticosteroid use and side effects

Variables	Characteristics	The recommendation to use corticosteroids was prescribed		χ 2	P
		Yes n (%)	No n (%)
Awareness of various potencies of topical steroids	No	76 (48.7%)	80 (51.3%)	10.752	0.001
	Yes	171 (65.0%)	92 (35.0%)
		Did you stop using cortisone crosstabulation?
		Gradually n (%)	Suddenly n (%)
The recommendation to use corticosteroids was prescribed	Yes	142 (67.6%)	68 (32.4%)	18.018	0.001
	No	54 (43.9%)	69 (56.1%)
		Knowledge about side effects
		No n (%)	Yes n (%)
Awareness of various potencies of topical steroids	No	118 (75.6%)	38 (24.4%)	96.719	0.001
	Yes	69 (26.2%)	194 (73.8%)

Discussion

The objective of this research was to investigate the awareness, knowledge, attitudes, and behaviors related to the use of TCSs among residents of Hail, Saudi Arabia. Of the 535 respondents sampled in the study, 419 (78%) reported having used corticosteroids, while 116 (22%) reported having never used them. These findings indicate that corticosteroid use in this community ranges from informed choices under medical supervision to completely uninformed use, suggesting some positive progression but also highlighting persistent challenges in ensuring safe use. With respect to patterns of use and medical supervision, this study found that more than half of users (58.9%) followed medical recommendations when using corticosteroids; however, 41.1% relied on self-medication. The high level of unsupervised use is consistent with the community-based study by Saha et al.,[14] which reported considerable self-medication practices in Bhutan and Bangladesh. In Saudi Arabia, previous work has also documented the use of TCSs without prescription and with limited awareness of their risks, reinforcing concerns about inappropriate access and misuse.[5,15] The ease of accessibility to corticosteroids and assumptions about rapid efficacy may therefore perpetuate corticosteroid misuse as a public health concern. The duration of corticosteroid use also varied. While most participants (50.8%) applied them for less than a week, a small fraction (3.3%) continued use for more than a year. This pattern echoes concerns raised in reviews of chronic systemic glucocorticoid therapy, which highlight that prolonged use increases the risk of skin thinning, adrenal suppression, and metabolic complications.[2,3] These findings underscore the need for clear guidance on treatment duration and regular follow-up. The study found that mometasone was the most commonly used TCS (33.9%), aligning with prior work by Qutob et al.,[5] who also reported that mometasone predominated among users in Riyadh. Interestingly, 36.8% of respondents were unsure about which corticosteroid they had used, highlighting the need for improved labeling, better communication at the point of dispensing, and stronger patient education by prescribers and pharmacists. The reasons for use were varied. Miscellaneous skin issues (21.7%), acne (20%), and melasma (17.9%) were the most commonly reported indications, with fewer participants using corticosteroids for cosmetic fairness purposes (3.3%). Eczema accounted for only 1.4% of uses in this study, which is lower than the proportion reported by Qutob et al. (18.2%),[5] suggesting potential regional or population differences in patterns of use. The fact that 4.3% were unsure about their diagnosis further illustrates the risks of unsupervised use, consistent with reports emphasizing inappropriate TCS application in routine practice.[16,17] Misuse of TCSs for facial dermatoses and pigmentary concerns has been reported in Saudi Arabia and is associated with clinically significant facial adverse effects (steroid-damaged face), reinforcing the risks of unsupervised use for acne/melasma.[18] In terms of frequency, potency awareness, and side effects, our study showed that application frequency varied, with most participants applying corticosteroids once daily (60.6%), but a small fraction using them more than three times daily, raising concerns about overexposure. Regarding potency, moderate-strength preparations were most common (38.4%), followed by ultra-high-potency agents (25.3%). Knowledge of potency and side effects was not universal; 62.8% were aware of potency differences, and 55.4% reported knowing potential side effects. These gaps in knowledge are concerning, given the range of local and systemic adverse effects described in the literature.[1,2] In our study, 45% of participants experienced at least one side effect, with mood changes (7.5%), itching (6.6%), increased thirst or urination (6.3%), skin thinning (4.2%), and discoloration (4.2%) being the most common. These results are consistent with evidence that even low or moderate doses of corticosteroids can cause clinically significant adverse effects, particularly when used inappropriately or for prolonged periods.[1,2] This reinforces the need for cautious prescribing, clear counseling, and regular review of ongoing corticosteroid therapy. Moreover, this study shows that most participants (79.5%) had stopped corticosteroid use at some point. Of these, 58.9% discontinued gradually, while 41.1% stopped abruptly. Sudden discontinuation was more common among non-prescribed users, highlighting the importance of medical guidance in preventing withdrawal effects and symptom rebound. TCS withdrawal is increasingly recognized as a distinct adverse outcome of prolonged, inappropriate use, especially of moderate to high potency steroids on sensitive areas, and can present with rebound erythema/burning after discontinuation.[19] Relapses occurred in 23.7% of those who discontinued, usually within the first week after stopping. Symptom resolution was the main reason for discontinuation (72.1%), followed by lack of improvement (19.5%) and worsening symptoms (8.4%). These patterns are consistent with reports that improper cessation or abrupt stopping increases the likelihood of corticosteroid withdrawal phenomena and recurrence of the underlying disease.[1,2] Regarding awareness, prescription, and safe use, our analysis revealed a strong relationship between awareness of corticosteroid potency and safer usage behaviors. Participants who were aware of potency categories were more likely to have received a prescription, to discontinue gradually, and to know about potential side effects. This supports the view that patient education is critical for safe corticosteroid use and aligns with Saudi studies that have shown improved usage patterns among individuals with better knowledge and counseling about topical steroids.[5,6] Beyond TCSs, anabolic-androgenic steroid (AAS) use also reflects broader patterns of unsupervised steroid exposure. A meta-analysis by Sagoe et al.[20] estimated global AAS lifetime prevalence at 3.3%, with higher use among males (6.4%). In Saudi Arabia’s Eastern Province, 21.3% of gym users reported AAS use, mainly for muscle building, and 77% reported adverse effects such as hair loss, acne, and sexual dysfunction.[21,22] These findings highlight the broader problem of steroid misuse in the region and underscore the importance of regulatory measures, educational programs, and awareness campaigns addressing both medical and non-medical steroid use. Recent Saudi studies continue to show knowledge gaps and non-prescription TCS use, supporting our finding that a substantial minority relied on self-medication.[23,24] Saudi clinical evidence on “topical steroid-damaged face” further underscores the risks of unsupervised facial application, relevant to our high self-reported use for acne and melasma.[18] What distinguishes our Hail study is that it provides region-specific community data and links potency awareness to safer behaviors and discontinuation/relapse timing, while aligning with evidence of variability in pharmacist counseling/dispensing practices.[25]

Study limitations and future research

There are several limitations to this study. First, the reliance on self-reported data introduces the possibility of recall bias and misclassification, particularly regarding the exact product used, potency, and duration of therapy. Second, the cross-sectional design limits the ability to infer causality between awareness, behaviors, and outcomes. Third, as the sample was restricted to residents of Hail, the findings may not be fully generalizable to other regions of Saudi Arabia. Finally, some participants were not certain about the type of corticosteroid they had used or the underlying medical diagnosis, which may have affected the precision of reported usage patterns and side effects. Future studies may therefore consider longitudinal designs to monitor corticosteroid use and outcomes over time, expand sampling across multiple regions, and formally evaluate the impact of educational interventions, pharmacist counseling, and regulatory changes on knowledge and behavior. It would also be worthwhile to explore psychological and social factors influencing self-medication behaviors to gain a deeper understanding of misuse patterns and to inform more targeted public health strategies.

Conclusion

TCS use was common among adults in Hail, with a substantial proportion reporting self-medication and limited awareness of potency and adverse effects. Mometasone was the most frequently reported agent, and some users reported adverse effects such as mood changes, itching, and skin thinning. Potency awareness was associated with safer use, including prescription-based use, gradual discontinuation, and better recognition of potential adverse effects. These findings underscore the need for targeted public education, pharmacist-led counseling, and clearer labeling to reduce inappropriate use and promote safe TCS practices.

Ethics

Ethical approval was obtained from the Research Ethics Committee at Hail Health (approval number: H-2025-798). Informed consent was obtained from all participants.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.