Atopic dermatitis (AD) is a chronic relapsing inflammatory skin disorder with a significant impact on the quality of life.1 Globally, its prevalence is increasing, affecting up to 20% of children and 10% of adults.2–5 Topical anti-inflammatory therapies are the first step of treatment in AD flares.6,7 Topical corticosteroids (TCS) are the mainstay of treatment in most patients with AD and they often require long-term treatment with TCS for many years. Poor adherence to treatment is common in AD and can lead to treatment failure.8–10 TCS resistance may be partially due to non-adherence because of TCS phobia.11 TCS phobia, also known as corticophobia, defines the negative feelings and beliefs related to TCS experienced by patients and their caregivers. The prevalence of corticophobia in AD ranges from 21% to 84%.12 Health literacy is the term used to describe people's capacities to meet the complex demands related to health in modern society. It results from health education and communication activities and determines the individual ability to gain access to, understand, and use information in order to promote and maintain good health.13,14 The present group of authors proposed to study the effect of health literacy on corticophobia.

Patient characteristics are listed in Table 1. A total of 61 patients were included, 35 (57.4%) females, with a mean age of 20 ± 13.8 years. We had 25 patients (41.0%) with ≤ 15 years and 36 (59.0%) with > 15 years. Ten (16.4%) of the responders worked on a healthcare setting. The mean duration of AD was 12.5 ± 11.4 years. Other atopic diseases (asthma and/or allergic rhinitis) were present in 35 patients (57.4%) and 31 (50.8%) had a family history of AD. Most of the patients had mild disease (38 patients, 62.3%). Fifty-nine patients (96.7%) confirmed treatment with TCS. Other treatments used for AD are described in Table 1.

TOPICOP© levels ranged from 8.3 to 88.9, with a mean score of 44.8 ± 20.0, which indicates a moderate level of TCS phobia. Nine patients (14.8%) had a low TOPICOP© score, 31 (50.8%) had an intermediate score and 21 (34.4%) had a high score.

HLS-EU-PT scores ranged from 1.1 to 47.9, with a mean score of 30.5 ± 8.5, considered a level of problematic HL. Inadequate HL was present in 13 (21.3%), problematic HL in 26 (42.6%), sufficient in 16 (26.2%) and excellent in 6 (9.8%).

No statistically significant difference was found for TOPICOP© score between the caregivers’ responders (patients with ≤ 15 years) and patients’ responders (> 15 years) (p = 0.189). Similarly, no statistically significant difference was found for TOPICOP© scores between healthcare professionals and other occupations, family history of AD, personal history of other atopic diseases, and disease severity (Table 2). TOPICOP© value was shown to be negatively correlated with HLS-EU-PT value (p = 0.002, r = -0.382,  r2 = 0.146), with higher levels of TOPICOP© associated with lower HLS-EU-PT value (Table 3).

TCS is the first-line anti-inflammatory treatment for AD.6 Corticophobia may impair an adequate treatment regimen, leading to an uncontrolled disease with a negative impact on the quality of life. The right amount of TCS to use and frequency of applications are some of the concerns that should be addressed with these patients.20 The fear of TCS side effects may be a major concern in AD patients and their caregivers and is frequently implicated in TCS resistance.9,20,21 Cutaneous atrophy, purpura, telangiectasias, striae, perioral dermatitis, or acne are some of the adverse events that may occur with prolonged and inadequate administration of TCS.22 The increased percutaneous absorption may be responsible for systemic adverse effects, such as hypothalamic-pituitary-adrenal axis suppression and glaucoma, but the risk seems to be low.23,24 In general, TCS long-term treatments are considered safe in both adults and children.23,25–27

Nowadays, there is accessible access to the medical information in the media, such as newspapers, magazines, and the internet. However, much of this information is not produced by healthcare professionals and may erroneously induce the patient to undertreat with TCS. In fact, a Korean study showed that the internet (49.2%), television or other broadcasting media (45.2%), doctors/healthcare professionals (37.3%), and magazines/newspapers were sources of information associated with steroid phobia.28 Patients may have difficulties in selecting correct and trustworthy medical information.

TOPICOP© is currently the only validated score to assess TCS phobia. 16 In the present study, TOPICOP© questionnaire showed an average level of 44.8% in our population, which indicates an intermediate level of TCS phobia. Other groups reported similar levels of corticophobia levels.16,19,29 Stalder et al. reported a mean global TOPICOP© score of 44.7% in a prospective multicenter study conducted with 1796 participants from 17 countries.16 In a smaller study, Bos et al. found a TOPICOP© score of 44% in a group of 29 parents of patients with AD from the Netherlands.29 A French study by Dufresne et al. with 191 parents found a TOPICOP© score of 39.8%, slightly lower than the other studies, but these parents attended a therapeutic education program, which may have been responsible for the better results.19

In the present study, the authors’ main goal was to evaluate the association between TCS phobia and health literacy. The general HL index reported for Portugal was 33.0, and 11% of the Portuguese population had an “inadequate” HL score, and 38% had a “problematic” score.30 In the present study, we had a mean HLS-EU-PT of 30.5 ± 8.5 and 63.9% had lower levels (“inadequate” and “problematic”). Interestingly, we found a significant negative correlation between TOPICOP© score and HLS-EU-PT. Furthermore, lower HL was a predictor of higher corticophobia. This emphasizes the importance of HL in healthcare. The present results contrast with the findings of Dufresne et al., in which the literacy score was significantly associated with higher TCS phobia.19 Most of the corticophobic parents of their study had direct access to scientific and online resources and a higher TOPICOP© score was associated with completed years after graduation. However, these authors had a more homogenous group, including only parents of AD children (<18 years). The inclusion of a group of parents of younger patients and a group of older patients may be a limitation of the present study since it makes a more heterogenous cohort and may impact the general group analysis. Another limitation was the small number of patients in each group. Future studies with larger and more homogenous cohorts should be done in order to confirm the present findings.

Physicians should develop teaching techniques in order to properly educate their patients about the disease and the recommended treatment.11 However, TCS phobia is also present among healthcare professionals, and it may affect patients (or their caregivers) perspectives of TCS use and adherence.29,31 Education of these professionals may improve patients' adherence to treatment. It was shown that having trust toward a physician is significantly associated with taking medication as directed.9 Education of pharmacy staff to provide patient counseling was also shown to be effective in reducing TCS phobia.32 Doctors should provide detailed written instructions on TCS regimens and answer any concerns that patients and caregivers may have.

The promotion of HL should be a priority in public health. The improvement of individual and social critical skills regarding their health will maximize the engagement of healthy behaviors.

Corticophobia is an impediment towards an appropriate therapeutic regimen in cutaneous conditions such as AD. The easy accessibility to information on TCS and their side effects may paradoxically contribute to the fear and worries about them. Patients need to be capable of selecting and filtering reliable content. HL is responsible for the capacity and critical choice in health behaviors. The present study suggests that higher HL is associated with lower TCS phobia, but more studies are needed to clarify this association. To the authors’ knowledge, this study provides the first evaluation of TCS phobia in Portugal.

None declared.

Tiago Fernandes Gomes: Effective participation in research orientation; data collection, analysis, and interpretation; statistical analysis; critical literature review; preparation and writing of the manuscript.

Katarina Kieselova: Approval of the final version of the manuscript; data collection, analysis, and interpretation; manuscript critical review.

Victoria Guiote: Approval of the final version of the manuscript; data collection, analysis, and interpretation; effective participation in research orientation; manuscript critical review.

Martinha Henrique: Approval of the final version of the manuscript; data collection, analysis, and interpretation; manuscript critical review.

Felicidade Santiago: Study conception and planning; approval of the final version of the manuscript; data collection, analysis, and interpretation; statistical analysis; intellectual participation in propaedeutic and/or therapeutic management of studied cases; manuscript critical review.

None declared.