Dhanalakshmi K, Pious, Sudarvizhi, and Jennifer: Awareness and attitude of medical students over the misuse of topical steroids- Prospective study in 3rd year medical students in a Medical college, Tamil Nadu


Introduction

Misuse of topical steroids is not the new entity in this era but has increased exponentially, as the availability of over the counter medication in surplus combinations with both relevant and irrelevant. As we blame the society for the misuse secondary to lack of knowledge but misuse of topical steroids is rampant even in the healthcare fraternity. More alarmingly misuse in the medical students is increasing due to lack of application of knowledge or meagre knowledge on the usage of topical steroids. In many of the studies, general practitioners (GP) form a sizable population in prescribing the topical steroids for common skin ailments. GPs either use approved steroid combination like Kligman’s formula for pigment reduction or irrelevant steroid combination for fungal infection. Thorough knowledge about the steroid molecule regarding where not to use more than where to use is more important which should be ideally start from their first clinical dermatology exposure. This study analyses the awareness of the medical students towards topical steroids and imposes the knowledge regarding the same.

Table 1

knowledge regarding topical steroids and its combinations.

Knowledge regarding topical steroids and combinations available

Heard about the medications n (%)

Used the medications n (%)

Prescribed the medication. N(%)

Use by their close contacts n (%0

Yes

57 (75)

16 (21.1)

2 (2.6)

36 (47.3)

no

19 (25)

60 (78.9)

74 (97.4)

40 (52.7)

Table 2

Usage of topical steroids in the common scenario

Indication

No of patient

Percentage

Not used

18

13.5

Fungal infection

21

15.8

Fairness cream

35

26.3

Eczema

14

10.5

Rashes

8

6

Acne

14

10.5

Hyperpigmentation

23

17.3

Table 3

Reasons for using steroids beyond prescribed period

Reasons for using beyond prescribed period

No (n)

Percentage ( %)

0-not used

15

14

1-no relief from the symptoms

32

30

2-without any reason

5

4.6

3- glow after application

25

23.3

4-colour reducing effect

20

18.7

5- didn’t know when to stop

8

7.5

6-others

2

1.9

Table 4

Comparison of Pre and Post test results

S. No

Variable

Pre test

Post test

Chi square / p value

P value

1

Awareness of adverse effects on long term steroid use

1. Yes

37

53

5.12

0.02

1. No

39

23

2

Adverse events noticed

1. Don’t know

32

6

2. Increase in existing infection

9

17

3. Erythema

14

30

4. Shiny wrinkled skin/ epidermal atrophy

13

20

5. Striae

9

11

6. Dryness/xerosis

8

23

7. Hypo/Hyperpigmentation

17

14

8.1

0.01

8. Photosensitivity

9

14

9. Burning sensation

9

23

10. Telangiectasia

10

10

11. Eczema

2

2

12. Hypertrichosis

7

7

13. Acne

8

13

14. Increased sensitivity to other medications

4

5

3

Response after adverse event knowledge

1. Stopped the medication by self

22

39

2. Consulted the Dermatologist

30

36

18.95

0.0001

3. Continued the medication

24

2

4

Knowledge on potency of steroids and area of application

1. Don’t know

26

2

0.003

2. Correct option

10

52

9.3

3. Wrong option

40

22

5

Approach of the students after gaining knowledge 1. Counsel the patients

2. regarding pros and cons of steroid use while prescribing and increase patient and doctor rapport

62

75

4.48

0.03

3. Creating awareness in the public

11

15

4. Not interested

15

10

Table 5

Comparison of the relevant variables from other studies.

S.No

Place of study

Study details (Author/ Year)

Participants

Steroid formulation known

Prescribed by

Indication for use

Major ADR

Awareness given Yes/no

1

Chengalpattu, Tamilnadu

Our study

6th semester medical students

Combination steroids (relevant and irrelevant FDC)

Pharmacist ,friends and relatives (55.2)

Fairness cream, fungal infection

Hypo/hyper pigmentation, erythema, epidermal atrophy

Yes

2

Jeddah, Saudi Arabia 1

Dhiyaa Majed, Mahdi Alnujaidi, 2018

University students

Combination steroid and mild steroid

Friends and relatives, pharmacist

Acne, facial pigmentation, after shave erythema

Hypo/hyper pigmentation, dryness, sensitive skin, recurrence of condition

No

3

Perinthalmanna, Kerala, India 2

Karalikkattil T. Ashique, Feroze Kaliyadan, 2018

Pharmacy students- UG&PG

-

-

-

-

-

4

Bengaluru, Karnataka, India 3

T S Nagesh, A Akhilesh,2016

Patients attending Dermatology OPD

Betamethasone, kligmans formula

General practitioners, friends, pharmacist

Acne, allergy, pigmentation, fairness cream

Aggravation of symptoms, hypo/hyper pigmentation, acne

No

5

Quaid-e-Azam Medical College, Bahawalpur, Pakistan 4

Sohail Shaheen, Asma Shahbaz, Nimra Maqbool, Jamil Ahmad Shaheen,2020

Female medical students

Betamethasone, clobetasol, mixed creams (irrelevant FDC)

Pharmacist, friends, some by beauty parlour

Acne, Fairness cream

-

No

6

King George's Medical University, Lucknow, India 5

Parul Verma , Sucheta Pathania , Swastika Suvirya , Prakriti Shukla

Medical students (Interns, postgraduates)

Clobetasol , Betamethasone, Beclomethasone.

-

Eczema, acne, infections

-

Yes

7

Saveetha university, Chennai, India 6

Aarthi Muthukumar, Dhanraj Ganapathy

Dental students

All classes

-

-

Aware of ADR

8

Dow University of Health Sciences, Karachi, Pakistan 7

Fakhsheena Anjum, Auwais Ahmed Khan et al

Pharmacy students and Allied health sciences

Topical, oral and injectable

Medical practitioner> self > trainer

Skin brightening, antiinflammatory, anti infective

Aware of ADR

No

9

Allama Iqbal Medical College, Lahore 8

Samina Naz Chohan, Majid Suhail, Samia Salman

Patients attending dermatology OPD

Potent topical steroids- clobetasol and beta-methasone

Friends> relatives >peers> GP

Acne, pigmentation, melasma

Facial erythema, aggravation of existing symptoms, hypertrichosis

No

10

Mamata Dental College, Khammam, India 9

Kokkalgave Supriya1 , K. V. N. R. Pratap2 ,

Dental students both UG and PG

Topical corticosteroid

-

Acne, hyper pigmentation

Aware of ADR

No

11

Adichunchanagiri Institute of Medical Sciences, Karnataka, India 10

Mukunda Ranga Swaroop1,*, Suman Swamynathan

Patients attending dermatology OPD

Irrelevant combination with steroid

Friends > GP> neighbours and relatives

Acne, pigmentary disturbance

Acneform eruptions, pigmentation and burning sensation

12

Riyadh, Kingdom of Saudi Arabia 11

Sarah F. Alsukait, Najd A. Alshamlan et al

Primary care physicians (GP, Family medicine, Internal medicine , pediatrics)

Topical steroid

-

Atopic dermatitis, psoriasis, alopecia areata, acne vulgaris

Atrophy, hypopigmentation, striae

No

Materials and Methods

6th semester medical students were enrolled in this study with prior Institutional Ethical clearance and with informed consent from the individuals. Out of 100 students excluding absentees and the ones not interested in participating were excluded from the study. Enrolled 76 students were given a validated pretest questionnaire and were asked to fill out the same. Questionnaire included the demographic details, questions related to the topic including about the topical steroid used, duration of use, knowledge of adverse effects, potency of steroid and indications and contraindications around 15 questions. After that students were exposed to the presentation regarding topical steroid use and misuse. After 3 months of this activity, students were evaluated with the same set of questions. The results were analyzed by t test, p values and with 95% confidence interval via SPSS software.

Results

6th semester students who participated in this study were between 20-21 years and with 45 females and 21 male students. 75% of the students already heard about the topical steroid preparation with only 2% had prescribed the medication to others (Table 1 ). 47% had seen the topical steroid medications being used by their close contacts. Irrelevant steroid combinations (steroid, antifungal, antibiotic) were the ones commonly used in 57.9% followed by Kligman’s formula (36.8%) and only 5.3% had used plain topical steroids (n=57). Steroid based topical preparations were used as a fairness cream (26.3%) and for hyperpigmentation (17.3%) and closely followed by fungal infections (15.8%) rather than other causes (Table 2). Out of this Dermi5, Quadriderm, Fourderm and Castor NF were the ones used for fungal infection and Skinlite, Melacare, Skinshine were used for facial melanosis. Only 44.8% were prescribed by dermatologist and general practitioner but the remaining 55.2% medications bought without the prescription mostly suggested by the Pharmacist or by friends or by relatives or by self. About 13% of the patients used the topical medication beyond the prescribed period. 52.6% had used the medication for maximum one month and 14.4% had used up to 1 year duration. In this 40.8% patients used the medications continuously compared to 27.6% who had used intermittently. Reasons for usage beyond the prescribed period of steroid were no relief from the existing symptoms, glow to the skin on usage and colour reducing effect (Table 3).

On comparing the pre and post test results, there is significant increase in the awareness regarding long term use of topical steroids (p<0.5, chisquare 5.2) and the knowledge of the adverse events (p<0.5, chisquare 8.1). Students have gained significant knowledge regarding the potency and using the prescribed topical steroids for prescribed period of time. Most of the student’s knowledge regarding the counselling related to topical drug usage, advising regarding the adverse events had been significantly improved (Table 4).

Discussion

Most of the available literature regarding topical steroid abuse had only demographic details and are cross sectional studies and are not follow up studies. Comparison of other studies with our study is tabulated below (Table 5).

Currently available TCs differ widely, and knowledge of such differences is vital for proper prescribing practices. When prescribing TCs, it is important to consider the indication, patient’s age, TCs potency, vehicle, frequency, duration, site of lesion, severity of disease, and associated adverse effects. 12

If medical students, who are a vital part of the health community and who should be strongly opposing the idea of misuse of drugs are using TCs for cosmetic purposes upon themselves, then it will be a matter of immense concern.4 All MBBS students will not be dermatologists and dermatologists cannot be everywhere, so the knowledge regarding topical steroids is mandatory and it should be included in the curriculum.5

In a study conducted in Saveetha University with dental students concluded that most of them are aware of topical steroid formulation and their usage and adverse events which is comparable to our study. 6 Another study from Riyadh concluded that the knowledge among primary care physicians regarding use of topical corticosteroids was lacking in more than half of the PCPs 11 as with our study.

Knowledge gaps towards TCs could be attributed to the lack of proper dermatology training in undergraduate curriculum. Another fact observed was the physicians who felt comfortable treating dermatology patients had significant knowledge regarding topical steroid usage. 11 This supports our study that knowledge facilitated during their training will induce the students to treat comfortably the dermatology patients when they become medical graduates. Another important factor is reinforcing the importance of proper use of topical steroids and treating dermatology patients will gradually abolish the misuse of topical steroids.

In a study aimed to assess the learning outcomes of a 10-week postgraduate training course in dermatology among PCPs, most PCPs reported modifying their approach in managing common skin disorders after the course. 13 As with the study stated not only after the graduation but during their undergraduate curriculum also and this has to regularly reinforced during the curriculum which will make the medical graduate competent to treat dermatology patients and avoid the misuse of the topical corticosteroids.

Conclusion

As with the saying “The eye is blind if the mind is absent”, knowledge regarding the topical steroids which is not imparted in the undergraduate curriculum will lead to ultimate misuse. So inclusion of the topical steroid in the undergraduate curriculum is mandatory and also the dermatology postings in the internship period should be made compulsory rather than optional.

Acknowledgements

None.

Source of Funding

No financial support was received for the work within this manuscript.

Conflicts of Interest

There are no conflicts of interest.

References

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Received : 26-02-2021

Accepted : 19-04-2021

Available online : 26-05-2021


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https://doi.org/10.18231/j.ijced.2021.022


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