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Table of Contents
ORIGINAL ARTICLE
Year : 2021  |  Volume : 25  |  Issue : 2  |  Page : 76-79

Prevalence of topical corticosteroid use without prescription in Saudi Arabia: A cross-sectional study


1 Department of Dermatology, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
2 Department of Dermatology, King Abdulaziz Medical City, Riyadh, Saudi Arabia
3 College of Medicine, King Saud University, Riyadh, Saudi Arabia
4 Division of Dermatology, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia

Date of Submission10-Feb-2021
Date of Acceptance31-May-2021
Date of Web Publication29-Mar-2022

Correspondence Address:
Dr. Shaikah Al-Aojan
Department of Dermatology, Prince Sultan Military Medical City, P.O. Box 7897, Riyadh 11159
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdds.jdds_21_21

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  Abstract 


Background: Misuse of topical corticosteroids (TCS) is common and constitutes a serious problem in many parts of the world where they can be obtained without prescription. Limited studies have been performed in Saudi Arabia to address this issue. Purpose: We aim to study the prevalence, predisposing factors, and adverse consequences of TCS use without prescription in Saudi Arabia. Methods: A cross-sectional study was performed using an Arabic questionnaire distributed through social media applications in May 2020 in Saudi Arabia. Individuals aged 18 years and above who used TCS within the last 2 years were included. The questionnaire consisted of detailed questions about TCS use and demographic information. Results: A total of 720 participants completed the questionnaire. TCS were used without prescription by 43.1% of respondents. Being female was the only identified risk factor for the use of TCS without prescription. The main reason for purchasing TCS without prescription was that the problem seemed too trivial to consult a physician (36.6%). The most common conditions for which TCS were used were treatment of pruritus without skin disease (23.7%) and cosmetic reasons (19.9%). Side effects were reported in 25.6% of participants. The most common side effects were hypopigmentation, itching, redness, and skin sensitivity. Conclusion: The use of TCS without prescription is prevalent in Saudi Arabia. We recommend that local health authorities regulate the use of TCS.

Keywords: Over the counter, prescription, Saudi Arabia, topical corticosteroids, topical steroids


How to cite this article:
Al-Aojan S, Al-Marzoug A, Alaujan A, Abanmi S, AlJasser MI. Prevalence of topical corticosteroid use without prescription in Saudi Arabia: A cross-sectional study. J Dermatol Dermatol Surg 2021;25:76-9

How to cite this URL:
Al-Aojan S, Al-Marzoug A, Alaujan A, Abanmi S, AlJasser MI. Prevalence of topical corticosteroid use without prescription in Saudi Arabia: A cross-sectional study. J Dermatol Dermatol Surg [serial online] 2021 [cited 2022 Oct 6];25:76-9. Available from: https://www.jddsjournal.org/text.asp?2021/25/2/76/341200




  Introduction Top


Topical corticosteroids (TCS) have a wide range of uses in dermatology. However, the use of TCS is associated with several side effects if not used under medical supervision. TCS can be easily obtained over the counter without a prescription in many countries, including Saudi Arabia.

Misuse of TCS is a common global problem, as reported by several studies in India, China, Nigeria, Madagascar, and Korea.[1],[2],[3],[4],[5] Easy access to over-the-counter TCS without prescription can lead to many side effects related to potential misuse. Acne, hypopigmentation, atrophy, and steroid dependency were among the most commonly reported side effects from TCS misuse.[1],[4] Potent topical steroids are commonly used without a prescription as depigmenting or bleaching agents.[3] Studies from Africa showed that most patients obtained it from cosmetic retailers, where it was mixed with emollients. Superpotent topical steroids (Class 1) were the most commonly used class of TCS.[3],[4] Worldwide, risk factors associated with TCS misuse were found to be female gender, illiteracy, and unemployment.[1],[3],[4]

Although patients have access to TCS without prescription in Saudi Arabia, there are limited studies assessing this issue. We aim to study the prevalence, predisposing factors, and adverse consequences of TCS use without prescription in Saudi Arabia.


  Methods Top


The study was approved by the institutional ethics committee and performed in accordance with the ethical standards of the Declaration of Helsinki 1975. Individuals aged 18 years and above who used TCS within the last 2 years in Saudi Arabia were included. Pharmacists and physicians were excluded from the study, as were patients on oral corticosteroids or patients previously diagnosed with Cushing's syndrome. Adverse consequences were defined as the occurrence of side effects, the prolonged use of topical steroids beyond the recommended duration, or the use of topical steroids for improper indications, e.g. acne or skin lightening.

A sample size of 385 participants was calculated assuming a 5% margin of error and 95% confidence interval. The questionnaire was distributed to the different regions of Saudi Arabia according to the population statistics gathered by the General Authority for Statistics (2017).

The questionnaire was first validated by five dermatologists for its content. Next, pilot testing was carried out on 25 participants. The questionnaire was modified accordingly after each step. The final questionnaire consisted of two parts. The first part included detailed questions about TCS use and the second part was for demographic information. The lists of TCS available in the last 2 years were obtained through the Saudi Food and Drug Administration (SFDA) and local pharmacy records. Pictures of TCS along with their trade names were included in the survey to enable their recognition. The questionnaire was electronically distributed through social media applications (WhatsApp and Twitter) in the Arabic language in May 2020.

Statistical analyses were performed using Stata software version 15.1 (StataCorp., College Station, TX, USA). Categorical variables were presented as frequencies and percentages. Numerical variables were presented as mean and standard deviation. A test with P ≤ 0.05 was considered statistically significant.


  Results Top


A total of 720 participants completed the questionnaire. TCS use without prescription in the last 2 years was found to be 43.1% [Table 1]. Female gender was the only identified risk factor for the use of TCS without prescription (P < 0.001). The main reason for purchasing TCS without prescription was that the problem seemed too trivial to consult a physician [Table 2]. The conditions for which TCS were used are presented in [Table 2]. Mometasone furoate cream 0.1% was the most commonly used TCS (55.1%) [Table 3].
Table 1: Demographic data of participants (n=720)

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Table 2: Reasons and conditions for which topical corticosteroids were used without prescription

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Table 3: Topical corticosteroids used without a prescription in our study

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A third of participants (30.7%) did not know that what they had used was a TCS, while 22.8% were not sure. The TCS were used based on a previous prescription from a physician (42.4%), on the recommendation of family and friends (40.8%), on a pharmacist's recommendation (20.3%), and from websites or social media applications (16.5%). Sources of usage instructions included the medication leaflet (43%), self-experience (32.3%), family and friends (24.1%), verbal guidance from medical staff (15.5%), and websites or social media applications (12.3%).

The most common location of TCS application was the face (51.3%), followed by the extremities (46.5%), trunk (13.9%), genitals (6.3%), and scalp (5.7%). The frequency of use varied between less than once a day (25.9%), daily (45.6%), twice daily (24.1%), and more than twice daily (4.4%). Most participants (80.1%) used TCS continuously for fewer than 14 days and some (10.8%) used it for 14–30 days. However, 4.4% and 4.7% used it for extended periods of time (31–90 days and >91 days, respectively). Side effects from TCS were reported in 25.6% of participants. The most common side effects were hypopigmentation (9.8%), itching (6.3%), redness and skin sensitivity (5.7%), appearance of small vessels (4.4%), increase in body or facial hair (4.4%), and acne (4.1%).


  Discussion Top


The use of TCS without prescription in Saudi Arabia is a major emerging problem. With a prevalence of 43.1%, the use of TCS without prescription in our population is higher than the reported prevalence in Senegal, Korea, and Togo (37.7%, 33.6%, and 18.2%, respectively).[3],[5]

Females were more likely to use TCS without prescription in our study. This was also observed in females in other parts of the world such as India, Pakistan, Ethiopia, and Iraq.[6],[7],[8],[9] This can be attributed to females being more attentive to their skin health and cosmesis. Although the use of TCS without prescription is expected to be seen more in uneducated people, level of education did not seem to play a role in our study population. Participants with a lower educational status were two times more likely to use TCS without a prescription in a study from Ethiopia.[9] Similarly, 34.4% of TCS misusers in Madagascar were illiterate.[4]

Very few studies have been reported on the reasons for TCS misuse in Saudi Arabia. We found that using TCS without prescription was not related to difficulties accessing health care or to the cost of a doctor visit. The majority either thought the problem was too trivial for them to consult a physician or had a previous experience with the same medication. In an underdeveloped country like Madagascar, 45.2% of TCS misusers claimed that they could not afford the cost of dermatological care.[4]

More than a third of participants in our study used TCS based on a previous prescription from a physician. This was also observed in a study from India, where many patients were using the same old prescription without visiting their doctor for a long period of time.[10] The practice of patients diagnosing themselves with the same problem previously diagnosed by a physician and using the same treatment repeatedly can be harmful. Awareness should be raised that the potency, formulation, and duration of application of TCS differ based on the severity and location of the new lesions, even if the same diagnosis applies. Recommendations by family and friends were the second most common source of information in our study. The use of friends and relatives as a source of TCS recommendations was also commonly seen in Pakistan (64%), India (50.2%), and Iraq (20.7%).[6],[7],[8] In addition, the impact of social media is clearly observed in our study. More than 15% of participants obtained information regarding the use of TCS from online sources. The use of social media influencers and websites as sources of information was not widely reported in previous studies. Recently, we have been noticing that social media celebrities and influencers are being used to advertise topical products that contain corticosteroids for various beauty reasons. We have also observed in our study the practice of some participants obtaining TCS without prescription from beauty salons, or from anonymous people that mix them with emollients.

A good percentage of our population used TCS for improper indications. We report that 19.9% of participants used TCS for cosmetic purposes, 13.9% used them after hair removal, and 2.2% used them as a moisturizer. In addition, some participants admitted using them intermittently before special occasions for their brightening effects. Similar findings were reported in the literature, with TCS being used as brightening or skin-lightening agents in many Asian and African countries. Two-thirds of the study participants in Ethiopia, Iraq, and Nigeria used TCS for cosmetic purposes such as skin lightening and depigmentation.[3],[7],[9] In India, 29% of participants used TCS as a fairness or aftershave cream.[8] In those communities, fair or white skin is considered as a sign of beauty, and using TCS as a brightening agent to optimize dark skin complexion reinforces the widely held belief that “fair is beautiful.”[3],[6],[7],[11],[12]

We also asked about the details of using TCS without prescription. The most commonly used TCS without prescription is medium in potency and used most often on a site with a high absorption rate (the face). This, coupled with the lack of knowledge of its content (only 46.5% reported they knew it contained a corticosteroid), has the potential of leading to serious side effects. In other reported studies, potent and superpotent TCS were most commonly used. Clobetasol propionate 0.05% was misused by 49.9% of study participants in Nigeria and 42.1% in Iraq.[3],[7] Betamethasone valerate was the most commonly used formulation in Pakistan and India (76% and 72.8%, respectively).[6],[8] In the Saudi market, Mometasone furoate 0.1% cream is available from at least five different pharmaceutical companies. This wide availability could explain why this TCS formulation is the most used in Saudi Arabia.

The duration of use in our study was less than what was observed in previous studies. Most participants in our study used TCS for fewer than 14 days. However, the duration of use varied between months to years in most other studies.[4],[8],[9] Most participants used TCS once a day or less than once a day. Most users from previous studies used TCS once or twice a day.[5],[9] This intermittent use could be explained by the fact that TCS rapidly improves multiple skin conditions before side effects start to develop with prolonged use. This initial relief and experience from previous use of TCS give the person the confidence to try it over and over again.

The prevalence of side effects in our study was 25.6%. The most common side effects reported were well-known and widely recognized side effects of topical steroids. The most commonly reported in our study was hypopigmentation, followed by itching, redness and skin sensitivity, appearance of small vessels, increase in body or facial hair, and acne. In a study of Saudi university students who used TCS without prescription on the face, the most commonly reported side effects were comparable to ours. Those included skin dyspigmentation, sensitive skin, recurrence of problems after stopping the topical agent, redness, itching, appearance of small vessels, and acne.[13] The rate of side effects in some countries, like India and Madagascar, was higher than 90%.[4],[12] In Ethiopia, 52.4% of study participants experienced side effects.[9] This can be attributed to prolonged use of TCS for months and years, as observed in those studies.

The current study has several limitations. Our study did not include TCS combined with other active ingredients (such as antibiotics or antifungals), as side effects can be attributed to the other active component. In addition, TCS combined with antibiotics require prescriptions according to SFDA regulations. The study was restricted to TCS use in the last 2 years, which enabled us to generate a list of commercially available TCS with ease, and to minimize the recall bias of participants. Although our study was limited in the number of participants, it highlights the common practice of obtaining TCS without prescription among the general population in Saudi Arabia.


  Conclusion Top


As observed in our study, misuse of TCS is a very common practice in Saudi Arabia. Poor awareness of this issue among the general population is serious and needs to be addressed by local health authorities. We recommend increasing public education along with applying strict policies and surveillance programs from the Ministry of Health and SFDA to regulate the use of TCS. The results of the current study will hopefully aid policy makers in solving the issue of TCS misuse in Saudi Arabia.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Kim S, Lee S, Kim H. A survey of the awareness, knowledge, and behaviour of topical steroid use in dermatologic outpatients of the University Hospital. Korean J Dermatol 2008;46:473-9.  Back to cited text no. 5
    
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Chohan S, Suhail M, Salman S. Facial abuse of topical steroids and fairness creams: A clinical study of 200 patients. J Pakistan Assoc of Dermatol 2014;24:204-11.  Back to cited text no. 6
    
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Al-Dhalimi MA, Aljawahiry N. Misuse of topical corticosteroids: A clinical study in an Iraqi hospital. East Mediterr Health J 2006;12:847-52.  Back to cited text no. 7
    
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Mahar S. Topical corticosteroid misuse: The scenario in patients attending a tertiary care hospital in New Delhi. J Clin Diagn Res 2016;10:16-20.  Back to cited text no. 8
    
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Bilal A, Shimels T, Tsegaye M. Prevalence of topical corticosteroids-related adverse drug events and associated factors in selected community pharmacies and cosmetic shops of Addis Ababa, Ethiopia. Sudan J Med Sci 2018;13:62-77.  Back to cited text no. 9
    
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Chaudhary S. Misuse of topical corticosteroids and attitude towards self-medication: A rising alarm. Int J Res Dermatol 2017;3:485-8.  Back to cited text no. 10
    
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Kumar A, Neupane S, Shrestha P. Pattern and predictors of topical corticosteroid abuse on face: A study from Western Nepal. Res J Pharm Biol Chem Sci 2015;6:1154-9.  Back to cited text no. 11
    
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Saraswat A, Lahiri K, Chatterjee M, Barua S, Coondoo A, Mittal A, et al. Topical corticosteroid abuse on the face: A prospective, multicenter study of dermatology outpatients. Indian J Dermatol Venereol Leprol 2011;77:160-6.  Back to cited text no. 12
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Majed D, Alnujaidi M, Almohammadi N, Kokandi A. Use of topical steroids on the face among university students in Saudi Arabia. Biomed Res 2018;29:2786-9.  Back to cited text no. 13
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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