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General Public Knowledge Regarding Topical Corticosteroids: A Nationwide Survey in South Korea
Korean J Clin Pharm 2022;32(2):84-92
Published online June 30, 2022
© 2022 Korean College of Clinical Pharmacy.

Heenam Seo1†, Seoung Yeon Song1†, Dahye Kim2, Ji Hwan Park2, Yoonho Shin2, Kang Hyuk Lee2, Soo An Choi3, Ju-Yeun Lee4, Do Young Kim5, Wan Gyoon Shin4, and Eunyoung Kim1,2*

1Clinical Research Laboratory College of Pharmacy, Chung-Ang University, Seoul 06974, Republic of Korea
2Department of Pharmaceutical Industry, Chung-Ang University, Seoul 06974, Republic of Korea
3College of Pharmacy and Research Institute of Pharmaceutical Sciences, Korea University, Sejong 30019, Republic of Korea
4College of Pharmacy and Research Institute of Pharmaceutical Sciences, Seoul National University, Seoul 08826, Republic of Korea
5Department of Dermatology and Cutaneous Biology Research Institute, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
Correspondence to: *Eunyoung Kim, Department of Pharmaceutical Industry, Chung-Ang University, Seoul 06974, Republic of Korea Clinical Data Analysis, Evidence-Based Clinical Research Lab., Departments of Health Science & Clinical Pharmacy, College of Pharmacy, Chung-Ang University, Seoul 06974, Republic of Korea
Tel: +82-2-820-5791, Fax: +82-2-816-7339, E-mail:

The first two authors contributed equally to this work.
Received March 31, 2022; Revised May 18, 2022; Accepted May 18, 2022.
Background: Topical corticosteroids (TCs) are available both as over-the-counter drugs and prescription medicines at pharmacies. Although they are generally safe drugs, inappropriate and excessive use could result in potential side effects. Thus, it is important to have appropriate knowledge regarding the use of TCs. We performed a cross-sectional survey to assess public knowledge and the potential misuse or overuse of TCs. Methods: A cross-sectional and nationwide online survey was conducted among participants who were aware of TCs. The survey items included sources of information, indications, potential side effects, and methods of application of TCs. A comparative analysis was conducted between those with (TC users) and without (TC non-users) an experience of using TCs. Results: Among 3,000 participants, 74.4% were TC users. The mass media was the most common information source of TCs, and only one-third of the surveyed people relied on pharmacists or doctors for information. Regarding indications and application methods, incorrect answer rate was high in some items, but respondents showed adequate knowledge. However, awareness of the safety of TCs was low. Overall, the TC users showed a higher knowledge of TCs than TC non-users. Conclusions: Public knowledge of the use of TCs appears to be appropriate. However, we found potential misuse or overuse of some items and a lack of awareness of the side effects concerning TCs. Thus, healthcare professionals’ significant role is required.
Keywords : Topical steroid, survey, public awareness, public knowledge, South Korea

Topical corticosteroids (TCs) are widely used for various skin conditions. Although safe when used appropriately, misuse and abuse of TCs could result in local and systemic side effects.1-3) Reports of misuse and abuse resulting in serious adverse outcomes have been reported in India4-7) and Africa8) owing to the high availability of over-the-counter (OTC) TCs.7,8) In South Korea, TCs with various potencies are available without a prescription. Additionally, there is an increasing global trend of self-medication,9) and TCs are one of the most used therapeutics for self-medication against dermatological conditions.10,11) Thus, it is important that the public have appropriate knowledge regarding the TCs.

To our knowledge, no study has assessed the public awareness and knowledge of TCs at a national level. Thus, our study aimed to evaluate the nationwide awareness and knowledge of TCs in South Korea and analyze the potential for misuse and abuse of TCs.


In 2015, a nationwide web-based cross-sectional survey was conducted using the largest online panel in South Korea, Tillion. The survey targeted 18-65 adults and used a questionnaire with 42 items including demographic information and TCs specific knowledge. Individuals were asked whether they were aware of TCs after presenting an explanation of what TCs were. If ‘yes’, they were classified as ‘TC informed group’ and included in this study as participants. They were recruited until 3,000 participants were obtained using quota sampling stratified according to sex, age, and region of residence for a representative sample of the South Korean population. In contrast, if ‘no’, they were classified as ‘TC non-informed group’ and excluded from the survey. However, TC non-informed group was also asked to answer the demographic-related questions in the questionnaire and the difference between the two groups was analyzed. The 3,000 participants were asked whether they had previously used or were currently using TCs. Those with experience of using TCs were defined as ‘TC users,’ while those without experience were defined as ‘TC non-users.’ They were asked to answer the TC-specific questions and we compared the results between two groups. Further, TC users were classified into three groups based on the way they obtained TCs and used them as follows: (i) those who obtained TCs through prescription at least once were defined as ‘prescription-based TC users’; (ii) those who bought only OTC TCs were defined as ‘OTC-TC users’; and (iii) those who were neither 1 nor 2 were assigned to ‘others’ including using TCs of family members. Subgroup analyses were performed. Among the recruited individuals, the ones who provided informed consent could access the survey. The Institutional Review Board of Chung-Ang University approved the study protocol (approval number: 1041078-201409-HR-142-01C) and all procedures in this study before data collection.

The questionnaire consisted of 42 items that were based on a conceptual framework. It was reviewed by dermatologists, pharmacists, and non-medical persons, and modifications were made based on their feedback. The demographic information, including sex, age, the region of residence, marital status, level of education, occupation, monthly household income, and number and age of children <18 years, if present, were collected. The public knowledge of TCs was evaluated in the following four categories: (i) sources of information; (ii) indications considered appropriate by the participant; (iii) awareness and knowledge of TCs’ side effects; and (iv) appropriate methods of application, including application frequency and duration. The optional items of TC-specific questions were based on the approved label of TCs in South Korea regardless of the strength or whether it was OTC or a prescription drug. Additionally, commonly misunderstood items were included after a review of literature. All of the TC-specific questions were multiple choice. Lastly, the respondents were asked whether they would consult a pharmacist or doctor before purchasing TCs.

All analyses were performed using IBM Statistical Package for the Social Sciences version 23 (SPSS Inc., Chicago, IL, USA). The results of descriptive frequencies were expressed as percentages or mean±standard deviation. Pearson chi-square (χ2) tests and student’s t-tests were used to compare the characteristics of TC users and non-users, and prescription-based TC users and other TC users. All results were considered statistically significant when p<0.05.


Of the total 4,138 participants, 3,000 (72.5%) were aware of TCs and were, therefore, included in our study. The demographic characteristics of the TC-informed group and the non-informed group are presented in Table 1. TC-informed and non-informed participants were significantly different in terms of all characteristics; wherein TC-informed participants were mostly female, older, married, had children, lived in a regional area, and had a profession as well as higher education and income (all p<0.001). Of the 3,000 participants, 2,231 (74.4%) were TC users, while the rest (25.6%) were TC non-users. Of all TC users, 1,503 (67.4%) were prescription-based TC users, 628 (28.1%) were OTC-TC users, and 100 (4.5%) were other users.

Demographic information of TC informed and non-informed participants

TC informed (N = 3000) TC non-informed (N=1138)

No. % No. %
Male 1508 50.3 694 61.3
Female 1492 49.7 440 38.7
Age (years), mean ± SD 41.0 ± 11.6 38.76 ± 12.0
Marital status
Single 1016 33.9 512 45.0
Married or other 1984 66.1 626 55.0
Children younger than 18 years
None 1817 60.6 817 71.8
1 600 20.0 160 14.1
2 511 17.0 146 12.8
≥3 72 2.4 15 1.3
Residential area
Metropolitan 1518 50.6 660 58.0
Regional 1482 49.4 478 42.0
Professional 480 16.0 120 10.5
Service 1354 45.1 485 42.6
Business 215 7.2 127.0 11.2
Unemployed 893 29.8 367 32.3
Other 58 1.9 39 3.4
< University degree 779 26.0 448 39.4
≥ University degree 2221 74.0 690 60.6
Monthly household income
No income 31 1.0 39 3.4
Low-income 926 30.9 458 40.2
Mid-income 1174 39.1 439 38.6
High-income 869 29.0 202 17.8

TCs, topical corticosteroids; SD, standard deviation

The sources of information among the participants regarding the use of TCs are shown in Table 2. The main sources of information were ‘articles or news from magazines, newspapers, and/or broadcasts’ followed by the ‘friends or family’ among TC users and TC non-users, while only one-third of the surveyed people selected pharmacists or doctors for information. However, as a result of sub-analysis, ‘doctor’ (46.1%) and ‘pharmacist’ (40.9%) were the most frequently selected information sources among prescription-based TC users, while ‘pharmacist’ (35.1%) followed ‘articles or news from magazines, newspapers, and/or broadcasts’ and ‘friends or family’ among OTC-TC users.

Source of information

Source TC informed *(n = 3000) TC users* (n = 2231) TC non-users* (n = 769) p-value**

No. % No. % No. %
Articles or news from magazines. newspapers, and/or broadcasts 1190 39.7 866 38.8 324 42.1 0.110
Friends and/or family 1107 36.9 835 37.4 272 35.4 0.200
Pharmacist 954 31.8 830 37.2 124 16.1 <0.001
Doctor 916 30.5 786 35.2 130 16.9 <0.001
TV health programs 905 30.2 699 31.3 206 26.8 <0.001
Package inserts and/or leaflets 746 24.9 656 29.4 90 11.7 <0.001
Internet search 616 20.5 514 23.0 102 13.3 <0.001
Advertisement 464 15.5 375 16.8 89 11.6 <0.001
Others 26 0.9 17 0.8 9 1.2 0.900

TCs: topical corticosteroids

*Percentages do not add up to 100% due to multiple selections.

** P-value is from χ2 test performed between TC users and TC non-users.

The majority of the study participants (85.5%) selected at least one correct indication. The most frequently selected indication was ‘itchy skin’, followed by ‘atopic dermatitis’, ‘seborrheic dermatitis’, ‘eczema’, and ‘contact dermatitis’. All of these conditions were approved for TC usage. A significantly higher proportion of TC users selected approved indications, while the TC users also chose most inappropriate indications as appropriate options by a significantly higher proportion than TC non-users, except ‘arthritis or pain relief’. These results were similar for the prescription-based TC user group.

Of these, 90.6% selected at least one appropriate option, while 78.6% selected at least one unapproved indication. Of the unapproved and commonly misused indications, ‘bacterial infection’ and ‘fungal infection’ were the most frequently selected in both the TC users and TC non-users. Detailed results of the comparison regarding the selection of appropriate indications between TC users and non-users are presented in Table 3.

Indications of topical corticosteroids as selected by respondents

Indications Approved TC informed (n = 3000) TC users (n = 2231) TC non-users (n = 769) p-value**

No. %* No. %* No. %*
Itchy skin Yes 1425 47.5 1164 52.2 261 33.9 <0.001
Atopic dermatitis Yes 1240 41.3 996 44.6 244 31.7 <0.001
Seborrheic dermatitis Yes 1032 34.4 835 37.4 197 25.6 <0.001
Eczema Yes 1005 33.5 853 38.2 152 19.8 <0.001
Contact dermatitis Yes 990 33.0 837 37.5 153 19.9 <0.001
Bacterial infection No 968 32.3 770 34.5 198 25.7 <0.001
Fungi infection No 900 30.0 717 32.1 183 23.8 <0.001
Psoriasis Yes 778 25.9 631 28.3 147 19.1 <0.001
Rash or erythema Yes 757 25.2 615 27.6 142 18.5 <0.001
Wound No 658 21.9 535 24.0 123 16.0 <0.001
Arthritis or pain relief No 652 21.7 442 19.8 210 27.3 <0.001
Acne No 637 21.2 497 22.3 140 18.2 0.017
Cracked skin No 582 19.4 465 20.8 117 15.2 0.001
Insect bites Yes 456 15.2 395 17.7 61 7.9 <0.001
Nappy rash No 346 11.5 291 13.0 55 7.2 <0.001
Moisturizing No 264 8.8 204 9.1 60 7.8 0.257
Whitening No 141 4.7 98 4.4 43 5.6 0.175
Others 25 0.8 15 0.7 10 1.3 0.099

TCs, topical corticosteroids

Percentages do not add up to 100% due to multiple selections.

p-Value is from χ2 test performed between TC users and TC non-users.

Participants showed lower awareness regarding the side effects than regarding the indications for TCs. Approximately >50% of the respondents answered that they were unaware of the side effects of TCs, and 1% indicated that there were no side effects associated with TCs. The degree of awareness in most options was significantly higher in TC users than non-users. Of TC users, prescription-based TC users (60.5%) showed the highest awareness followed by OTC-TC users (42.4%). Among the potential side effects, ‘thinning of the skin’ was most frequently selected, followed by ‘changes in skin color’ and ‘itchy skin’. ‘Systemic side effects’ were selected by only 2% of the survey respondents (Table 4).

Side effects of topical corticosteroids selected by respondents

TC informed (n = 3000) TC users (n = 2231) TC non-users (n = 769) p-value**

No. % No. % No. %
Awareness of side effects <0.001
Aware of the side effects 1438 47.9 1213 54.4 225 29.3
Unaware of the side effects 1541 51.4 1009 45.2 532 69.2
No side effects 21 0.7 9 0.4 12 1.6
Side effects** (N = 1438) (N = 1213) (N = 225)
Thinning of the skin 607 42.2 533 43.9 74 32.9 0.002
Changes in skin color 535 37.2 468 38.6 67 29.8 0.012
Itchy skin 522 36.3 463 38.2 59 26.2 0.001
Skin irritation 519 36.1 458 37.8 61 27.1 0.002
Telangiectasia 507 35.3 441 36.4 66 29.3 0.043
Dry skin 432 30.0 386 31.8 46 20.4 0.001
Susceptibility to skin infections 267 18.6 232 19.1 35 15.6 0.206
Acne 255 17.7 226 18.6 29 12.9 0.038
Easy bruising 151 10.5 129 10.6 22 9.8 0.700
Hypertrichosis 147 10.2 124 10.2 23 10.2 1.000
Others 31 2.2 24 2.0 7 3.1 0.283
Systemic side effects 26 1.8 24 2.0 2 0.9 0.260

TCs, topical corticosteroids

Percentages do not add up to 100% due to multiple selections.

p-Value is from χ2 test performed between TC users and TC non-users.

The responses regarding the appropriate frequency and duration of TC application are presented in Figs. 1 and 2, respectively. Once- or twice-daily application is usually recommended for TCs,3) although some TCs such as hydrocortisone can use more frequently. However, 4% (n=115) of the participants chose ‘≥5 times a day’. With respect to the duration of application, one-fourth (n=710) of the participants concurred that TCs should be used ‘until symptoms resolve regardless of the duration’. Of these respondents, 81%(n=572) were TC users and of them, prescription-based TC users accounted for the most at 60.5%. The responses to the knowledge of correct usage of TCs are shown in Table 5. All the items were answered correctly by most of the respondents except for items 7 and 8. Except for item 8, TC users showed a greater likelihood of selecting the correct responses and were less likely to select ‘do not know’.

Knowledge regarding topical steroids

Item correct response TC informed* (n=3000) TC users* (N=2231) TC non-users*(N=769) p-value**

Yes (%) No (%) DN (%) Yes (%) No (%) DN (%) Yes (%) No (%) DN (%)
If you reuse the remaining external medicine
1 (including steroid external medicine) after use, you need to check the expiration date and use it Yes 74.8 16.5 8.7 75.6 17.3 7.1 72.1 13.8 14 <0.001
2 Steroids have different potency depending on the Yes 73.3 10 16.7 74.2 10.6 15.2 70.3 8.1 22 <0.001
3 Different brands of topical steroids have different Yes 67.3 10.9 21.8 68.7 11.1 20.2 62 10.7 27 <0.001
4 Different steroid potency needs to be used for Yes 66.4 13.2 20.4 67.5 13.6 18.9 63 11.9 25 0.002
5 For optimal absorption, steroids should be applied No 17.3 72.2 10.5 19.4 73.2 7.4 10.7 68.8 21 <0.001
6 For optimal absorption, one should cover the area No 18.5 63.7 17.8 18.6 67.6 13.8 18.2 50.6 31 <0.001
7 For optimal absorption, steroids should be applied No 37.3 52.4 10.3 39.7 53 7.3 29.2 50.5 20 <0.001
8 Remaining steroids can be used for other similar No 31.7 47.7 20.6 34.1 47.5 18.4 23.5 48.5 28 <0.001

TCs: topical corticosteroids; DN: do not know

*Percentages do not add up to 100% due to multiple selections.

*p-Value is from χ2 test performed between TC users and TC non-users.

Fig. 1. Appropriate frequency of topical corticosteroid application

Fig. 2. Appropriate duration of topical corticosteroid application

When enquired if the respondent would consult a doctor or pharmacist before purchasing TCs, 2,131 (71.0%) answered ‘yes,’ 708 (23.6%) answered ‘not sure,’ and 161 (5.4%) answered ‘no’. These results did not differ significantly between TC users and TC non-users (70.6% vs. 72.4%, p=0.322). However, there was a significant difference between the prescription-based TC user group and the OTC-TC user group (77.2% vs. 56.1%, p<0.001).


This study is the first attempt to assess the level of public awareness and knowledge of TCs, a commonly used medication for various dermatological conditions, at the national level. In South Korea, the public is exposed to an environment with a wide range of topical steroid products that are available without a prescription. The general Korean population has a high interest in health and wellbeing. It is a common topic discussed in the media.12) In addition, internet access, one of the important sources of health information, is easy here.13-14) Possibly due to such a nature, high awareness of TCs was observed with 73% of the participants answering that they were aware of TCs, despite only 54% of them having used TCs previously.

In support of our theory of high media exposure regarding medication in South Korea, ‘articles or news from magazines, newspapers, and/or broadcasts’ option was selected most frequently as the source of information, regardless of any previous experience of TC use. Also, ‘TV health program’ was selected by one-third of the participants. In particular, the latter was selected at a higher rate than the doctor or pharmacist in the TC non-user group. In the USA, nearly half of the respondents (49%) reported advertising or promotions from television, newspapers, or magazines as the source of information for non-prescription medications.15) In our study, advertising was ranked the lowest except ‘others’. This might be related to decreased public advertisements due to the strengthening of regulation and review of medication in South Korea.16) Previous studies had reported that doctors or pharmacists were the most frequent sources of medications among interpersonal channels.15,17-19) In our study, friends and/or family were most often selected at a higher rate than doctors or pharmacists. Although these sources might sometimes have professional knowledge, they are often unlikely to have any formal training in providing appropriate healthcare advice, which could lead to misuse or overuse.18) About one-third of the TC users selected ‘package inserts and/or leaflets’ as the information sources. These are important information sources for the safe and effective use of medications, especially OTC medications. However, even if package inserts and/or leaflets can provide accurate information to patients, such information obtained without appropriate verbal communication from healthcare professionals could lead to unnecessary panic and lower adherence. ‘Internet search’ as the source of information was also commonly selected by TC users. The internet is not a validated source of information for medications. It provides non-patient-specific data and often inaccurate information to consumers, which could increase the possibility of misuse.20) Thus, the provision of patient-specific and accurate information from healthcare professionals is essential for the rational use of medicines. In our study, ‘doctors’ or ‘pharmacists’ were the main information source among the prescription-based TC users. Of all participants, however, only one-third of the TC users selected them as the source of TC information. In particular, the OTC-TC users showed a low selection of pharmacists and only 56% answered that they were willing to consult a healthcare professional before purchasing TCs. Such low selection rates of healthcare professional are alarming, as drug use without any correct direction to use may be associated with serious side effects. Thus, pharmacists’ role is crucial to prevent possible problems related to TCs for patients requesting non-prescription TCs.

High awareness regarding indications for TCs was observed in this study. However, interestingly, the TC users showed a significantly higher selection of most inappropriate options and so did the prescription-based TC users. This is related with the result that the TC users agreed with the ‘remaining steroids can be used for other similar symptoms’ by a significantly higher proportion. These results are alarming, as they possibly suggest the potential drug misuse, which can lead to serious side effects. ‘Bacterial infection’ and ‘fungal infection’ were the most frequently selected inappropriate indications. TCs can exacerbate fungal infections when used alone, and long-term use might even lead to secondary infections. A study including the patients who used topical steroids for dermatoses where it is an absolute contraindication, as well as those who developed side effects, reported that the common incorrect use superficial dermatophytosis in 89% and the most common adverse effect was recurrence/increase in the extent of the infection in 76% patients.21) However, combination products containing TC and anti-infective agents can be employed for bacterial or fungal infections. Thus, healthcare professionals should provide more comprehensive and informative counseling to TC users. In particular, community pharmacists need to intervene and evaluate whether TCs are appropriate for patients requesting non-prescription TCs.

Participants showed low knowledge regarding the side effects. Just under half of the respondents answered that they were aware of the TC side effects with 1% answering that there are no side effects with TCs. Fortunately, the awareness of TC side effects among TC users was higher. However, they were mostly aware of the local side effects and only 2% were aware of the systemic side effects. This could be because, with non-prescription medications, users tend to be more interested in the potential benefits than the potential risks.22,23) Thus, providing information on side effects of TCs, including both OTC and prescription, is crucial to ensure the public’s safety while using TCs.

Regarding the appropriate use of TCs, considerable respondents, particularly TC users, including the prescription-based TC users, selected ‘until symptoms resolve regardless of the duration’ as the appropriate duration of TC application, which was a matter of concern about the possibility of overuse. A study conducted in Great Britain that surveyed patients using non-prescription TCs found that most of the respondents would continue using TCs as long as it was necessary until the resolution of the symptoms.24) This possibly suggests that TC users might be unaware of the possible risk of long-term use of TCs. Furthermore, a relatively high proportion of respondents agreed with the statements ‘remaining steroids can be used for other similar symptoms’ and ‘for optimal absorption, steroids should be applied repetitively’ as the proper TC use, which could potentially lead to problems associated with misuse and overuse of the drugs. Thus, appropriate education from healthcare professionals is required for safe use of TCs

This study has some limitations. This was a drug-related study that included considerable medical terminology in the questionnaire. Although we provided an explanation of each terminology and the questionnaire was reviewed by non-medical persons as well as pharmacists and dermatologists for improving readability, it might be quite difficult for the general public to understand completely and thus, may affect the study results. In addition, the TC user group was determined based on the answer whether the respondents had ever used TCs. Thus, the results of this study may have been affected by recall bias. Finally, participants were not instructed that responses regarding all of the TC-specific questions should be made for TC single agents only, except in combination products containing ingredients other than TCs, such as antifungal and TC or antibacterial and TC. This may affect the high selection of bacterial infection and fungal infection as appropriate indications. Despite these limitations, this study is important. Previous studies related to general knowledge of TCs have mostly targeted patients coming to dermatology outpatient departments or pharmacies,4,21,24,25) or health professionals.21,26) However, this study is first nationwide and large scale survey focused on the general public, including those without TC experience. In conclusion, most of the participants were aware of at least one TC indication and how to use TCs, regardless of their experience of using TCs. However, the awareness of TC safety was low. Furthermore, they showed a high response for inappropriate indications and some specific options of frequency and duration of TC usage, especially in the TC user group. These are alarming in terms of the possibility of misuse or overuse; thus, for the correct and safe TC use, healthcare professionals should prescribe or recommend the optimal product to the patients, explain why it should be used and its potential side effects, and provide specific dosage instructions including frequency, duration, and how to apply.


This research was supported by a grant (14172MFDS159) from the Ministry of Food and Drug Safety.

Conflicts of Interest

The authors declare that there is no conflict of interest.

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