Introduction
Topical corticosteroids (TCSs) were first introduced in the early 1950s and since then, they become one of the most commonly prescribed medications in dermatology1 They exert anti-inflammatory, immunosuppressive, and vasoconstrictive effects and are used to manage conditions such as eczema, psoriasis, dermatitis, and allergic reactions, providing relief from redness, swelling, itching, and discomfort.2
Long-term or unsupervised use raises safety concerns. Prolonged application, especially of potent agents on high-absorption sites, can cause skin thinning and striae.3 Systemic complications, including adrenal suppression and Cushing’s syndrome, have also been reported, particularly with high-potency preparations.4 Studies indicate that application of as little as 7.5 g per week of very potent TCS has been reported to cause secondary adrenal failure.5 Epidemiological studies further suggest an association between TCS use and increased risk of osteoporosis and fractures, with a higher risk among younger women.5
Concerns about long-term safety, therefore, persist despite decades of clinical use6
In Jordan, TCSs are easily available without prescription, leading to self-medication and reliance on advice from pharmacists, relatives, or previous prescriptions. This practice increases the risk of inappropriate use, such as incorrect potency selection, prolonged application, and use for non-indicated conditions. Consequently, adverse outcomes from misuse may be more prevalent.
Given the limited data on TCS use in Jordan, this study aimed to evaluate prevalence, patterns of use, sources of prescription, awareness of potential side effects, and recognition of specific corticosteroid products. It also sought to assess sociodemographic factors associated with misuse and knowledge gaps.
Methods
Study Design and Setting
Data were collected using a validated self-administered questionnaire. The questionnaire was created using Google Forms and distributed through social media platforms, including Facebook, Instagram, Twitter, and WhatsApp, to ensure broad participation across diverse Jordanian demographic groups.
Participants & Ethical Approval
To be eligible, participants had to be residents of Jordan and at least 18 years old. Individuals who did not complete the questionnaire or could not provide informed consent were excluded. The study was conducted following the ethical principles of the Declaration of Helsinki and was approved by the Institutional Review Board at Jordan University of Science and Technology (IRB number 25/174/2024). Informed consent was obtained electronically before participation. The consent form outlined the purpose of the study, the voluntary nature of participation, and assurances of anonymity and confidentiality.
Questionnaire Development and Validation
The questionnaire was developed in collaboration with two board-certified dermatologists to ensure content validity, clinical relevance, and unbiased item design. The initial draft was constructed in Arabic to match the local language, then translated into English for reporting. To evaluate its appropriateness for use among the general population, the instrument underwent pilot testing with 25 participants of different ages and educational backgrounds. Feedback from the pilot highlighted areas for improvement in clarity and flow. The complete self-administered questionnaire is provided in Supplementary File 1.
The internal reliability of the knowledge and awareness items was assessed using Cronbach’s alpha, which yielded a score of 0.81, indicating good internal consistency. In addition, where recognition of corticosteroid products was required, visual aids (images of common cream packaging in Jordan) were included to facilitate understanding and reduce misclassification by participants without medical training. The final version of the questionnaire included sections on demographics, recognition of corticosteroid creams (via names and images), usage patterns (application site, frequency, duration, and source), awareness of potential side effects, self-reported adverse effects, and whether participants recommended use to others.
The final survey was distributed online over eight weeks. Responses were reviewed for completeness, and data cleaning was performed before analysis to ensure accuracy and quality. It should be emphasized that the reported side effects represent participants’ self-perceived experiences and were not confirmed by clinical examination or physician diagnosis.
Statistical Analysis
Data were analyzed using Jamovi software (version 2.3.28). Descriptive statistics, including frequencies and percentages, were employed to summarize demographic data, familiarity with steroid creams, and usage patterns. Cross-tabulations were used to explore relationships between steroid cream use and demographic variables. Statistical significance was assessed using Pearson’s chi-square test or Fisher’s exact test for small frequencies, with a two-tailed p-value of <0.05 considered statistically significant.
Result
Demographics and Usage Characteristics
A total of 714 participants were included in this study. The majority were young adults aged 18–25 years (36.7%) and predominantly female (59.0%). Most participants held a bachelor’s degree (72.4%), and nearly one-third were students (30.7%). A significant portion of the sample reported having health insurance (81.4%) and residing in the northern region of Jordan (53.2%). Table 1
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Table 1 Demographic and Social Characteristics of the Sample
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Corticosteroid Cream Usage Characteristics
Nearly half of the participants (46.8%) reported keeping corticosteroid creams at home. The most commonly reported sites of application were the hands (36.6%) and face (31.2%), followed by the legs (11.0%) and genital area (9.1%). Regarding frequency of use, over half (53.1%) applied the cream once daily, while 36.4% reported use two to three times per day. A smaller proportion used it more than three times daily (1.6%) or on an intermittent basis, such as twice weekly (7.3%). While 76.2% indicated that the usage of the cream had been explained to them, only 63.2% reported reading the medication leaflet. 61.3% of users reported awareness of side effects, and 45.5% stated they had recommended corticosteroid creams to family or friends. Most participants used the cream for less than one month (73.9%), while only a small percentage reported prolonged use beyond a year (6.5%). Regarding the sources of acquisition, over half (52.4%) obtained the cream via prescription from a dermatologist, whereas others received it from pharmacists (22.8%), non-dermatologist doctors (9.8%), or through informal channels such as friends/relatives (12.6%) or the internet (2.3%). Table 2
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Table 2 Corticosteroid Cream Usage Characteristics
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Recognition and Utilization of Topical Corticosteroid Creams by Potency Class
Participants demonstrated varying levels of recognition and use of different topical corticosteroid creams. Hydrocortisone 1% (Class 7, least potent) was the most commonly recognized corticosteroid (45.1%), followed by betamethasone valerate 0.1% (39.6%) and clobetasol propionate 0.05% (30.6%). In terms of usage, clobetasol propionate was the most frequently used (20.0%), despite being classified as a super potent corticosteroid (Class 1), followed by hydrocortisone 1% (12.6%) and betamethasone valerate (12.3%). Mometasone furoate and methylprednisolone aceponate were used less frequently, at 10.5% and 4.6%, respectively. Notably, 39.9% of participants reported using corticosteroid creams not listed in the survey, and 29.5% were unable to recognize any of the named creams. These findings highlight a concerning pattern of higher usage of potent corticosteroids, potentially without adequate knowledge of their classification or risks.
When considered alongside acquisition sources, these findings indicate that while many participants accessed potent and super potent corticosteroids such as clobetasol through dermatologist prescriptions, a substantial proportion also obtained them via pharmacists, non-specialist physicians, or informal channels, suggesting that a notable share of use occurred without direct medical supervision Table 3
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Table 3 Recognition and Usage Patterns of Topical Corticosteroid Creams by Potency
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Reported Indications and Perceived Side Effects of Topical Corticosteroid Use Among Participants
Participants reported several reasons for using topical corticosteroids. The most frequently cited indication was eczema (32.6%), followed by skin itchiness (17.0%) and acne (8.4%). Other common reasons included skin fungal infections (7.5%), sunburns (4.7%), and use after laser sessions (2.6%). Less commonly reported indications were vitiligo (1.4%) and rosacea (0.5%). Importantly, 2.1% of users indicated using corticosteroids for skin lightening purposes.
Regarding adverse effects, 39 participants (9.1%) reported having increased hair growth, and an equal percentage reported skin redness. Other common side effects included skin thinning (8.9%), irritation and itching (8.4%), and pigmentation changes (6.3%), which were also frequently reported. Less frequent adverse effects were vasodilation (6.3%), acne (5.1%), and white spots (3.7%). A smaller proportion noted more serious or specific concerns, such as bacterial/viral infections (2.1%), stretch marks (2.6%), and worsening of the underlying condition (0.9%). However, the majority (60.1%) reported no observable side effects. Table 4
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Table 4 Reported Indications and Perceived Side Effects of Topical Corticosteroid Use Among Participants
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Factors Influencing Corticosteroid Cream Usage
Chi-square analysis showed several significant associations between demographic factors and corticosteroid use patterns. Duration of use was significantly associated with age (χ² = 63.3, p <0.001) and gender (χ² = 28.2, p <0.001), but not with education or job status. Usage frequency was significantly related to educational level (χ² = 27.2, p = 0.039) only.
Reason for use showed significant associations with age (χ² = 112, p = 0.028), gender (χ² = 38.2, p = 0.002), and job status (χ² = 140, p <0.001). The application site was significantly associated with age (χ² = 48.6, p = 0.017) and job status (χ² = 44.9, p = 0.039).
Awareness of side effects was significantly related to gender only (χ² = 6.69, p = 0.010). Previous corticosteroid use showed a strong association with gender (χ² = 40.0, p <0.001) and a borderline association with age (χ² = 37.1, p = 0.057). Cream source was significantly associated with job status (χ² = 38.1, p = 0.008) and showed a borderline association with age (χ² = 30.6, p = 0.060). Table 5
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Table 5 Chi-Square Analysis of Factors Influencing Corticosteroid Cream Usage
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Predictors of Cream Recognition and Reported Side Effects Among Users
Our analysis showed that age, gender, educational level, job, insurance status, reason for use, cream source, and awareness of side effects were significantly associated with the number of recognized corticosteroid creams (p < 0.05). Specifically, participants over the age of 65 and males were significantly less likely to recognize multiple creams (p = 0.032 and p = 0.045, respectively). Additionally, individuals employed in the public (p = 0.027) and private (p = 0.043) sectors demonstrated greater recognition compared to housewives.
Prolonged corticosteroid use was significantly associated with increased awareness of side effects, particularly among those using creams for 3–6 months (p < 0.001) and 6–12 months (p = 0.006). Furthermore, frequent application (2–3 times daily) was significantly linked to a higher number of reported side effects (p = 0.01), whereas infrequent use (eg, twice per week) correlated with fewer side effects (p = 0.022).
In contrast, no significant associations were found between reported side effects and gender, education, cream source, or awareness status (p > 0.05). Table 6
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Table 6 Predictors of Cream Recognition and Reported Side Effects Among Users
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Influence of Demographics and Usage Patterns on Cream Recognition and Reported Side Effects
Recognition of Cream Names
Linear regression analysis identified gender and occupation as significant predictors of the number of recognized topical corticosteroid creams. Males recognized significantly fewer cream names than females (β = −0.34, p = 0.045). Compared to housewives, retired participants (β = 0.87, p = 0.021), public sector (β = 0.56, p = 0.027), and private sector employees (β = 0.53, p = 0.043) had higher recognition scores. No significant associations were found for age, duration of use, or frequency of application, though those using creams twice weekly showed a non-significant trend toward lower recognition (p = 0.071).
Reported Side Effects
Side effects were significantly associated with age, duration, and frequency of use. Compared to the 18–25 age group, participants aged 26–35, 46–55, and >65 years reported fewer side effects (all p < 0.05). Longer duration of use was consistently linked to more side effects, with all periods beyond one month showing significant increases (eg, 3–6 months: β = 1.47, p < 0.001; 6–12 months: β = 0.93, p = 0.006). Higher frequency of application (2–3 times daily) was associated with more side effects (β = 0.26, p = 0.01), while twice-weekly use was linked to fewer side effects (β = −0.45, p = 0.022). Gender and occupation were not significantly associated with reported side effects (p > 0.05). Table 7
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Table 7 Influence of Demographics and Usage on Cream
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Discussion
Our results revealed that 46.8% of participants reported keeping corticosteroid creams at home. This finding is supported by the results of Ah et al’s research, which showed that many people use topical corticosteroids through both prescription and over-the-counter (OTC) routes, with 27.8% of users acquiring these medications without a prescription. Their nationwide, community-based study in Korea demonstrated that topical corticosteroids are widely available and commonly used for a variety of dermatological conditions, indicating that these products are often regarded as standard household medical supplies. Additionally, the study found that a significant proportion of users were prevalent users with ongoing or recent use, indicating routine household storage of corticosteroid creams. These findings suggest that widespread home storage of topical corticosteroids extends beyond our population and reflects a common pattern of accessibility and use in general communities.7
This study showed that the most frequent sites of topical corticosteroid application were the hands (36.6%) and face (31.2%), the facial use align closely with the international literature, where the face is consistently reported as the most common site of misuse8,9 The widespread of facial application is particularly concerning due to the greater vulnerability of facial skin to steroid-induced adverse effects because of its thinner stratum corneum and higher permeability, which significantly increases the risk of complications including skin atrophy, telangiectasias, and steroid-induced rosacea.10
The majority of users (73.9%) reported using TCS for less than a month, but a considerable number of users continued to use TCS for much longer, with 6.5% using TCS for over a year.
Most participants (53.1%) applied corticosteroid cream once daily, aligning with standard recommendations. However, over one-third (36.4%) applied it 2–3 times daily; this frequent application raises concerns about cumulative exposure and the potential for both local and systemic side effects. This pattern is consistent with studies from other regions, such as Ethiopia, where prolonged and frequent use was also observed, often without adequate medical supervision.11
In our cohort, eczema (32.6%) and skin itchiness (17.0%) were the most frequent reasons for topical corticosteroid (TC) use, followed by acne (8.4%), fungal infections (7.5%), and sunburns (4.7%). This distribution aligns with established dermatological practice, where TCs are primarily indicated for inflammatory conditions such as eczema.5 However, the use of topical corticosteroids for non-indicated conditions such as acne and fungal infections suggests inappropriate self-treatment practices. This issue is highlighted in the study by Freeze et al (2020), which analyzed prescribing patterns and found frequent off-label use, particularly beyond approved age ranges and indications. This misuse is especially prevalent in settings where topical corticosteroids are available without prescription, therefore increasing the risk of adverse effects and complications.12
The results from our study indicate a discrepancy between corticosteroid recognition and usage patterns by potency class. Although hydrocortisone 1% (Class 7, weakest) was the most recognized (45.1%), clobetasol propionate 0.05% (Class 1, strongest) showed high usage rates (20.0%) despite lower recognition (30.6%). This suggests that users may not fully understand the differences in potency among TCSs; this knowledge gap has also been observed among healthcare professionals. Alamri et al (2024) found that 81% of primary care physicians in Saudi Arabia could not identify clobetasol propionate as an ultra-high potency steroid, yet 44.3% prescribed it regularly.13 While dermatologist-supervised use of super-potent corticosteroids such as clobetasol may be appropriate, their availability through pharmacists, non-specialist physicians, or informal sources raises concern for misuse and unsupervised exposure.
Recognition and usage patterns varied significantly across demographics. The predominance of young adults in our sample may partly reflect recruitment bias from online distribution, as younger individuals are more active on social media. Within this group, females demonstrated significantly higher recognition (p<0.001), consistent with evidence that women generally exhibit greater health literacy.14,15 However, younger females also reported higher misuse rates, particularly for cosmetic purposes such as skin lightening and acne treatment. In contrast, males and older adults (>65 years) were less familiar with corticosteroid creams and their risks. Occupational status was also significant, with employees showing greater awareness compared to housewives. These demographic patterns are consistent with findings from India, Ethiopia, and Saudi Arabia, where factors such as age and education were linked to steroid misuse and adverse outcomes.11,16,17 These findings highlight the need for targeted education, especially for males, older adults, and housewives.
In addition to demographics, regression analysis revealed that longer duration and higher frequency of corticosteroid use were significantly associated with more side effects. Participants using corticosteroids for more than one month, particularly 3–6 months, reported the highest side effects. This is consistent with literature on cumulative corticosteroid toxicity and risks of perioral dermatitis, steroid-induced acne, skin atrophy, and rosacea.18,19 Furthermore, those applying creams two to three times daily reported more side effects than twice-weekly users, supporting evidence that intermittent regimens reduce adverse outcomes.20
Although dermatologists were the primary source of prescriptions (52.4%), a substantial proportion obtained these medications from non-specialist sources, including pharmacists (22.8%), friends/relatives (12.6%), and non-dermatologist physicians (9.8%). This pattern mirrors previous findings where non-specialist sources were linked to corticosteroid misuse.21 Studies from India have highlighted that pharmacists and paramedical personnel are key contributors, often dispensing potent steroids without prescriptions or adequate counseling.16
Furthermore, the tendency of 45.5% of users to recommend topical corticosteroids to family or friends indicates that self-medication with these products is considered a normal practice. Additionally, the involvement of friends and family as influencing factors is particularly concerning, as they often recommend topical corticosteroids for various conditions, including facial acne and skin lightening without medical evaluation.16,22
Also, gaps in patient education were evident: only 76.2% received usage explanations, 63.2% read medication leaflets, and 61.3% were aware of potential side effects, leaving a substantial minority uninformed about risks. Sharma et al also emphasized that such educational deficits contribute significantly to misuse, particularly for cosmetic purposes.21
In our study, 60.1% of participants reported no adverse effects from topical corticosteroid (TC) use, suggesting that many users apply these agents appropriately. However, 39.9% did experience side effects, most commonly increased hair growth and skin redness (both 9.1%), followed by skin thinning (8.9%) and itching (8.4%). These findings are consistent with the known adverse effect profile of TCs, particularly when used on sensitive areas or over prolonged periods.18,23
Limitation
This study has several limitations that should be considered when interpreting the findings. First, because the survey was conducted online using a self-administered questionnaire distributed through social media platforms, there is an inherent risk of selection bias. Participation was restricted to individuals with internet access and active social media use, which may not fully represent the general Jordanian population; older adults and those with limited digital literacy may therefore be underrepresented. Second, the survey did not capture participants’ field of study or profession; thus, it is possible that some healthcare professionals responded, which may have influenced recognition and reporting patterns. Third, all reported side effects were self-perceived by participants rather than confirmed through medical evaluation, meaning that clinically verifiable adverse effects such as skin thinning may have been under- or over-reported. Finally, despite visual aids, some participants may have misidentified corticosteroid creams, potentially causing inaccurate reporting of usage.
Conclusion
This study highlights the widespread use of topical corticosteroids among the general population in Jordan, with a substantial number obtaining these medications from non-prescription sources such as pharmacists, friends, or online platforms, alongside many who received them through dermatologist prescriptions. Despite the high prevalence of use, there remains limited public awareness regarding the relative strength (potency), appropriate indications, and potential adverse effects of these medications, particularly among users with prolonged or frequent application. The strong associations between demographic factors and both product recognition and adverse event reporting underscore the need for targeted public education campaigns and tighter regulation of corticosteroid dispensing. These findings indicate the need for effective collaboration between dermatologists, pharmacists, and public health authorities to minimize misuse and ensure safer, evidence-based use of these important medications.
Ethics Statement
The study was conducted following the ethical principles of the Declaration of Helsinki and was approved by the Institutional Review Board at Jordan University of Science and Technology (IRB number 25/174/2024). Informed consent was obtained electronically before participation. The consent form outlined the purpose of the study, the voluntary nature of participation, and assurances of anonymity and confidentiality.
Acknowledgments
The authors declare that no funding was received for this study and have nothing further to acknowledge.
Disclosure
The authors declare no conflict of interest.
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