From the Podcast of the 25^th WCD

Episode 17- Dr Etienne Wang (EW) and Dr Shashen Alponso discuss Topical Steroid Phobia; and a chat with Professor Jerry Shapiro

Etienne. Hi, welcome back to the official podcast of the WCD, that is the world Congress of dermatology, which will be hosted in Singapore in 2023. I am Dr. Etienne Wang from the National Skin Center of Singapore and I will be a host for this podcast. You can listen to us on Apple podcasts, Spotify, Pocketcast, and wherever else to get your podcasts.

In this podcast I speak with dermatologist and skin researchers from all over the world to talk about all things dermatology. And today my resident co-host Shahen is back with a derm topic for discussion. Welcome back Shashin!

Shashen. Hi, Dr. Wang, and thanks for having me back.

E. And what will you discuss with us today?

S. So for today’s discussion, I thought we’d talk about topical steroid phobia or the irrational fear of using topical steroids, which often results in undertreatment of skin conditions.

E. Yes. It’s quite prevalent in Singapore. What do you find about this?

S. Actually, what got me thinking about the topic was that sometimes we do get patients in our clinic who say that they applied the cream, but nothing really worked. And when you ask them how much they apply to how often they applied it, they said that they just applied it for a day or two, because the label said “topical steroids” or “steroids” and they didn’t want any side effects from that.

So it got me thinking :

a)      how prevalent is this in dermatology patients or patients in general?

b)      how can we change this to improve patient’s adherence to treatment?

Now, there were some studies that have been done out there and, interestingly, the prevalence of topical steroid phobia has ranged from about 21% to 83.7% in some populations and I thought that this was extremely high.

E. I think it’s very culturally specific as well and also, there’s so many things that go into a patient’s perception of topical steroids, everything from the media to the patient, sitting next to them in the waiting room, to a lot of different things so it’s very hard to pinpoint. What do you think is the actual cause of this?

S. I think for one it’s the lack of patient education: patients hear the word steroid used in many contexts all the way from anabolic steroids to steroids, like prednisolone that has to be taken in tablet form and the moment they find that word on an ointment or a tube of cream, they do think it’s the same strength or has the same potency as a systemic steroid. I think a large part of it is equating the steroids that patients hear about and those side effects with what the patient encounters in the dermatology clinic.

E. There’s also the complete opposite patient who comes in with very potent topical steroids, obtained from either a general practitioner or overseas in some pharmacy, and refuses to stop using it, I think it’s pretty much the flip side of the same coin.

S. Yes, two ends of the spectrum. I remember a story about a patient who had been using potent topical steroid, almost like a moisturizer daily, and only came to see the doctor once they had developed striae, for example. So it is two extremes of this spectrum.

E. What do you think is a solution to this problem?

S. I think the physician, either dermatologist or the general practitioner, who first sees the patient has a lot of power in educating the patient.

At SGH, for example, we try to give the patient a leaflet to counsel them about topical steroids because it’s at that first visit that the patient usually forms a very strong, sometimes even unshakeable, idea about the medication that they’re about to apply. And often when patients come to us say for the second visit or the third visit, they often say, I wish the previous doctors had told me that this is how I should apply the topical steroids, or this is what steroids can do to my skin, if I knew that I would have used it correctly.

I think educating them early on before they come up with their own ideas or get misconceptions is very important.

E. Well, coincidentally, our co-host Ellie has a study that tells almost exactly what we’re talking about. Can you tell us a bit more about this study?

S. Yes. This study was a double-blinded randomized control trial, it had about 275 patients. The patients in the intervention were given an educational video and a patient information leaflet, which targeted some common misconceptions on topical corticosteroids.

Thereafter they assessed these patients’ steroid phobia using a scale, called the topic of topical corticosteroid phobia scale.

Interestingly, the mean score in the intervention arm decreased at one month and three months respectively. A lot of this reduction was mainly in the knowledge domain.

Patients do have certain fears and behaviours, but what this study did show is that even a targeted education, given that a single time point, improve this goal in the knowledge domain, and I think that’s a great starting point.

E. Yeah. I think a patient video, or even a very well-produced public education video is very useful in this situation. I went on YouTube earlier to see where they could find any videos educating about topical steroids. And I found out that none of the skincare influencers actually talking about it, I think it would make a great topic for a video.

S. Absolutely. And I find that especially in today’s climate, a video is more accessible and more interesting to watch than a leaflet, it would be a much far-reaching media.

E. Yes, absolutely. Thank you for that very thought-provoking topic Shashen, and I’m sure everyone in listening will have some sort of experience with this kind of.

S. I hope it’s helpful, thank you!

E. Thank you! All right. Bye-bye.

And now I’d like to invite Professor Jerry Shapiro to the podcast. He is a professor at the Ronald Perelman department of dermatology at the NYU Grossman School of Medicine and previously he was at Vancouver, Coastal Health research Institute and he was the president of the WCD in Vancouver in 2015.

Welcome Jerry to the Podcast!

J. Oh, thank you for having me!

E. Jerry, you are a worldwide expert on hair loss. Can you just tell us what excites you about hair loss these days?

J. There are a lot of things that excites me, for instance the newer treatments that are being developed for alopecia areata as well as a newer thing for androgenetic alopecia.

When I started 30 years ago, there was very little to offer patients who came into our office. Now, three decades later, we have a palette of options to offer our patients.

E. Yes. I agree. These days are a consultation for androgenic alopecia. It takes quite a long time going through all of the options that are out there. What do you think is the most promising thing on the horizon for androgenetic alopecia?

J. In terms of what we can use now, what is a little bit newer than most is the use of low dose oral monoxide. I think that that has been shown to be quite useful for both men and women, a low dose oral monoxide meaning a dose of five milligrams or less. We determine the milligram dosage based on the weight of the individual. I think that’s something that’s kind of newish.

There are all sorts of new discoveries that are being worked on, but they’re not available yet. I think we will have maybe five, 10 or 15 years from now. They’re actively being worked on by many labs throughout the world, but right now, we have the oral minoxidil, we also have platelet rich plasma. It is something that we’ve published on as well at the American academy of dermatology journal and it does have a place.

It’s not something that works in everybody, but it works in some, and it is a good XXXX therapy for so many people, so I think that’s another good option.

How it works, we don’t really know. We think it has growth factors, epidermal growth factor VGF are various factors that may promote hair growth. For androgenetic alopecia, those are kind of the newer things.

When it comes to surgery there’s the robots and all sorts of new pieces of equipment that have come out. But the most important thing is follicular unit extractions taking just a few hairs at a time, like two or three hairs or follicular units taking each unit and transplanting it rather than taking large strip.

E. Jerry. I don’t know whether you remember, but I think I’ve taught you this, that you were quite an inspiration for me to doing hair. And actually the reason why I went into hair research was to get closer to getting a fellowship with you. Do you still do a lot of hair transplantation nowadays?

J. No, not at NYU. We did do transplantations at the university of British Columbia, but when I moved to NYU, I decided to strictly do medical hair restoration.

E. A lot of the other lectures that have left a very lasting impression on me, including things like scarring, alopecia, what are the new things in scarring alopecia these days?

J. In terms of the treatments, there are new things, but we need more work to study them. For instance, the whole idea of mast cells and lichen planopilaris, which was found by the Angela Cristiana lab, may have some importance in terms of treating patients with antihistamines, but we need more studies to help prove that it really makes a difference. I think of her discovery as another tool that we might be able to use.

Also the use of JAK inhibitors in scarring alopecia may be of benefit both topical and oral in certain individuals who have like implant Polaris. So they’re there various, newer immunomodulators that can be used in scarring hair loss.

E. Of course I mentioned earlier that you were the President of the WCD in Vancouver in 2015. Do you have any advice about running the WCD for next year?

J. Well, I think that the main thing is to get the word out, we went everywhere! As president, I went to several meetings, definitely the AAD, the Latin American meetings, the European meetings, the Asian meetings, we went to all the meetings to help promote. We had booths at every meeting at the most important thing is to promote it.

Now, because of COVID, you didn’t really have the opportunity to do all those things and it was a problem. For us, we had carte blanche in terms of time to go to these places and promote the meeting and that’s how people knew about us. I’m always at talks, present a slide that promotes the meeting and make sure that people know about it and what fabulous things your city or your country can do to make it very interesting.

Singapore is such an interesting place, one of the most interesting in the world, so it is important to highlight the beauty and all the activities, the restaurants, everything that is just so wonderful about Singapore.

E. Well, thank you.

Jerry, you were a visiting professor from our hospital a few years ago. Do you remember this, when I first met you?

J. Yes. And you approached me for a fellowship even at that point!

I wanted you but somehow it didn’t work out. I definitely was there, and I’ve been there many times. One of my former fellows, Eileen Tan, is there and I visited her as well. So it’s a wonderful place. I’ve been to Singapore quite a few times and I love it.

E. What’s your favourite memory of Singapore?

J. Well, I was going to Marina Bay Sands, the MBS, where there is the casino and a pool on the top of the restaurant. I remember that was a highlight.

And then I went to see the Louis Vuitton Island, that was absolutely interesting because I had not seen such a big store for Louis Vuitton with an island just created for it!

E. And now there is one next to it for Apple!

J. Oh, it does, wow! I mean, you’ve got everything there!

E. Yeah, people should be very excited to come to the WCD next year!

J. Yes. Oh, they should. There’s so much to do and it is not only clean, but it’s a hundred percent safe! Everyone feels safe in that city, women have no problem, they feel safe wherever they go.

I think it’s just a great city in terms of cleanliness, beauty, and safety.

E. Well, thank you. That is a great advertisement for the WCD! And I’d like to thank you again for coming on this podcast, Jerry, and also for being an inspiration and a mentor to me as well!

J. My pleasure. Hope to collaborate very soon!

E. Yes. Thank you, bye bye!

J. Bye bye!

E. That was the official podcast of the WCD. Don’t forget to follow us on all our socials on Facebook, Instagram at WCD 2023 Singapore. Check out our WCD website, WCD2023Singapore.org for more updates and content on the WCD. And until next time stay safe and use sunblock!