Abbreviated table of themes and quotations explaining the factors influencing the attitudes and usage of TCS
| Theme | Representative quote |
| Attitudes towards TCS | |
| 2.1 Attitudes towards TCS: beliefs about TCS | |
| Perceived benefits | ‘I will say it improved my quality of living because it helped to ease the condition of my rashes.’ ‘Because once when we try the cream, it really works.’ |
| Perceived risks | ‘I’ve noticed this… if you keep applying the steroid creams, the skin surrounding the area will become lighter.’ ‘Just the skin getting slightly thinner, at the usual spots that I apply [TCS]…because when I scratch, it’s easier to bleed.’ |
| Perceived lack of benefit (eg, lack of durability of response) | ‘Benefits [of TCS] are temporary relief, can live a normal life for a few weeks maybe, then it starts to flare up again.’ ‘It seems to be that currently steroids [are] only helping the symptoms… it doesn’t solve the root issue, only the symptom.’ |
| 2.2 Attitudes towards TCS: knowledge of TCS | |
| Sources of information | ‘My friend actually told me; eh you shouldn’t use steroid cream.’ ‘Mainly also because I also googled online.’ |
| Critical appraisal of information | ‘But after a while, my skin still didn’t get better then I will start questioning [the treatment with TCS].’ ‘I’m more of a follower, so I just follow whatever the doctor says.’ |
| 2.3 Presence of alternatives | |
| Presence of alternatives | ‘I would rather that it naturally heals… I find that natural healing is still the best.’ ‘Without steroids, basically the rashes just doesn’t go off at all… I have no other ways of getting rid of it other than steroid creams.’ |
| 2.4 Treatment inconvenience | |
| Treatment inconvenience | ‘So inconvenience is one [reason for non-use]… 30 minutes applying lotion and cream or 30 minutes getting another nap, I would choose a 30 minute nap.’ ‘Every day you need to do it [apply creams], so it’s really tiring and that’s why sometimes I tend to skip it.’ |
| 2.5 Personality | |
| Personality type (eg, openness to experience) | ‘What I’ve noticed of people who have become so called addicted or dependent on steroids is that they tend to be sensitive individuals in general.’ (An advocate for TSW who actively reaches out to those with TSA/TSW) ‘Some people are more sensitive, it’s like a psychological thing, a distorted perception of topical steroids, that they are no good.’ |
| 2.6 Patient’s evaluation of clinical response to TCS | |
| Patient’s evaluation of clinical response to TCS | ‘I realized like it keeps getting worse and not better… that was when the first red flag occurred and then I thought like maybe is steroid really the way to go?’ ‘I think just, deep down, I knew it wasn’t working anymore… So I just felt it wasn’t working and I decided to just stop… it was an internal decision.’ |
| 2.7 Doctor–patient relationship | |
| Response of doctors to steroid concerns | ‘It felt like they [dermatologists] were rushing for time or something…. It felt like I was just speaking my piece, but it wasn't a two-way conversation.’ ‘It’s well known inside the TSW community that when you go to the doctor and you show them your skin condition, while you are on withdrawal, they will just say “can you please put on steroids and don’t be ridiculous?“’ |
| Doctor–patient relationship | ‘After this episode of my eczema, I sort of lost respect for dermatologists…it appears like they are sort of salesmen for these big pharmas selling steroid creams.’ |
| 2.8 Healthcare-seeking behaviour | |
| Association with standard healthcare or dermatologist | ‘It [skin condition] didn’t improve at all. So I was very angry at him [doctor] and I didn't go back.’ ‘So at that time, I didn’t know what any other options I have other than steroids. So that’s why I kept doctor hopping.’ |
| Association with alternative opinions | ‘Nearing the withdrawal, I sought out TCM [traditional Chinese medication].’ ‘I started this treatment. It is a skin regenerative treatment… it helps to regenerate the skin cells or boost the whatever ATP thing in your cells so that it will start regenerating again.’ |
TCS, topical corticosteroid; TSA, topical steroid addiction; TSW, topical steroid withdrawal.