Ethics statement

This study received ethical approval from Nepal Health Research Council (NHRC Ref # 388, August 27, 2021). All respondents provided written informed consent to participate in the study.

Design and overview

This was a phenomenological study that explored a particular phenomenon under the research question to explore the experiences and responses to it. The particular phenomenon in this study refers to the skin condition patients have developed and sought treatment at the dermatological clinic served by the first author (YP). To explore the phenomenon under the study, data were collected using in-depth interviews (IDIs) and observations of patients with skin conditions. The specific type of patients (respondents) for this study comprised patients with any skin diseases that made them use topical steroids. Grounded in the philosophical tradition of phenomenology, this study aimed to understand participants’ lived experiences and their encounters with steroid use and skin conditions. The study followed a COREQ (Consolidated criteria for Reporting Qualitative research) guideline (S1 Text).

Study setting

This study was conducted at Sarnath Skin Centre, a private dermatology clinic in the urban center of Bhairahawa. Established in 2017, the clinic serves approximately 40 patients daily, primarily those with skin-related conditions. Consultation fees at such clinics in the area typically range from USD 5–7.

Bhairahawa, officially known as Siddharthanagar, is a municipality and the administrative center of Rupandehi District in Lumbini Province, Nepal. Located on the southern plains near the Indian border, the city has a population of approximately 75,000 [30]. The city has a tertiary hospital hosted by Universal College of Medical Sciences with specialist clinics including dermatology. There are private hospitals and clinics where patients also seek specialist care.

Bhairahawa as an administrative and urban center of the district receives patients from the settlements around the urban center including patients from northern mountains who visit for specialist clinic care. Most of the patients attending the specialist clinic came from outskirts of the urban Bhairahawa and were mostly working in the farmlands, particularly rice fields.

Selection of respondents

All respondents were selected purposively in this study, and the total number of participants was decided based on data saturation [31]. The data saturation in this study was considered achieved when additional interviews began to yield repeated themes, insights, nuances, and understandings of the phenomenon [32]. Patients with specific skin conditions with prior history of use of topical corticosteroid were selected to align with the research question of this study. Participants were first verbally asked if they were interested in participating in the study during their clinical examination. Each prospective participant was briefed on the study, its procedures, and its implications, as outlined in the informed consent form. It was explained that their anonymized perspectives would contribute to the study findings, and the only potential risk—that they would need to share details about their skin conditions and the treatments they had sought—was clearly communicated. Once they verbally agreed, a written informed consent was obtained and were interviewed in the separate room within the clinic premise. Confidentiality was maintained by conducting interviews in private within the clinic, securely storing data on the first author’s password-protected laptop, sharing data only among co-authors for analysis and interpretation, anonymizing the data when reporting, and removing identifiers wherever possible.

No repeat interviews were conducted, and each interview lasted around 45 minutes to 1 hour. The study was conducted between September 2021 and March 2022. Participants were also selected based on their logistical feasibility to sit for interviews after the clinical services. A total of 31 patients were interviewed including ten non-participant observations based at the drug shop. Non-participant observation notes were written by the first author on skin patients’ interactions with the dispenser and their decision-making dynamics before they attended the dermatologist.

YP is a dermatologist (MBBS, MD) with more than 10 years of dermatological practice in the region. The interviews were conducted by YP with participants meeting following inclusion criteria: any participant aged 18 years or older who had experienced a long-standing skin condition that failed to recover after home-based treatments or treatment elsewhere. Participants were excluded if they were unwilling to allocate time for the interviews, had long-standing skin conditions but were seeking treatment for the first time at the clinic, were unsure about past treatments received, or had co-morbid conditions requiring concomitant treatments. In addition, individuals who were not physically or mentally fit, or unwilling to provide written informed consent were respected and excluded from the study.

Data collection guide

Data were collected using an IDI guide that included a range of topics incorporating patients’ experiences regarding their skin conditions, normative health-seeking behavior, knowledge of OTC and TC, and policies related to TC (S2 Text). The thematic guide for the interviews was prepared and reviewed by the authors (YP and BA). All interviews were conducted in Nepali and recorded using an audio recorder, with additional non-verbal cues and relevant information noted during the interviews and documented as field notes. Subsequently, all recorded interviews were translated and transcribed into English for analysis.

Data analysis

Participants’ personal information was anonymized to protect their identity. All transcribed data were stored in Microsoft Word and then analyzed by two coders (NA and AR) using NVivo software. Six phases of thematic analysis outlined by Braun and Clarke [33] were utilized that included 1. Familiarizing with the data (transcribing data, reading and rereading the data, noting down initial ideas); 2. Generating initial codes (coding interesting features of the data systematically across the entire data set, collating data relevant to each code); 3. Searching for themes (collating codes into potential themes, gathering all data relevant to each potential theme); 4. Reviewing themes (checking if the themes work in relation to the coded extracts and the entire data set, generating a thematic map); 5. Defining and naming themes (ongoing analysis to refine the specifics of each theme, and the overall story the analysis); and 6. Producing the report (selection of vivid, compelling extract examples, final analysis of selected extracts, relating back of the analysis to the research question and literature, producing a scholarly report of the analysis) [33,34].

The thematic analysis in this study entailed a mix of deductive and inductive approaches to coding of data and was critically reviewed by BA, YP and BJ. The major themes were informed by a framework of parent and sub-codes (S1 Fig). The analyzed data were thoroughly cross-checked for any mis-association and misinterpretations. By focusing on the subjective experiences of the participants, the research sought to uncover deeper meanings and insights into their personal events.

Reflexivity

YP, the principal investigator and treating dermatologist, conducted the interviews with patients (S3 Text). As a dermatologist, YP’s interactions with patients may have been influenced by epistemic and power dynamics, potentially introducing social desirability bias in the responses.

NA and AR, both Nepalese public health practitioners, independently coded the data and generated the initial codes and themes. YP and BA participated regularly in the coding and thematic synthesis processes. BA is a social scientist and Nepali medical practitioner with prior research experience on the over-the-counter use of antimicrobials in Nepal and provided input on coding and the final thematic synthesis.

MG, SA, SR, BJ, and SP are medical doctors with extensive experience in Nepal’s healthcare landscape. PYC is a professor of ethics with significant collaborative research experience on antimicrobial resistance in South and Southeast Asia.

Skin conditions and the knowledge gaps

Daaz, Daad [dermatophytosis] was the most common skin condition reported by participants later confirmed by the dermatologist. Other frequently encountered skin issues in their locality were melasma, scabies, vitiligo, and acne. These conditions represented a significant portion of the dermatological problems faced by the community.

I don’t exactly know the name, but in our language, we call it “Daad”. Only Daad is prevalent in our family members and locality. – Pt-22, 20–30 years, male.

Most of the participants associated their skin condition with factors such as hot weather, sun exposure, and sweating. They believed that these environmental and personal habits were primary causes of their skin conditions. Their overall basic knowledge about skin diseases was very limited. Even for diseases like dermatophytosis, which affected almost all the members of the household, they did not realize its infective nature.

Skin conditions are due to the use of wet clothes, wet underwear and due to sweat and if we don’t bathe regularly. – Pt-16, 18–20 years, male

People did not have sufficient knowledge regarding their skin diseases and its treatment processes. Whenever they were affected by any condition, they were unaware of where to go or whom to consult for healthcare services. It was common thinking among the participants that their disease was not complicated, unaware of its potential risks and resorting to haphazard drug use rather than seeking treatment from a certified specialist. But after prolonged illness and recurrent symptoms, they realized that the disease was not as common as they had initially thought.

ya at first, I used to think it simple…….in initial phase it used to get cured after applying ringguard …… so I took it simply……but now when it kept on repeating for so many years I thought of getting consultation. – Pt-31, 40-50 years, male

Due to this misinformation and knowledge gap, people practiced some unusual home remedies, such as using goat’s urine, Harpic (a toilet cleaner containing hydrochloric acid), detergent powder, and even considered invocation rituals which was extremely concerning.

Some people even suggested using goat urine, but that didn’t work either. Then there were recommendations to use bitter gourd and camphor, so I tried mixing those as well, but nothing worked. Eventually, I became tired of applying anything at all. – Pt- 30, 30–40 years, Male.

Patients were not properly instructed by the medical shop owner about the necessity of a prescription for medications. Another common phenomenon was that the medical shop owner/pharmacist/dispenser would normally provide medicines to the participants after they requested it, without inspecting and physically seeing their skin disease.

….He used to ask what happened…..and I used to say “daaz”….than I used to ask for ringguard,.. and he used to give it immediately. – Pt-31, 40-50 years, male

Treatment seeking behavior

Observations at the skin clinic’s pharmacy revealed that patients often wavered between consulting the specialist or trying over-the-counter medications first. Positive counseling from the dispenser about the benefits of seeing a dermatologist influenced many of their decisions. However, some patients opted to see the specialist without needing further discussion. Some of these patients who had already decided to see the skin specialist were either suffering from long-standing skin conditions or had not been cured by their repeated use of OTC medications.

Initially, when individuals noticed symptoms of their skin condition, they either went to a medical shop to get medication without a prescription or relied on advice from family, friends, neighbors, and relatives. They even applied home remedies or medications in the form of ointments, creams, and gels, which temporarily eased their symptoms, allowing them to return to their usual activities. However, after a few weeks or months, the condition recurred prompting them to obtain the same treatment from the pharmacy. This cycle was repeated until they either became exhausted or their condition worsened significantly. This pattern illustrated their coping mechanism of relying on dispensers (pharmacists) for symptom management whenever their skin issues reappeared. Moreover, it was common for people in local communities to heavily rely on medical shop owners for medical advice and treatment, despite the lack of formal medical training. This habit underscored the accessibility and convenience of medical shops, which often served as the first point of contact in healthcare for many individuals.

I got advice from the villagers who had suffered from similar disease earlier regarding how their disease got cured. I followed their advice. Then I thought, if I didn’t cure then I visited a skin doctor. – Pt-19, 18–20 years, male

While using the medicine my face became very dry, it removed the black spots, but it looked as if the moisture from my face had disappeared. So, I stopped using that medicine. After that, I went again for an incantation (to invoke a magical effect or influence) through which I got some relief. I used aloe vera for 10–20 days, but nothing happened. Later on, one person gave me the address of this clinic. – Pt-29, 30–40 years, male

Commonly used medicines for skin condition among participants included Sonaderm (clobetasol propionate, gentamycin sulphate, miconazole nitrate), Derma-KT (ketoconazole, neomycin sulphate, Iodochlorohydroxyquinoline, tolnaftate, clobetasol propionate), Derma-5 (clobetasol propionate, gentamycin, iodochlohydroxyquinoline, ketoconazole), Mofur (mometasone), quadriderm (clotrimazole, neomycin, beclomethasone), Melalite (hydroquinone, mometasone, tretinoin), Ring Guard (miconazole nitrate, neomycin sulphate, chlorocerol), SkinLite (Hydroquinone, mometasone, tretinoin). SkinLite was also found in non-medical settings such as fancy or cosmetic shops. It seemed they were used as cosmetics without understanding its potential side effects. Almost all of the participants were unaware of its composition and its potential side effects.

Everything is available in the fancy shops. In Mahilwar, every shop has Chinese cream, and night cream like Melalite, and SkinLlite. I have a brother who owns a medical store. He gave me SkinLite and told me, “Sister, use this cream and you’ll glow like a foreigner” and I used that cream and my skin became fair. But my skin was damaged with time. I used that for about 2–3 months. – Pt-15, 20–30 years, female

Patients delayed seeking specialist care for their skin conditions due to various factors, such as the distance, time required to reach healthcare facilities, financial constraints, and the temporary relief provided by medications obtained from pharmacies. The long and significant travel distance to the clinic posed substantial difficulties for both first-time patients and those requiring regular visits. Most people relied on local transportation and bikes to reach the clinic, adding to the challenge of accessing necessary medical care.

Today I also came all the way from Rajahar (approx. 80 km from the interview site) because I have some work over here and relatives here told me to get a checkup from you. – Pt-4, 30–40 years, male

I used medicine from India for six months, I used to travel to India every 15 days. – Pt- 29, 30–40 years, female

Additionally, some patients were unaware of where to find dermatologists, while others felt embarrassed about their condition. However, some individuals prioritized finding an effective cure, even if the expenses were high, as they were tired of the recurrent nature of their skin problems. In the absence of professional medical guidance, patients often resorted to alternative remedies like turmeric, garlic, neem, aloe vera, camphor, alum, herbal juices, and bean leaves, which provided some temporary relief but did not address their underlying cause. Some of them also watched various advertisements on TV and the internet and tried the remedies/medications suggested for their problem.

When I first noticed this disease, I thought it was just a simple irritation of skin folds and I applied a powder for 2–3 days. But nothing changed and that area became red. There were small red dots, and I thought about what to do with it. Then, one friend told me it is a simple daaz. I remember watching ring guard advertisements on TV. I searched for it, bought it and applied. – Pt-31, 40–50 years, male

The excessive and prolonged use of TCs raised concerns, including diminished efficacy due to tachyphylaxis, skin atrophy, and steroid-induced dermatoses. Patients, often in an attempt to manage chronic dermatological conditions, resorted to applying TC creams and ointments far beyond recommended dosages and durations.

I kept on applying those tubes 7–8 times after an interval of some months that is around 25–30 tubes for the whole 2 years. – Pt-26, 30–40, male

Despite receiving immediate healthcare from specialist doctors on several occasions with multiple consultations, the patient continued to experience recurring issues with their condition. This indicated a more prevalent recalcitrant type of dermatophytosis, which is not even cured with the standard treatment regimen, making treatment long and costly. This has led patients lose faith in specialist consultation and has fueled steroid abuse.

In the past two years, I went to the medical college and underwent some tests, but my condition still did not improve. I visited the doctor 2–3 times for regular follow-ups, and my condition completely disappeared, making me feel that the disease was gone. However, when it reappeared, I started to think that either the medication was incorrect or the doctor prescribed it without proper evaluation. I believed that even consulting a doctor wouldn’t help, so I continued taking the same medication repeatedly. – Pt-3, 20–30 years, female

Participants perceived that visiting a medical shop was more convenient, cheaper, and less time-consuming due to the lack of access to nearby doctors or information on where to find certified medical professionals. People who worked in medical shops and provided medications were informally referred to as “doctors,” despite not necessarily holding medical degrees or qualifications. Many were unaware of the benefits of being treated by a certified doctor and often could not allocate time for a proper medical visit. Consequently, they adapted to using medicines from nearby medical shops, experiencing only temporary relief rather than a cure.

Participants also tended to hide their skin conditions out of fear of social rejection and shame. However, after suffering for extended periods, some were persuaded by close relatives to visit a specialist, particularly those who themselves had been successfully treated by a dermatologist. For others, unbearable pain eventually compelled them to seek professional help. Upon visiting a specialist, they realized they had been using unnecessary medications and ointments and discovered that their conditions could be permanently cured with appropriate treatment.

We refer to the individuals who work in medical shops and dispense medications as “doctors”. – Pt-23, 18–20 years, male.

They might feel ashamed because daaz often appears in areas like the groin. – Pt- 24, 20–30 years, male

Implications

The study highlights the high OTC use of topical corticosteroid and thus warrants an urgent set of efforts to curb the treatment seeking behaviour. First, community and public engagement efforts are critical to enhance the awareness of skin conditions and the rationale for consulting physicians which could safeguard the ethics and interests of various stakeholders [57,58]. Public awareness activities should focus on the fundamentals of skin conditions, consequences, and the use of corticosteroids, including the concomitant use of antimicrobials, could be streamlined as a concerted effort. The potential consequences of delayed treatment seeking behaviour [46,49,50] as outlined in this study, further highlight the addition of both direct and indirect costs, stress, time and resources on both supplier and provider sides. Future studies could explore these dimensions through health economics research, including stakeholder analysis (e.g., examining how stakeholders’ interests interact and influence policy and practice), to further investigate the potential for policy changes. Future studies could integrate quantitative data collection and analysis to complement the qualitative findings, including exploring the magnitude of OTC steroid use for skin conditions. In addition, the OTC use of these products is highly likely to trigger the concomitant use of antimicrobials and thus antimicrobial resistance interventions would require a concerted effort. Third, engagement with dispensers, pharmacies (drug shops) and stakeholders are critical to promote their understanding of the OTC use of steroids, beauty products and antimicrobials and their consequences. Multi-pronged engagement on the basics of various medications (e.g., steroids, antimicrobials), their over-the-counter use, and associated implications should be promoted through both formal and informal media. Public engagement initiatives—such as podcasts and dialogues [59] in accessible language—are especially critical. Regulatory scrutiny on the widespread use of topical corticosteroids, including advertisements in the media on beauty products such as recommending their categories and extent, is critical. The International League of Dermatological Societies (ILDS), an umbrella organization for professional dermatological societies, has released a position paper with two key recommendations [60] that align with this study’s findings:

• Moderate to strong topical corticosteroids, whether alone or combined with other active compounds like antimicrobials, should only be used when prescribed by a properly trained health professional.
• In countries where unregulated use is common, clear guidelines should be in place to protect patients and the public from overuse or misuse.

The ILDS recommendations, along with the World Health Assembly’s recognition of skin health as a global public health priority for universal health coverage in May 2025, highlight the urgent need to strengthen primary health care in low- and middle-income countries [61].

Strengths and limitations of study

The study included specific respondents with skin conditions and a history of using TCs for a variable period, thus it may not address the treatment seeking behaviour for other general skin conditions. These respondents had rich lived experiences and thus the insights provided by these respondents highlight the scenario of skin conditions among patients including factors influencing topical steroid misuse. Nonetheless, by virtue of selecting these specific patients we may have incurred selection bias. Furthermore, as this is a clinic-based study only those cases with symptoms secondary to steroid abuse were recruited, potentially overlooking asymptomatic instances of steroid misuse. The use of a qualitative method with a specific cohort of participants from a specialist clinic limits the generalizability of the findings to broader social and cultural contexts.