Truth telling: Physicians often use TC for symptom relief when they are faced with an irate patient who has severe itching or redness of the skin of unclear etiology, without paying sufficient attention to diagnosing the illness and getting to the root of the problem. The reasons may be multiple, ranging from overcrowded OPDs to a natural human tendency to ease the pain of the patient. However, in most such situations, the patient is not aware that the physician has not been able to arrive at a firm diagnosis and is merely buying time by prescribing something that will give quick relief while planning investigations or a more detailed examination at a subsequent visit. The problem with such an approach is quite evident: the patient happily continues to use the TC for a long time, without bothering to return to the physician for another evaluation or investigations. If the physician honestly confesses to the patient that he is unable to arrive at a firm diagnosis and needs a revisit or investigations to do so, patients can become more amenable to tolerate their unpleasant symptoms while this is done. Quite a few prescriptions of TC can be avoided in this way, thereby minimizing the chances of misuse.

Patient autonomy: This refers to respect for the individuals’ right to make informed decisions about their personal matters. In other words, the patient has the right to refuse or choose their treatment (Voluntas aegroti suprema lex). In direct contrast to this is the concept of paternalistic medicine, where physicians simply order the patients to take a drug, without regard to his personal preferences, beliefs, etc. With regard to TCs, this law applies when we are faced with a steroid-phobic patient. In this situation, “soft paternalism” [12] is often a good approach whereby such a patient should be counselled about the potential benefits of TC use, the harm that can be caused by nonuse, and how common adverse effects can be avoided. However, they should also be informed about alternative therapies, e.g., topical calcineurin inhibitors or calcipotriol and their efficacy vis-à-vis TCs. After this, whatever their ultimate decision be, it should be respected and a prescription given accordingly.

Non-malfeasance: This is the principle of primum non nocere (first, do no harm). There are important ramifications of this principle in a TC prescription. A common scenario where non-malfeasance needs to be remembered is a patient who is obsessed with a fair complexion and asks for a TC prescription which he/she may have heard about from a friend. It is absolutely essential to avoid the temptation to give in to the patient’s request in this situation. This is especially true in esthetic practice, where healthcare providers are dealing with healthy clients, not sick patients. The desire to give the client what he/she wants can sometimes come into conflict with non-malfeasance in this situation. For example, TC are sometimes used to control redness or post-inflammatory hyperpigmentation caused by a chemical peel or laser resurfacing, which would perhaps not been done if the principle of non-malfeasance had been observed strictly. Non-malfeasance also becomes relevant when we are dealing with an undiagnosed rash and a demanding, distressed patient. Several studies have been reported on the misuse of TCs, especially on the face [6, 7] where the initial prescription was given for an undiagnosed facial rash which then led to prolonged misuse of TCs leading to considerable morbidity. In such a scenario, pending a diagnosis, TCs should be avoided and relief given with safer options like topical antipruritics and oral antihistamines. In the absence of a clear diagnosis and treatment plan, a physician should not hesitate to refer a patient to a senior colleague or an expert instead of using TCs to suppress unpleasant symptoms indefinitely.

Beneficence vs. autonomy: This kind of conflict occurs when patients disagree with recommendations that doctors believe are in the patients’ best interest. An appropriate example would be a patient with widespread eczema who is applying potent TCs over a large area leading to adverse effects [13]. The appropriate approach in such a situation would be to start a systemic steroid-sparing drug like azathioprine and gradually taper the TC. However, many patients are scared of systemic immunosuppressives and resist such treatment. Appropriate counselling about the dangers of potent TC use over large areas along with laboratory demonstration of adrenal suppression, low serum cortisol levels, etc. will be needed to convince the patient.

The right diagnosis: There are relatively few conditions where there is good evidence of efficacy of TCs. Various eczemas, psoriasis, lichen planus, immunobullous diseases in their localized form, and skin manifestations of collagen vascular diseases like lupus erythematosus or dermatomyositis are the best-established indications. Other conditions where careful, short-term use may be warranted are superficial fungal or bacterial infections associated with significant inflammation, localized itch of any origin, and certain idiopathic diseases characterized by dermal inflammation, e.g., superficial variants of pyoderma gangrenosum. In the absence of a diagnosis, it is very important to avoid TC use so that conditions like tinea incognito and Majocchi’s granuloma are not produced [15]. If a patient is already applying TC, thereby obscuring the clinical features of a disease, an appropriate treatment-free interval should be given after explaining to the patient that his/her symptoms may flare up temporarily to facilitate a diagnosis.