Oral Corticosteroid Prescription Trends in South Korea: A 10-Year Nationwide Population-Based Study Using the NHIS-NSC

Oral Corticosteroid Prescription Trends in South Korea: A 10-Year Nationwide Population-Based Study Using the NHIS-NSC | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Oral Corticosteroid Prescription Trends in South Korea: A 10-Year Nationwide Population-Based Study Using the NHIS-NSC YoungWoo Jo, Jae-Woo Kwon, Joon-Hong Min, Young Her This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6706699/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objectives To investigate long-term trends in oral corticosteroid (OCS) prescribing among the adult population in South Korea and to evaluate variations in prescribing patterns across diagnoses, healthcare institution types, and clinical specialties using a comprehensive national claims database. Methods This population-based retrospective cohort study was conducted using the National Health Insurance Service–National Sample Cohort (NHIS-NSC), a nationally representative administrative claims database comprising approximately 1 million individuals in South Korea, sampled in 2002 and followed longitudinally. Adults aged 20 years or older who received at least one prescription for oral corticosteroids (OCS) between January 1, 2003, and December 31, 2012, were included in the analysis. Individuals with incomplete demographic or prescription data or those who received only inhaled or topical corticosteroids during the study period were excluded. The primary outcome was the annual prevalence of OCS users, defined as individuals with at least one OCS prescription per year. Users were further classified by frequency into short-term (1–2 prescriptions/year), mid-term (3–5 prescriptions/year), and long-term (≥ 6 prescriptions/year) groups. Secondary outcomes included the most frequently associated diagnostic categories and subcategories based on ICD-10 codes, and the distribution of OCS prescriptions by healthcare institution type (clinics, hospitals, general hospitals) and clinical specialty. Particular attention was given to prescribing trends in dermatologic (L20–L30), urticarial (L50), and respiratory (J00–J99) conditions, given their high contribution to overall corticosteroid use and relevance to guideline-based prescribing. Results Between 2003 and 2012, the proportion of OCS users increased from 20.8–29.2%, representing a 40% relative rise. While the proportion of short-term users declined, mid- and long-term use increased steadily. Dermatologic and respiratory conditions were the leading causes of OCS prescriptions, particularly allergic contact dermatitis (L23) and urticaria (L50), which showed long-term use in 14.5% and 5.9% of users, respectively. Prescribing rates for these conditions were disproportionately high in clinic settings compared to hospitals and general hospitals. Cross-national comparisons revealed that South Korea has higher rates of long-term OCS use and more frequent use in conditions where systemic corticosteroids are not routinely recommended, as compared to countries such as France, the United Kingdom, Denmark, and Iceland. Conclusions OCS prescribing in South Korea has increased significantly over the past decade, particularly in primary care for dermatologic and allergic conditions that are not strongly supported by current clinical guidelines. The high prevalence of long-term use in mild-to-moderate conditions and in clinic-based care highlights the need for more rigorous prescribing protocols, expanded education on adverse effects, and broader implementation of alternative treatment strategies. These findings underscore the importance of national-level interventions to promote evidence-based corticosteroid use and mitigate the risk of unnecessary exposure in the general population. oral corticosteroids prescribing trends Korea health insurance claims dermatology primary care guideline adherence long-term use Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 INTRODUCTION Oral corticosteroids (OCS) are widely used anti-inflammatory and immunosuppressive agents that play a critical role in the treatment of numerous acute and chronic conditions, including allergic diseases, autoimmune disorders, dermatological conditions, and respiratory illnesses. 1 Despite their therapeutic efficacy, OCS are associated with a range of adverse effects, especially when used frequently or inappropriately. 2 – 3 Concerns about metabolic complications, infections, and bone loss have prompted increasing scrutiny over prescribing practices in both outpatient and hospital. 4 – 7 Recent population-based studies from the United States, France, Taiwan, and other countries have highlighted a global trend of increasing OCS prescriptions, particularly for short-term use in self-limited conditions. 8 – 10 While some of this increase may reflect improved access to care, others have raised concerns about unjustified prescriptions. 11 – 13 Moreover, these studies have consistently reported variability in prescribing behavior based on physician specialty and healthcare setting. 14 – 17 Despite this international interest, there has been limited investigation into OCS prescribing patterns in South Korea. Prior to this study, little was known about how OCS are used across different age groups, disease categories, or levels of healthcare institutions within the Korean healthcare system. Understanding such patterns is essential for identifying areas of potential overuse, improving prescribing guidelines, and mitigating risks at the population level. Using a nationally representative sample from the National Health Insurance Service-National Sample Cohort (NHIS-NSC), this study aimed to evaluate the trends, indications, and institutional variations in oral corticosteroid prescriptions in South Korea between 2003 and 2012. METHODS Data source and Study population This retrospective observational study was conducted using the National Health Insurance Service National Sample Cohort (NHIS-NSC) database, a population-based dataset constructed from a 2% stratified random sample of all enrollees in the Korean National Health Insurance (NHI) program. The NHIS-NSC provides comprehensive longitudinal data on demographics, diagnoses (ICD-10), healthcare utilization, and prescription records. The study period covered the years 2002 through 2013, with primary analysis focused on oral corticosteroid (OCS) prescriptions from 2003 to 2012. We identified individuals who had received at least one prescription for an oral corticosteroid between 2002 and 2013. To ensure consistency in exposure assessment, we excluded the following individuals: (1) those under the age of 20 years; (2) those who were prescribed OCS only in 2002, which served as a washout period; and (3) those whose first prescription occurred in 2013, to allow for at least one year of follow-up. After applying these criteria, only patients who initiated OCS use between 2003 and 2012 and met the age requirement were included in the final analysis (Fig. 1 .). Definition and Classification of Oral Corticosteroids Oral corticosteroids included in this study were betamethasone, deflazacort, dexamethasone, hydrocortisone, methylprednisolone, and triamcinolone. All prescriptions were extracted from outpatient prescription claims. For standardization of dosage, the World Health Organization’s Defined Daily Dose (DDD) methodology was applied, but classification of users was based on frequency rather than cumulative dose. (Defined Daily Dose (DDD)) Classification by Frequency of OCS Use Based on the number of OCS prescriptions received within a single calendar year, patients were categorized into three groups: short-term users (1 prescription per year), mid-term users (2 to 5 prescriptions per year), and long-term users (6 or more prescriptions per year). This classification reflects annual prescribing frequency rather than treatment duration, and was informed by previous literature. Disease Classification and Covariates All diagnoses were coded using the 10th revision of the International Classification of Diseases (ICD-10). Diagnoses were grouped by major disease categories (e.g., dermatologic, respiratory, musculoskeletal, circulatory, neurological) and further analyzed at the block and subcategory levels. Specific focus was given to the most common indications for OCS use, including dermatitis and eczema (L20–L30), urticaria and erythema (L50–L54), upper respiratory infections (J00–J06), and chronic lower respiratory diseases (J40–J47). Covariates included age (categorized into 10-year intervals), sex, medical specialty, and healthcare institution type. Healthcare institutions were classified into clinics (< 30 beds), hospitals (≥ 30 beds), and general hospitals (≥ 100 beds with specific departmental requirements), in accordance with the Korean Medical Services Act. Statistical Analysis To examine the trends in the usage of OCS, time series analysis and chi-square tests were employed. The dataset was constructed using SAS software (version 9.4; SAS Institute, Cary, NC, USA), while all statistical analyses were conducted using IBM SPSS Statistics (version 27.0; IBM Corp., Armonk, NY, USA). Tables and graphical work were performed using Excel. Results From 2003 to 2012, the annual prevalence of oral corticosteroid (OCS) use steadily increased among adults in the study population. In 2003, 155,087 out of 746,816 individuals (20.8%) received at least one OCS prescription, which rose to 231,640 out of 792,560 individuals (29.2%) in 2012. This corresponds to a 40.4% relative increase compared to the baseline in 2003 (Fig. 2A). This upward trend was consistently observed across all age groups and both sexes. Over the same period, notable changes were observed in prescription frequency categories. The proportion of short-term users (1 prescription/year) declined from 57.9% in 2003 to 45.9% in 2012. Meanwhile, mid-term users (2–5 prescriptions/year) increased from 37.7–64.9%, and long-term users (≥ 6 prescriptions/year) increased from 4.4–15.9% (Table 1). Throughout the study period, OCS use was consistently more common in women than in men (Fig. 2A). By age group, individuals aged 40–49 showed the highest prevalence, followed by those aged 60 years and older. These patterns remained stable over time (Fig. 2B). According to ICD-10 chapters, dermatologic conditions (L00–L99) accounted for the largest proportion of OCS use (38.9%), followed by respiratory diseases (J00–J99) at 29.6%. Musculoskeletal disorders (M00–M99) accounted for 7.4%, while circulatory (I00–I99) and neurologic (G00–G99) diseases represented 1.5% and 0.8%, respectively (Fig. 3). Among the top minor diagnostic categories, allergic contact dermatitis (L23) accounted for the highest proportion of OCS users, with 76,114 individuals (15.5%) initiating treatment. Of these, 3,511 individuals (14.5%) were classified as long-term users, receiving six or more prescriptions per year (Table 2). This long-term usage rate is substantially higher than other subtypes within the same category (L20–L30), suggesting that L23 may be associated with persistent or recurrent symptoms that result in extended corticosteroid exposure. It also raises concern regarding the potential discordance with treatment guidelines, which generally do not recommend prolonged OCS use for contact dermatitis (Table 3). Table 2 Top minor categories in OCS use. CODE Minor Type All GC initiators short-term users Mid-term users Long-term users L23 Allergic contact dermatitis 76,114 (15.5%) 42,514 (16.2%) 30,089 (14.7%) 3,511 (14.5%) L50 Urticaria 36,058 (7.3%) 20,690 (7.9%) 13,944 (6.8%) 1,424 (5.9%) J30 Vasomotor and allergic rhinitis 23,766 (4.8%) 12,465 (4.7%) 10,319 (5%) 982 (4.1%) J20 Acute bronchitis 20,216 (4.1%) 11,368 (4.3%) 8,153 (4%) 695 (2.9%) J03 Acute tonsillitis 19,905 (4%) 11,313 (4.3%) 8,067 (3.9%) 525 (2.2%) L24 Irritant contact dermatitis 16,609 (3.4%) 9,182 (3.5%) 6,619 (3.2%) 808 (3.3%) L30 Other dermatitis 13,482 (2.7%) 7,279 (2.8%) 5,454 (2.7%) 749 (3.1%) H10 Conjunctivitis 12,219 (2.5%) 7,244 (2.8%) 4,656 (2.3%) 319 (1.3%) L21 Seborrhoeic dermatitis 11,762 (2.4%) 5,734 (2.2%) 5,236 (2.6%) 792 (3.3%) J45 Asthma 10,406 (2.1%) 5,128 (2.0%) 4,646 (2.3%) 632 (2.6%) Table 3 Prevalence of subcategories within category L20-L30. CODE Minor Type All GC initiators short-term users Mid-term users Long-term users L20-L30 Dermatitis and eczema 139,459 (28.3%) 76,128 (29.0%) 56,292 (27.5%) 7,039 (29.1%) L20 Atopic dermatitis 4,911 (1.0%) 2,361 (0.9%) 2,153 (1.1%) 397 (1.6%) L21 Seborrhoeic dermatitis 11,762 (2.4%) 5,734 (2.2%) 5,236 (2.6%) 792 (3.3%) L22 Diaper dermatitis 9 (0.0%) 7 (0.0%) 2 (0.0%) 0 (0.0%) L23 Allergic contact dermatitis 76,114 (15.5%) 42,514 (16.2%) 30,089 (14.7%) 3,511 (14.5%) L24 Irritant contact dermatitis 16,609 (3.4%) 9,182 (3.5%) 6,619 (3.2%) 808 (3.3%) L25 Unspecified contact dermatitis 7,939 (1.6%) 4,383 (1.7%) 3,211 (1.6%) 345 (1.4%) L26 Exfoliative dermatitis 81 (0.0%) 40 (0.0%) 39 (0.0%) 2 (0.0%) L27 Dermatitis due to substances taken internally 2,634 (0.5%) 1,513 (0.6%) 1,035 (0.5%) 86 (0.4%) L28 Lichen simplex chronicus and prurigo 3,298 (0.7%) 1,687 (0.6%) 1,399 (0.7%) 212 (0.9%) L29 Pruritus 2,620 (0.5%) 1,428 (0.5%) 1,055 (0.5%) 137 (0.6%) L30 Other dermatitis 13,482 (2.7%) 7,279 (2.8%) 5,454 (2.7%) 749 (3.1%) Similarly, urticaria (L50), a subtype of the L50–L54 category (urticaria and erythema), represented 36,058 users (7.3%). Notably, 1,424 users (5.9%) received long-term OCS prescriptions (Table 4). While urticaria is typically an acute condition manageable with antihistamines, this notable proportion of long-term steroid users may reflect either frequent relapses or insufficient symptom control. The data suggest that OCS may be overprescribed for these conditions, particularly in primary care settings, and further clinical scrutiny is warranted. Table 4 Prevalence of subcategories within category L50-L54. CODE Minor Type All GC initiators short-term users Mid-term users Long-term users L50-L54 Urticaria and erythema 37,564 (7.6%) 21,498 (8.2%) 14,574 (7.1%) 1,492 (6.2%) L50 Urticaria 36,058 (7.3%) 20,690 (7.9%) 13,944 (6.8%) 1,424 (5.9%) L51 Erythema multiforme 506 (0.1%) 262 (0.1%) 218 (0.1%) 26 (0.1%) L52 Erythema nodosum 135 (0%) 59 (0.0%) 65 (0.0%) 11 (0.0%) L53 Other erythematous conditions 862 (0.2%) 485 (0.2%) 346 (0.2%) 31 (0.1%) L54 Erythema in diseases classified elsewhere 3 (0.0%) 2 (0.0%) 1 (0.0%) 0 (0.0%) OCS prescription patterns varied by specialty and institution type (Fig. 4). Overall, dermatology (31.6%) and internal medicine (29.3%) accounted for the largest share of prescriptions, followed by otorhinolaryngology (12.6%), orthopedics (8.8%), and ophthalmology (5.3%). In general hospitals, internal medicine dominated OCS prescribing (55.1%), while dermatology accounted for a relatively small share (13.5%). In contrast, dermatology contributed the largest share in clinics (33.9%), followed by internal medicine (27.3%). This variation may reflect differences in clinical composition, case mix, and access to specialty care. In hospitals (non-general), orthopedics had a notable share (27.3%), followed by internal medicine (36.7%) and dermatology (2.6%). This likely reflects a higher prevalence of musculoskeletal conditions in these settings. The share of otorhinolaryngology and ophthalmology remained relatively stable across institution types. Top diagnoses for OCS use differed markedly by institution type (Table 5.). Table 5 Top 10 Diagnoses by prescription volume across medical institution types. RANK General hospital Hospital Clinic 1 Seropositive rheumatoid arthritis (7.1%) Urticaria (7.9%) Allergic contact dermatitis (15.7%) 2 Other rheumatoid arthritis (6.2%) Asthma (4.5%) Urticaria (6.0%) 3 Asthma (4.3%) Allergic contact dermatitis (4.4%) Vasomotor and allergic rhinitis (5.3%) 4 Allergic contact dermatitis (3.5%) Atopic dermatitis (4.3%) Acute bronchitis (4.2%) 5 Urticaria (3.2%) Other intervertebral disc disorders (3.2%) Irritant contact dermatitis (3.4%) 6 Systemic lupus erythematosus (3.1%) Gonarthrosis[arthrosis of knee] (3.0%) Acute tonsillitis (3.2%) 7 Other systemic involvement of connective tissue (2.5%) Vasomotor and allergic rhinitis (3.0%) Asthma (3.1%) 8 Other chronic obstructive pulmonary disease (2.3%) Other spondylopathies (2.5%) Seborrhoeic dermatitis (3.0%) 9 Polyarthrosis (1.8%) Acute tonsillitis (2.4%) Other dermatitis (2.8%) 10 Chronic sinusitis (1.5%) Shoulder lesions (2.4%) Conjunctivitis (1.9%) In general hospitals, autoimmune diseases predominated: rheumatoid arthritis (M05, 7.1%) and other rheumatoid disorders (M06, 6.2%) were most common, followed by systemic lupus erythematosus (M32, 3.1%) and other connective tissue diseases (M35, 2.5%). However, allergic contact dermatitis (L23, 3.5%) and urticaria (L50, 3.2%) also remained among the top 10 diagnoses. In hospitals, urticaria (L50, 7.9%) ranked highest, followed by asthma (J45, 4.5%), allergic contact dermatitis (L23, 4.4%), and atopic dermatitis (L20, 4.3%). Musculoskeletal conditions such as lumbar disc disorders (M51) and knee osteoarthritis (M17) also contributed prominently. In clinics, the prescribing pattern was even more concentrated. Allergic contact dermatitis (L23, 15.7%) and urticaria (L50, 6.0%) were the top two diagnoses, indicating a strong focus on relatively mild dermatologic conditions. Other frequent diagnoses included rhinitis (J30), bronchitis (J20), irritant contact dermatitis (L24), tonsillitis (J03), and seborrheic dermatitis (L21), which are typically seen in primary care. From 2003 to 2013, the proportion of OCS prescriptions for key diagnoses—dermatitis and eczema (L20–L30), urticaria and erythema (L50–L54), and rhinitis (J30) varied notably by institution type Prescriptions for L20–L30 were consistently highest in clinics, where they accounted for 55–60% of all OCS prescriptions, compared to ~ 35% in hospitals and < 25% in general hospitals (Fig. 5). A similar pattern was observed for L50–L54, particularly urticaria, with clinics prescribing disproportionately more than higher-level institutions (Fig. 6). In contrast, OCS prescriptions for rhinitis (J30) showed a marked decline over time, particularly in clinics. From a peak in 2003, the proportion of OCS use for rhinitis dropped sharply by around 2010 and remained low thereafter. This trend may reflect growing awareness of the limited indication for OCS in allergic rhinitis and changes in prescribing behavior over time. In hospitals and general hospitals, rhinitis consistently accounted for a smaller proportion of OCS use, with relatively stable patterns across the study period (Fig. 7). Discussion This study analyzed the long-term prescribing trends of oral corticosteroids (OCS) in the adult population of South Korea using National Health Insurance Service (NHIS) claims data from 2003 to 2012. While prior domestic studies have intermittently examined OCS usage patterns in specific disease groups such as asthma, atopic dermatitis, and chronic urticaria, this is the first study to comprehensively analyze prescribing patterns across all diagnostic categories, considering age, sex, specialty, institution type, and prescription frequency. Therefore, this study serves as a foundational dataset for understanding the broader landscape of corticosteroid use in Korea. The results showed a consistent increase in OCS prescribing over time, with a decrease in short-term users and a gradual increase in the proportion of mid- and long-term users. This trend was consistently observed across both sexes and all age groups throughout the study period. Prescriptions were concentrated among dermatologic conditions (L20–L30), respiratory diseases (J00–J99), urticaria (L50), and allergic rhinitis (J30)—many of which are not considered primary indications for systemic corticosteroid therapy under current clinical guidelines. Notably, 14.5% of users with allergic contact dermatitis (L23) and 5.9% of those with urticaria (L50) received six or more prescriptions per year. This finding suggests that routine, repeated exposure to corticosteroids occurs even in conditions typically considered acute. For allergic contact dermatitis, systemic corticosteroids are generally reserved for extensive or severe cases and are recommended only for short-term use due to the risk of rebound flares and systemic side effects. 18 – 20 Similarly, in urticaria, current treatment guidelines recommend systemic corticosteroids only as a brief intervention in cases unresponsive to high-dose antihistamines or when accompanied by angioedema. 21 – 23 The discrepancy between actual prescribing patterns and guideline recommendations may reflect not only clinical uncertainty or lack of adherence, but also extrinsic factors such as patient demand for rapid symptom relief and the influence of reputation-driven practice environments where treatment outcomes are often subject to online reviews. In such contexts, physicians may face subtle pressures to meet patient expectations swiftly, contributing to habitual overprescribing, particularly in high-turnover primary care settings. When stratified by institution type, clinics had substantially higher prescription rates for these conditions compared to hospitals and general hospitals. For instance, in the case of dermatitis and eczema (L20–L30), clinics accounted for approximately 55–60% of all OCS prescriptions, while general hospitals accounted for less than 25%. Similar patterns were observed for urticaria (L50–L54) and allergic rhinitis (J30), which were predominantly managed and treated with OCS in primary care settings. These differences cannot be explained solely by differences in specialty composition but likely reflect a combination of factors including patient disease severity, physician training, awareness of steroid-related adverse effects, time constraints in outpatient care, and distorted reimbursement structures. Especially in clinics, where patient turnover is high and consultation times are limited, clinicians may be pressured to prioritize rapid symptom relief, reinforcing a structural reliance on corticosteroids. Patient expectations and physician burden may further compound this trend. This study also provides a basis for international comparisons of corticosteroid prescribing patterns. In France, a large-scale study reported that 98.2% of OCS users were short-term users, with only 1.8% being classified as long-term users. 8 In the United States and Taiwan, OCS prescriptions are also often concentrated in primary care for self-limited or allergic conditions. 9 However, structured education, policy interventions, and insurance-based regulatory mechanisms are more commonly implemented to curb overuse. In the U.S., co-prescribing of gastroprotective agents, osteoporosis prophylaxis, and blood glucose monitoring is more standardized within primary care. In Denmark and Iceland, 10 , 24 OCS usage rates are low relative to population size, and prescriptions are typically limited to autoimmune or severe inflammatory diseases. In the United Kingdom, 25 the introduction of biologic therapies has contributed to a gradual decline in systemic corticosteroid use, and the growing range of treatment options has reduced reliance on repeated OCS prescriptions. These international comparisons highlight the disproportionate concentration of OCS use in specific diagnostic groups in Korea and underscore the frequent repetition of prescriptions in primary care, often without clear or guideline-based criteria. In Korea, standardized guidelines for corticosteroid prescribing, adverse event prevention, and use of prophylactic co-medications are lacking. As a result, the decision to prescribe OCS is largely left to the individual judgment and experience of each physician. Particularly in outpatient-based specialties such as dermatology, internal medicine, and otolaryngology, corticosteroids are often perceived as a symbol of fast and effective treatment. This perception, in the absence of oversight or structural checks, contributes to excessive or prolonged corticosteroid prescribing. The resulting increase in adverse event risk including Cushing’s syndrome, osteoporosis, hyperglycemia, and immunosuppression is further exacerbated by limited patient education and lack of risk communication in clinical encounters. 8 , 26 – 30 Most of the diagnoses analyzed in this study were for mild to moderate conditions, making careful consideration of the risk-benefit ratio of corticosteroid use all the more critical. Yet our findings suggest that such consideration is often absent in routine practice. In light of these observations, coordinated policy and educational interventions are urgently needed to ensure more appropriate corticosteroid prescribing. For diagnostic groups frequently associated with repeated OCS use (e.g., L20–L30, L50–L54, J30), clear clinical guidelines must be established, and real-time feedback systems should be implemented to detect patterns of overuse by institution type and specialty. In addition, a national-level monitoring system for long-term users should be built using claims data, and the dissemination of guidelines for prophylactic co-therapy and adverse event prevention must be expanded. Patients should be adequately informed about the benefits and risks of corticosteroid therapy and available treatment alternatives. Insurance policies should support improved access to safer or steroid-sparing alternatives such as biologics, topical agents, and immunomodulators. While this study provides a robust analysis of long-term OCS prescribing using a nationwide cohort, it is not without limitations. First, because this is a claims-based study, we were unable to account for clinical details such as disease severity, symptom duration, diagnostic accuracy, or treatment intentfactors necessary for a precise assessment of prescribing appropriateness. Second, we could not assess medication adherence; thus, actual drug consumption may differ from prescription claims. Moreover, details such as dosage, duration, and refill intervals could not be sufficiently evaluated, limiting estimation of cumulative exposure. Third, although we analyzed prescription patterns by specialty, the NHIS-NSC database does not explicitly distinguish board-certified specialists from general practitioners in clinic-level institutions. While prescriptions from hospitals and general hospitals can generally be assumed to have been issued by board-certified specialists, in clinics, the specialty designation is based on the diagnostic code submitted for reimbursement, not on the physician's actual certification. As a result, some prescriptions classified under a particular specialty may have been issued by general practitioners rather than specialists, and we were unable to separate or exclude these cases. Finally, as the data analyzed span from 2003 to 2012, they do not reflect more recent developments such as updated clinical guidelines, expanded insurance coverage for biologics, or changing prescribing behavior in the last decade. Future studies should incorporate more recent data and consider linkage with clinical records to enable more nuanced analyses. Declarations Ethics approval and consent to participate: The study was approved by the Institutional Review Board of the Kangwon National University Hospital (KNUH-2025-02-011) and was conducted in accordance with the principles of the Declaration of Helsinki. All participants provided written informed consent prior to their inclusion in the study. Consent for publication: Not applicable. Availability of data and materials: The data used in this study are available from the National Health Insurance Service-National Sample Cohort (NHIS-NSC), but restrictions apply to the availability of these data, which were used under license for the current study and so are not publicly available. Data are, however, available from the authors upon reasonable request and with permission of NHIS. Competing interests The authors declare that they have no potential conflicts of interest to disclose. Funding: No financial support was received for this study. Authors ’ contributions: Young Woo Jo: data curation, formal analysis. Jae-Woo Kwon: data curation, writing – review & editing. Joon-hong Min: conceptualization, writing – original draft, writing – review & editing. Young Her: conceptualization, writing – review & editing, funding acquisition. All authors read and approved the final manuscript. Acknowledgments: Not applicable. References CHAST, F. Histoire de la corticothérapie. 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DOI: 10.1016/j.jaad.2015.02.1144. BOURKE, J.; COULSON, I.; ENGLISH, J. Guidelines for the management of contact dermatitis: an update. British Journal of Dermatology , 2009, 160.5: 946-954. DOI: 10.1111/j.1365-2133.2009.09106.x. SUNG, Calvin T., et al. Systemic treatments for allergic contact dermatitis. Dermatitis , 2019, 30.1: 46-53. DOI: 10.1097/DER.0000000000000435. ZUBERBIER, Torsten, et al. The international EAACI/GA²LEN/EuroGuiDerm/APAAACI guideline for the definition, classification, diagnosis, and management of urticaria. Allergy , 2022, 77.3: 734-766. DOI: 10.1111/all.15090. GRATTAN, C. E. H.; HUMPHREYS, F.; BRITISH ASSOCIATION OF DERMATOLOGISTS THERAPY GUIDELINES AND AUDIT SUBCOMMITTEE. Guidelines for evaluation and management of urticaria in adults and children. British Journal of Dermatology , 2007, 157.6: 1116-1123. DOI: 10.1111/j.1365-2133.2007.08283.x. ZUBERBIER, Torsten. A summary of the new international EAACI/GA2LEN/EDF/WAO guidelines in urticaria. World Allergy Organization Journal , 2012, 5: S1-S5. dOI: 10.1186/1939-4551-5-S1-S1. LAUGESEN, Kristina, et al. Fifteen-year nationwide trends in systemic glucocorticoid drug use in Denmark. European Journal of Endocrinology , 2019, 181.3: 267-273. DOI: 10.1530/EJE-19-0305. MENZIES-GOW, Andrew N., et al. Trends in systemic glucocorticoid utilization in the United Kingdom from 1990 to 2019: a population-based, serial cross-sectional analysis. Pragmatic and Observational Research , 2024, 53-64. Doi: 10.2147/POR.S442959. SEIBEL, Markus J.; COOPER, Mark S.; ZHOU, Hong. Glucocorticoid-induced osteoporosis: mechanisms, management, and future perspectives. The lancet Diabetes & endocrinology , 2013, 1.1: 59-70.doi: 10.1016/S2213-8587(13)70045-7. COMPSTON, Juliet. Glucocorticoid-induced osteoporosis: an update. Endocrine , 2018, 61.1: 7-16. Doi: 10.1007/s12020-018-1588-2. HUMPHREY, Mary Beth, et al. 2022 American College of rheumatology guideline for the prevention and treatment of glucocorticoid‐induced osteoporosis. Arthritis & Rheumatology , 2023, 75.12: 2088-2102. doi: 10.1002/art.42646. SULLIVAN, Patrick W., et al. Oral corticosteroid exposure and adverse effects in asthmatic patients. Journal of Allergy and Clinical Immunology , 2018, 141.1: 110-116. e7. doi: 10.1016/j.jaci.2017.04.009. FARDET, Laurence, et al. Corticosteroid-induced adverse events in adults: frequency, screening and prevention. Drug safety , 2007, 30: 861-881. DOI: 10.2165/00002018-200730100-00005. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6706699","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":472747871,"identity":"418bcef0-589c-4f1e-b348-33a13a8ca500","order_by":0,"name":"YoungWoo Jo","email":"","orcid":"","institution":"Kangwon National University Hospital, Kangwon National University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"YoungWoo","middleName":"","lastName":"Jo","suffix":""},{"id":472747872,"identity":"f4d12381-6504-4d20-bd61-d162f3f34acc","order_by":1,"name":"Jae-Woo Kwon","email":"","orcid":"","institution":"Kangwon National University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Jae-Woo","middleName":"","lastName":"Kwon","suffix":""},{"id":472747873,"identity":"3b5f70e5-7864-41fb-9462-7f1bdc7a5a29","order_by":2,"name":"Joon-Hong Min","email":"","orcid":"","institution":"Kangwon National University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Joon-Hong","middleName":"","lastName":"Min","suffix":""},{"id":472747874,"identity":"a673a257-4335-4bab-8053-5dde48a18aa5","order_by":3,"name":"Young Her","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABAUlEQVRIiWNgGAWjYNACNhDBfBhZKIEYLWzJJGvhMSZOi8HxHrOHX8ps8nXbz3w2+LmjNrFfuoHxww+GtHycWs6cMTeWOZdmue1M7ubE3jPHE2fOOcAs2cOQY9mAS8uNHDNpybbDBmYHcjcf4G07lrvhRgKDNANDhQFOWyBa/huYnX/z+OBfiBbm34S0SH5sO2BgdiOHOZm3rQakhQ1oSw5OLZJnjpVJM5xLBmp5Zmws23agfuaMxDbLHoM0nFr4jjdvk/xRZgd0WPJjybdtdcb8EsmHb/yoSMapReEAMNp5EHxQCmBsADoYlwYGBnmgNOMPBL8Ot9JRMApGwSgYsQAA6JlcSAHW1TEAAAAASUVORK5CYII=","orcid":"","institution":"Kangwon National University School of Medicine","correspondingAuthor":true,"prefix":"","firstName":"Young","middleName":"","lastName":"Her","suffix":""}],"badges":[],"createdAt":"2025-05-20 10:23:24","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6706699/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6706699/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":84966410,"identity":"c769bbf5-9f49-4a53-9b59-c92d3bbbecc6","added_by":"auto","created_at":"2025-06-19 09:57:20","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":281961,"visible":true,"origin":"","legend":"\u003cp\u003eFlowchart of study cohort selection from NHIS-NSC.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6706699/v1/31f353c3284a05e79e4371e6.png"},{"id":84966412,"identity":"267c35aa-6248-46b1-943e-39f5c6de5300","added_by":"auto","created_at":"2025-06-19 09:57:20","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":351811,"visible":true,"origin":"","legend":"\u003cp\u003eAnnual Trends in Oral Corticosteroid Use.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6706699/v1/e523ad0061705b9b0c942627.png"},{"id":84966414,"identity":"2ca49a9e-ffba-456e-acaf-c50f1b773089","added_by":"auto","created_at":"2025-06-19 09:57:20","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":344518,"visible":true,"origin":"","legend":"\u003cp\u003eDistribution of Steroid Use by Category and Usage Duration.\u003c/p\u003e\n\u003cp\u003eL00-L99: Diseases of the skin and subcutaneous tissue; J00-J99: Diseases of the respiratory system; M00-M99: Diseases of the musculoskeletal system and connective tissue; H00-H59: Diseases of the eye and adnexa\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-6706699/v1/b12ee7e700a3c55dcf04e653.png"},{"id":84967834,"identity":"20a274b7-2d93-4cc6-8e1f-49033df99ee3","added_by":"auto","created_at":"2025-06-19 10:13:20","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":467997,"visible":true,"origin":"","legend":"\u003cp\u003ePrescription Distribution by Department Across Medical Institution Types.\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-6706699/v1/c3697c4b4d42d0337d8510bc.png"},{"id":84966894,"identity":"d8248621-bc63-422b-8a4e-5063a9517386","added_by":"auto","created_at":"2025-06-19 10:05:20","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":430478,"visible":true,"origin":"","legend":"\u003cp\u003ePrevalence of OCS prescriptions for Dermatitis and eczema(L20-L30) Across Hospital Types from 2003 to 2013.\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-6706699/v1/048768e01283e2c7c6821ecc.png"},{"id":84966899,"identity":"65dd8e6b-0f8d-4010-a0c3-80d1839acecf","added_by":"auto","created_at":"2025-06-19 10:05:20","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":437155,"visible":true,"origin":"","legend":"\u003cp\u003ePrevalence of OCS prescriptions for Urticaria and Erythema(L50-L54) Across Hospital Types from 2003 to 2013.\u003c/p\u003e","description":"","filename":"6.png","url":"https://assets-eu.researchsquare.com/files/rs-6706699/v1/82e93c7c084f0b74cd025cac.png"},{"id":84966912,"identity":"f0a0e864-dfbe-4625-b544-386945f60a28","added_by":"auto","created_at":"2025-06-19 10:05:21","extension":"png","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":413626,"visible":true,"origin":"","legend":"\u003cp\u003ePrevalence of OCS prescriptions for Vasomotor and allergic rhinitis(J30) Across Hospital Types from 2003 to 2013.\u003c/p\u003e","description":"","filename":"7.png","url":"https://assets-eu.researchsquare.com/files/rs-6706699/v1/f157a910613bd7246b10d2f8.png"},{"id":86742455,"identity":"12cf89f3-df01-456d-9019-fa0e741ae5d5","added_by":"auto","created_at":"2025-07-15 07:09:56","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":4074333,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6706699/v1/afa5163e-5dac-46c6-aab5-d7bdd2128730.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eOral Corticosteroid Prescription Trends in South Korea: A 10-Year Nationwide Population-Based Study Using the NHIS-NSC\u003c/p\u003e","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eOral corticosteroids (OCS) are widely used anti-inflammatory and immunosuppressive agents that play a critical role in the treatment of numerous acute and chronic conditions, including allergic diseases, autoimmune disorders, dermatological conditions, and respiratory illnesses.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e Despite their therapeutic efficacy, OCS are associated with a range of adverse effects, especially when used frequently or inappropriately.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e Concerns about metabolic complications, infections, and bone loss have prompted increasing scrutiny over prescribing practices in both outpatient and hospital.\u003csup\u003e\u003cspan additionalcitationids=\"CR5 CR6\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eRecent population-based studies from the United States, France, Taiwan, and other countries have highlighted a global trend of increasing OCS prescriptions, particularly for short-term use in self-limited conditions.\u003csup\u003e\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e While some of this increase may reflect improved access to care, others have raised concerns about unjustified prescriptions.\u003csup\u003e\u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e Moreover, these studies have consistently reported variability in prescribing behavior based on physician specialty and healthcare setting.\u003csup\u003e\u003cspan additionalcitationids=\"CR15 CR16\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eDespite this international interest, there has been limited investigation into OCS prescribing patterns in South Korea. Prior to this study, little was known about how OCS are used across different age groups, disease categories, or levels of healthcare institutions within the Korean healthcare system. Understanding such patterns is essential for identifying areas of potential overuse, improving prescribing guidelines, and mitigating risks at the population level.\u003c/p\u003e \u003cp\u003eUsing a nationally representative sample from the National Health Insurance Service-National Sample Cohort (NHIS-NSC), this study aimed to evaluate the trends, indications, and institutional variations in oral corticosteroid prescriptions in South Korea between 2003 and 2012.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eData source and Study population\u003c/h2\u003e \u003cp\u003eThis retrospective observational study was conducted using the National Health Insurance Service National Sample Cohort (NHIS-NSC) database, a population-based dataset constructed from a 2% stratified random sample of all enrollees in the Korean National Health Insurance (NHI) program. The NHIS-NSC provides comprehensive longitudinal data on demographics, diagnoses (ICD-10), healthcare utilization, and prescription records. The study period covered the years 2002 through 2013, with primary analysis focused on oral corticosteroid (OCS) prescriptions from 2003 to 2012. We identified individuals who had received at least one prescription for an oral corticosteroid between 2002 and 2013. To ensure consistency in exposure assessment, we excluded the following individuals: (1) those under the age of 20 years; (2) those who were prescribed OCS only in 2002, which served as a washout period; and (3) those whose first prescription occurred in 2013, to allow for at least one year of follow-up. After applying these criteria, only patients who initiated OCS use between 2003 and 2012 and met the age requirement were included in the final analysis (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eDefinition and Classification of Oral Corticosteroids\u003c/h3\u003e\n\u003cp\u003eOral corticosteroids included in this study were betamethasone, deflazacort, dexamethasone, hydrocortisone, methylprednisolone, and triamcinolone. All prescriptions were extracted from outpatient prescription claims. For standardization of dosage, the World Health Organization\u0026rsquo;s Defined Daily Dose (DDD) methodology was applied, but classification of users was based on frequency rather than cumulative dose. (Defined Daily Dose (DDD))\u003c/p\u003e\n\u003ch3\u003eClassification by Frequency of OCS Use\u003c/h3\u003e\n\u003cp\u003eBased on the number of OCS prescriptions received within a single calendar year, patients were categorized into three groups: short-term users (1 prescription per year), mid-term users (2 to 5 prescriptions per year), and long-term users (6 or more prescriptions per year). This classification reflects annual prescribing frequency rather than treatment duration, and was informed by previous literature.\u003c/p\u003e\n\u003ch3\u003eDisease Classification and Covariates\u003c/h3\u003e\n\u003cp\u003eAll diagnoses were coded using the 10th revision of the International Classification of Diseases (ICD-10). Diagnoses were grouped by major disease categories (e.g., dermatologic, respiratory, musculoskeletal, circulatory, neurological) and further analyzed at the block and subcategory levels. Specific focus was given to the most common indications for OCS use, including dermatitis and eczema (L20\u0026ndash;L30), urticaria and erythema (L50\u0026ndash;L54), upper respiratory infections (J00\u0026ndash;J06), and chronic lower respiratory diseases (J40\u0026ndash;J47).\u003c/p\u003e \u003cp\u003eCovariates included age (categorized into 10-year intervals), sex, medical specialty, and healthcare institution type. Healthcare institutions were classified into clinics (\u0026lt;\u0026thinsp;30 beds), hospitals (\u0026ge;\u0026thinsp;30 beds), and general hospitals (\u0026ge;\u0026thinsp;100 beds with specific departmental requirements), in accordance with the Korean Medical Services Act.\u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eTo examine the trends in the usage of OCS, time series analysis and chi-square tests were employed. The dataset was constructed using SAS software (version 9.4; SAS Institute, Cary, NC, USA), while all statistical analyses were conducted using IBM SPSS Statistics (version 27.0; IBM Corp., Armonk, NY, USA). Tables and graphical work were performed using Excel.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eFrom 2003 to 2012, the annual prevalence of oral corticosteroid (OCS) use steadily increased among adults in the study population. In 2003, 155,087 out of 746,816 individuals (20.8%) received at least one OCS prescription, which rose to 231,640 out of 792,560 individuals (29.2%) in 2012. This corresponds to a 40.4% relative increase compared to the baseline in 2003 (Fig.\u0026nbsp;2A). This upward trend was consistently observed across all age groups and both sexes.\u003c/p\u003e\n\u003cp\u003eOver the same period, notable changes were observed in prescription frequency categories. The proportion of short-term users (1 prescription/year) declined from 57.9% in 2003 to 45.9% in 2012. Meanwhile, mid-term users (2–5 prescriptions/year) increased from 37.7–64.9%, and long-term users (≥ 6 prescriptions/year) increased from 4.4–15.9% (Table\u0026nbsp;1).\u003c/p\u003e\n\u003cp\u003e\u003cimg 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\"\u003e\u003c/p\u003e\n\u003cdiv\u003eThroughout the study period, OCS use was consistently more common in women than in men (Fig. 2A). By age group, individuals aged 40–49 showed the highest prevalence, followed by those aged 60 years and older. These patterns remained stable over time (Fig. 2B).\u003c/div\u003e\n\u003cp\u003eAccording to ICD-10 chapters, dermatologic conditions (L00–L99) accounted for the largest proportion of OCS use (38.9%), followed by respiratory diseases (J00–J99) at 29.6%. Musculoskeletal disorders (M00–M99) accounted for 7.4%, while circulatory (I00–I99) and neurologic (G00–G99) diseases represented 1.5% and 0.8%, respectively (Fig.\u0026nbsp;3).\u003c/p\u003e\n\u003cp\u003eAmong the top minor diagnostic categories, allergic contact dermatitis (L23) accounted for the highest proportion of OCS users, with 76,114 individuals (15.5%) initiating treatment. Of these, 3,511 individuals (14.5%) were classified as long-term users, receiving six or more prescriptions per year (Table\u0026nbsp;2). This long-term usage rate is substantially higher than other subtypes within the same category (L20–L30), suggesting that L23 may be associated with persistent or recurrent symptoms that result in extended corticosteroid exposure. It also raises concern regarding the potential discordance with treatment guidelines, which generally do not recommend prolonged OCS use for contact dermatitis (Table\u0026nbsp;3).\u003c/p\u003e\n\u003cdiv\u003e\n \u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 2\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003eTop minor categories in OCS use.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCODE\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMinor Type\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eAll GC initiators\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eshort-term users\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMid-term users\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eLong-term users\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eL23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAllergic contact dermatitis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e76,114 (15.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e42,514 (16.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30,089 (14.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3,511 (14.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eL50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUrticaria\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e36,058 (7.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20,690 (7.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13,944 (6.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1,424 (5.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eJ30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eVasomotor and allergic rhinitis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e23,766 (4.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12,465 (4.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10,319 (5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e982 (4.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eJ20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAcute bronchitis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20,216 (4.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11,368 (4.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8,153 (4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e695 (2.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eJ03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAcute tonsillitis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e19,905 (4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11,313 (4.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8,067 (3.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e525 (2.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eL24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIrritant contact dermatitis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16,609 (3.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9,182 (3.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6,619 (3.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e808 (3.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eL30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOther dermatitis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13,482 (2.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7,279 (2.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5,454 (2.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e749 (3.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eH10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eConjunctivitis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12,219 (2.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7,244 (2.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4,656 (2.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e319 (1.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eL21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSeborrhoeic dermatitis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11,762 (2.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5,734 (2.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5,236 (2.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e792 (3.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eJ45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAsthma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10,406 (2.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5,128 (2.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4,646 (2.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e632 (2.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cdiv\u003e\n \u003ctable id=\"Tab3\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 3\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003ePrevalence of subcategories within category L20-L30.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCODE\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eMinor Type\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eAll GC initiators\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eshort-term users\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMid-term users\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eLong-term users\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eL20-L30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDermatitis and eczema\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e139,459 (28.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e76,128 (29.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e56,292 (27.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7,039 (29.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eL20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAtopic dermatitis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4,911 (1.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2,361 (0.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2,153 (1.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e397 (1.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eL21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSeborrhoeic dermatitis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11,762 (2.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5,734 (2.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5,236 (2.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e792 (3.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eL22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDiaper dermatitis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eL23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAllergic contact dermatitis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e76,114 (15.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e42,514 (16.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30,089 (14.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3,511 (14.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eL24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIrritant contact dermatitis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16,609 (3.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9,182 (3.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6,619 (3.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e808 (3.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eL25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUnspecified contact dermatitis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7,939 (1.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4,383 (1.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3,211 (1.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e345 (1.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eL26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eExfoliative dermatitis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e81 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e40 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e39 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eL27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDermatitis due to substances taken internally\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2,634 (0.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1,513 (0.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1,035 (0.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e86 (0.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eL28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLichen simplex chronicus and prurigo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3,298 (0.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1,687 (0.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1,399 (0.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e212 (0.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eL29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePruritus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2,620 (0.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1,428 (0.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1,055 (0.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e137 (0.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eL30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOther dermatitis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13,482 (2.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7,279 (2.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5,454 (2.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e749 (3.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eSimilarly, urticaria (L50), a subtype of the L50–L54 category (urticaria and erythema), represented 36,058 users (7.3%). Notably, 1,424 users (5.9%) received long-term OCS prescriptions (Table\u0026nbsp;4). While urticaria is typically an acute condition manageable with antihistamines, this notable proportion of long-term steroid users may reflect either frequent relapses or insufficient symptom control. The data suggest that OCS may be overprescribed for these conditions, particularly in primary care settings, and further clinical scrutiny is warranted.\u003c/p\u003e\n\u003cdiv\u003e\n \u003ctable id=\"Tab4\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 4\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003ePrevalence of subcategories within category L50-L54.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCODE\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eMinor Type\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eAll GC initiators\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eshort-term users\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMid-term users\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eLong-term users\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eL50-L54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUrticaria and erythema\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e37,564 (7.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e21,498 (8.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14,574 (7.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1,492 (6.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eL50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUrticaria\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e36,058 (7.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20,690 (7.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13,944 (6.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1,424 (5.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eL51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eErythema multiforme\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e506 (0.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e262 (0.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e218 (0.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e26 (0.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eL52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eErythema nodosum\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e135 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e59 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e65 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eL53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOther erythematous conditions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e862 (0.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e485 (0.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e346 (0.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e31 (0.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eL54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eErythema in diseases classified elsewhere\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eOCS prescription patterns varied by specialty and institution type (Fig.\u0026nbsp;4). Overall, dermatology (31.6%) and internal medicine (29.3%) accounted for the largest share of prescriptions, followed by otorhinolaryngology (12.6%), orthopedics (8.8%), and ophthalmology (5.3%).\u003c/p\u003e\n\u003cp\u003eIn general hospitals, internal medicine dominated OCS prescribing (55.1%), while dermatology accounted for a relatively small share (13.5%). In contrast, dermatology contributed the largest share in clinics (33.9%), followed by internal medicine (27.3%). This variation may reflect differences in clinical composition, case mix, and access to specialty care.\u003c/p\u003e\n\u003cp\u003eIn hospitals (non-general), orthopedics had a notable share (27.3%), followed by internal medicine (36.7%) and dermatology (2.6%). This likely reflects a higher prevalence of musculoskeletal conditions in these settings. The share of otorhinolaryngology and ophthalmology remained relatively stable across institution types.\u003c/p\u003e\n\u003cp\u003eTop diagnoses for OCS use differed markedly by institution type (Table\u0026nbsp;5.).\u003c/p\u003e\n\u003cdiv\u003e\n \u003ctable id=\"Tab5\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 5\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003eTop 10 Diagnoses by prescription volume across medical institution types.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eRANK\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eGeneral hospital\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eHospital\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eClinic\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSeropositive rheumatoid arthritis\u003c/p\u003e\n \u003cp\u003e(7.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUrticaria\u003c/p\u003e\n \u003cp\u003e(7.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAllergic contact dermatitis\u003c/p\u003e\n \u003cp\u003e(15.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOther rheumatoid arthritis\u003c/p\u003e\n \u003cp\u003e(6.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAsthma\u003c/p\u003e\n \u003cp\u003e(4.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUrticaria\u003c/p\u003e\n \u003cp\u003e(6.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAsthma\u003c/p\u003e\n \u003cp\u003e(4.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAllergic contact dermatitis\u003c/p\u003e\n \u003cp\u003e(4.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eVasomotor and allergic rhinitis\u003c/p\u003e\n \u003cp\u003e(5.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAllergic contact dermatitis\u003c/p\u003e\n \u003cp\u003e(3.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAtopic dermatitis\u003c/p\u003e\n \u003cp\u003e(4.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAcute bronchitis\u003c/p\u003e\n \u003cp\u003e(4.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUrticaria\u003c/p\u003e\n \u003cp\u003e(3.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOther intervertebral disc disorders\u003c/p\u003e\n \u003cp\u003e(3.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIrritant contact dermatitis\u003c/p\u003e\n \u003cp\u003e(3.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSystemic lupus erythematosus\u003c/p\u003e\n \u003cp\u003e(3.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGonarthrosis[arthrosis of knee]\u003c/p\u003e\n \u003cp\u003e(3.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAcute tonsillitis\u003c/p\u003e\n \u003cp\u003e(3.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOther systemic involvement of connective tissue\u003c/p\u003e\n \u003cp\u003e(2.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eVasomotor and allergic rhinitis\u003c/p\u003e\n \u003cp\u003e(3.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAsthma\u003c/p\u003e\n \u003cp\u003e(3.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOther chronic obstructive pulmonary disease\u003c/p\u003e\n \u003cp\u003e(2.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOther spondylopathies\u003c/p\u003e\n \u003cp\u003e(2.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSeborrhoeic dermatitis\u003c/p\u003e\n \u003cp\u003e(3.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePolyarthrosis\u003c/p\u003e\n \u003cp\u003e(1.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAcute tonsillitis\u003c/p\u003e\n \u003cp\u003e(2.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOther dermatitis\u003c/p\u003e\n \u003cp\u003e(2.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eChronic sinusitis\u003c/p\u003e\n \u003cp\u003e(1.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eShoulder lesions\u003c/p\u003e\n \u003cp\u003e(2.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eConjunctivitis\u003c/p\u003e\n \u003cp\u003e(1.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eIn general hospitals, autoimmune diseases predominated: rheumatoid arthritis (M05, 7.1%) and other rheumatoid disorders (M06, 6.2%) were most common, followed by systemic lupus erythematosus (M32, 3.1%) and other connective tissue diseases (M35, 2.5%). However, allergic contact dermatitis (L23, 3.5%) and urticaria (L50, 3.2%) also remained among the top 10 diagnoses.\u003c/p\u003e\n\u003cp\u003eIn hospitals, urticaria (L50, 7.9%) ranked highest, followed by asthma (J45, 4.5%), allergic contact dermatitis (L23, 4.4%), and atopic dermatitis (L20, 4.3%). Musculoskeletal conditions such as lumbar disc disorders (M51) and knee osteoarthritis (M17) also contributed prominently.\u003c/p\u003e\n\u003cp\u003eIn clinics, the prescribing pattern was even more concentrated. Allergic contact dermatitis (L23, 15.7%) and urticaria (L50, 6.0%) were the top two diagnoses, indicating a strong focus on relatively mild dermatologic conditions. Other frequent diagnoses included rhinitis (J30), bronchitis (J20), irritant contact dermatitis (L24), tonsillitis (J03), and seborrheic dermatitis (L21), which are typically seen in primary care.\u003c/p\u003e\n\u003cp\u003eFrom 2003 to 2013, the proportion of OCS prescriptions for key diagnoses—dermatitis and eczema (L20–L30), urticaria and erythema (L50–L54), and rhinitis (J30) varied notably by institution type\u003c/p\u003e\n\u003cp\u003ePrescriptions for L20–L30 were consistently highest in clinics, where they accounted for 55–60% of all OCS prescriptions, compared to ~ 35% in hospitals and \u0026lt; 25% in general hospitals (Fig.\u0026nbsp;5). A similar pattern was observed for L50–L54, particularly urticaria, with clinics prescribing disproportionately more than higher-level institutions (Fig.\u0026nbsp;6).\u003c/p\u003e\n\u003cp\u003eIn contrast, OCS prescriptions for rhinitis (J30) showed a marked decline over time, particularly in clinics. From a peak in 2003, the proportion of OCS use for rhinitis dropped sharply by around 2010 and remained low thereafter. This trend may reflect growing awareness of the limited indication for OCS in allergic rhinitis and changes in prescribing behavior over time. In hospitals and general hospitals, rhinitis consistently accounted for a smaller proportion of OCS use, with relatively stable patterns across the study period (Fig.\u0026nbsp;7).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study analyzed the long-term prescribing trends of oral corticosteroids (OCS) in the adult population of South Korea using National Health Insurance Service (NHIS) claims data from 2003 to 2012. While prior domestic studies have intermittently examined OCS usage patterns in specific disease groups such as asthma, atopic dermatitis, and chronic urticaria, this is the first study to comprehensively analyze prescribing patterns across all diagnostic categories, considering age, sex, specialty, institution type, and prescription frequency. Therefore, this study serves as a foundational dataset for understanding the broader landscape of corticosteroid use in Korea. The results showed a consistent increase in OCS prescribing over time, with a decrease in short-term users and a gradual increase in the proportion of mid- and long-term users. This trend was consistently observed across both sexes and all age groups throughout the study period. Prescriptions were concentrated among dermatologic conditions (L20\u0026ndash;L30), respiratory diseases (J00\u0026ndash;J99), urticaria (L50), and allergic rhinitis (J30)\u0026mdash;many of which are not considered primary indications for systemic corticosteroid therapy under current clinical guidelines. Notably, 14.5% of users with allergic contact dermatitis (L23) and 5.9% of those with urticaria (L50) received six or more prescriptions per year. This finding suggests that routine, repeated exposure to corticosteroids occurs even in conditions typically considered acute. For allergic contact dermatitis, systemic corticosteroids are generally reserved for extensive or severe cases and are recommended only for short-term use due to the risk of rebound flares and systemic side effects.\u003csup\u003e\u003cspan additionalcitationids=\"CR19\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e Similarly, in urticaria, current treatment guidelines recommend systemic corticosteroids only as a brief intervention in cases unresponsive to high-dose antihistamines or when accompanied by angioedema.\u003csup\u003e\u003cspan additionalcitationids=\"CR22\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e The discrepancy between actual prescribing patterns and guideline recommendations may reflect not only clinical uncertainty or lack of adherence, but also extrinsic factors such as patient demand for rapid symptom relief and the influence of reputation-driven practice environments where treatment outcomes are often subject to online reviews. In such contexts, physicians may face subtle pressures to meet patient expectations swiftly, contributing to habitual overprescribing, particularly in high-turnover primary care settings.\u003c/p\u003e \u003cp\u003eWhen stratified by institution type, clinics had substantially higher prescription rates for these conditions compared to hospitals and general hospitals. For instance, in the case of dermatitis and eczema (L20\u0026ndash;L30), clinics accounted for approximately 55\u0026ndash;60% of all OCS prescriptions, while general hospitals accounted for less than 25%. Similar patterns were observed for urticaria (L50\u0026ndash;L54) and allergic rhinitis (J30), which were predominantly managed and treated with OCS in primary care settings. These differences cannot be explained solely by differences in specialty composition but likely reflect a combination of factors including patient disease severity, physician training, awareness of steroid-related adverse effects, time constraints in outpatient care, and distorted reimbursement structures. Especially in clinics, where patient turnover is high and consultation times are limited, clinicians may be pressured to prioritize rapid symptom relief, reinforcing a structural reliance on corticosteroids. Patient expectations and physician burden may further compound this trend.\u003c/p\u003e \u003cp\u003eThis study also provides a basis for international comparisons of corticosteroid prescribing patterns. In France, a large-scale study reported that 98.2% of OCS users were short-term users, with only 1.8% being classified as long-term users.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e In the United States and Taiwan, OCS prescriptions are also often concentrated in primary care for self-limited or allergic conditions.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e However, structured education, policy interventions, and insurance-based regulatory mechanisms are more commonly implemented to curb overuse. In the U.S., co-prescribing of gastroprotective agents, osteoporosis prophylaxis, and blood glucose monitoring is more standardized within primary care. In Denmark and Iceland,\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e,\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e OCS usage rates are low relative to population size, and prescriptions are typically limited to autoimmune or severe inflammatory diseases. In the United Kingdom,\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e the introduction of biologic therapies has contributed to a gradual decline in systemic corticosteroid use, and the growing range of treatment options has reduced reliance on repeated OCS prescriptions. These international comparisons highlight the disproportionate concentration of OCS use in specific diagnostic groups in Korea and underscore the frequent repetition of prescriptions in primary care, often without clear or guideline-based criteria.\u003c/p\u003e \u003cp\u003e In Korea, standardized guidelines for corticosteroid prescribing, adverse event prevention, and use of prophylactic co-medications are lacking. As a result, the decision to prescribe OCS is largely left to the individual judgment and experience of each physician. Particularly in outpatient-based specialties such as dermatology, internal medicine, and otolaryngology, corticosteroids are often perceived as a symbol of fast and effective treatment. This perception, in the absence of oversight or structural checks, contributes to excessive or prolonged corticosteroid prescribing. The resulting increase in adverse event risk including Cushing\u0026rsquo;s syndrome, osteoporosis, hyperglycemia, and immunosuppression is further exacerbated by limited patient education and lack of risk communication in clinical encounters.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan additionalcitationids=\"CR27 CR28 CR29\" citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e Most of the diagnoses analyzed in this study were for mild to moderate conditions, making careful consideration of the risk-benefit ratio of corticosteroid use all the more critical. Yet our findings suggest that such consideration is often absent in routine practice.\u003c/p\u003e \u003cp\u003eIn light of these observations, coordinated policy and educational interventions are urgently needed to ensure more appropriate corticosteroid prescribing. For diagnostic groups frequently associated with repeated OCS use (e.g., L20\u0026ndash;L30, L50\u0026ndash;L54, J30), clear clinical guidelines must be established, and real-time feedback systems should be implemented to detect patterns of overuse by institution type and specialty. In addition, a national-level monitoring system for long-term users should be built using claims data, and the dissemination of guidelines for prophylactic co-therapy and adverse event prevention must be expanded. Patients should be adequately informed about the benefits and risks of corticosteroid therapy and available treatment alternatives. Insurance policies should support improved access to safer or steroid-sparing alternatives such as biologics, topical agents, and immunomodulators.\u003c/p\u003e \u003cp\u003eWhile this study provides a robust analysis of long-term OCS prescribing using a nationwide cohort, it is not without limitations. First, because this is a claims-based study, we were unable to account for clinical details such as disease severity, symptom duration, diagnostic accuracy, or treatment intentfactors necessary for a precise assessment of prescribing appropriateness. Second, we could not assess medication adherence; thus, actual drug consumption may differ from prescription claims. Moreover, details such as dosage, duration, and refill intervals could not be sufficiently evaluated, limiting estimation of cumulative exposure. Third, although we analyzed prescription patterns by specialty, the NHIS-NSC database does not explicitly distinguish board-certified specialists from general practitioners in clinic-level institutions. While prescriptions from hospitals and general hospitals can generally be assumed to have been issued by board-certified specialists, in clinics, the specialty designation is based on the diagnostic code submitted for reimbursement, not on the physician's actual certification. As a result, some prescriptions classified under a particular specialty may have been issued by general practitioners rather than specialists, and we were unable to separate or exclude these cases. Finally, as the data analyzed span from 2003 to 2012, they do not reflect more recent developments such as updated clinical guidelines, expanded insurance coverage for biologics, or changing prescribing behavior in the last decade. Future studies should incorporate more recent data and consider linkage with clinical records to enable more nuanced analyses.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003e\u003cbr\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003eThe study was approved by the Institutional Review Board of the Kangwon National University Hospital (KNUH-2025-02-011) and was conducted in accordance with the principles of the Declaration of Helsinki. All participants provided written informed consent prior to their inclusion in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u0026nbsp;\u003c/strong\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data used in this study are available from the National Health Insurance Service-National Sample Cohort (NHIS-NSC), but restrictions apply to the availability of these data, which were used under license for the current study and so are not publicly available. Data are, however, available from the authors upon reasonable request and with permission of NHIS.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;The authors declare that they have no potential conflicts of interest to disclose.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eNo financial support was received for this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u003c/strong\u003e\u003cstrong\u003e’\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;contributions:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eYoung Woo Jo: data curation, formal analysis.\u003cbr\u003e\u0026nbsp;Jae-Woo Kwon: data curation, writing – review \u0026amp; editing.\u003cbr\u003e\u0026nbsp;Joon-hong Min: conceptualization, writing – original draft, writing – review \u0026amp; editing.\u003cbr\u003e\u0026nbsp;Young Her: conceptualization, writing – review \u0026amp; editing, funding acquisition.\u003cbr\u003e\u0026nbsp;All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments:\u0026nbsp;\u003c/strong\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eCHAST, F. Histoire de la corticoth\u0026eacute;rapie. \u003cem\u003eLa Revue de m\u0026eacute;decine interne\u003c/em\u003e, 2013; 34.5: 258-263. Doi:10.1016/j.revmed.2012.12.009.\u003c/li\u003e\n\u003cli\u003eYao TC, Huang YW, Chang SM, Tsai SY, Wu AC, Tsai HJ. Association between oral corticosteroid bursts and severe adverse events: a nationwide population‐based cohort study. \u003cem\u003eAnn Intern Med\u003c/em\u003e. 2020;172(12):723. Doi: 10.7326/M20043.\u003c/li\u003e\n\u003cli\u003eDVORIN, Evan L.; EBELL, Mark H. Short-term systemic corticosteroids: appropriate use in primary care. \u003cem\u003eAmerican Family Physician\u003c/em\u003e, 2020, 101.2: 89-94.\u003c/li\u003e\n\u003cli\u003eBRIOT, Karine, et al. 2014 update of recommendations on the prevention and treatment of glucocorticoid-induced osteoporosis. \u003cem\u003eJoint Bone Spine\u003c/em\u003e, 2014, 81.6: 493-501. Doi:10.1016/j.jbspin.2014.10.001.\u003c/li\u003e\n\u003cli\u003eLEKAMWASAM, S., et al. A framework for the development of guidelines for the management of glucocorticoid-induced osteoporosis. \u003cem\u003eOsteoporosis International\u003c/em\u003e, 2012, 23: 2257-2276. Doi: 10.1007/s00198-012-1958-1.\u003c/li\u003e\n\u003cli\u003eWALSH, L. J., et al. Use of oral corticosteroids in the community and the prevention of secondary osteoporosis: a cross sectional study. \u003cem\u003eBmj\u003c/em\u003e, 1996, 313.7053: 344-346. Doi:10.1136/bmj.313.7053.344.\u003c/li\u003e\n\u003cli\u003eCURTIS, Jeffrey R., et al. Population‐based assessment of adverse events associated with long‐term glucocorticoid use. \u003cem\u003eArthritis Care \u0026amp; Research\u003c/em\u003e, 2006, 55.3: 420-426. Doi:10.1002/art.21984 doi:10.1097/BOR.0b013e3282f51031.\u003c/li\u003e\n\u003cli\u003eB\u0026Eacute;NARD-LARIBI\u0026Egrave;RE, Anne, et al. Prevalence and prescription patterns of oral glucocorticoids in adults: a retrospective cross-sectional and cohort analysis in France. \u003cem\u003eBMJ open\u003c/em\u003e, 2017, 7.7: e015905. DOI:10.1136/bmjopen-2017-015905.\u003c/li\u003e\n\u003cli\u003eWALLACE, Beth I., et al. Prevalence and prescribing patterns of oral corticosteroids in the United States, Taiwan, and Denmark, 2009\u0026ndash;2018. \u003cem\u003eClinical and Translational Science\u003c/em\u003e, 2023, 16.12: 2565-2576. DOI: 10.1111/cts.13649.\u003c/li\u003e\n\u003cli\u003eBJORNSDOTTIR, Hulda Hrund, et al. Nationwide prevalence of glucocorticoid prescriptions over 17 years and osteoporosis prevention among long-term users. \u003cem\u003eSAGE Open Medicine\u003c/em\u003e, 2024, 12: 20503121241235056. DOI: 10.1177/20503121241235056.\u003c/li\u003e\n\u003cli\u003eOVERMAN, Robert A.; YEH, Jun‐Yen; DEAL, Chad L. Prevalence of oral glucocorticoid usage in the United States: a general population perspective. \u003cem\u003eArthritis care \u0026amp; research\u003c/em\u003e, 2013, 65.2: 294-298. Doi:10.1002/acr.21796.\u003c/li\u003e\n\u003cli\u003eSARNES, Evelyn, et al. Incidence and US costs of corticosteroid-associated adverse events: a systematic literature review. \u003cem\u003eClinical therapeutics\u003c/em\u003e, 2011, 33.10: 1413-1432. Doi:10.1016/j.clinthera.2011.09.009.\u003c/li\u003e\n\u003cli\u003eVAN STAA, Tjeerd-Pieter, et al. Use of oral corticosteroids in the United Kingdom. \u003cem\u003eQjm\u003c/em\u003e, 2000, 93.2: 105-111. Doi:10.1093/qjmed/93.2.105.\u003c/li\u003e\n\u003cli\u003eLUO, Xiaobo, et al. Systemic glucocorticoid prescriptions pattern and factors of inappropriate use in primary care institutions of Southwest China. \u003cem\u003eFrontiers in Public Health\u003c/em\u003e, 2022, 10: 952098. DOI 10.3389/fpubh.2022.952098.\u003c/li\u003e\n\u003cli\u003eLI, Xiaoyi, et al. Trends and Patterns of Systemic Glucocorticoid Prescription in Primary Care Institutions in Southwest China, from 2018 to 2021. \u003cem\u003eRisk Management and Healthcare Policy\u003c/em\u003e, 2023, 2849-2868. Doi: 10.2147/RMHP.S436747.\u003c/li\u003e\n\u003cli\u003eWALLACE, Beth I., et al. Patterns of glucocorticoid prescribing and provider-level variation in a commercially insured incident rheumatoid arthritis population: a retrospective cohort study. In: Seminars in arthritis and rheumatism. \u003cem\u003eWB Saunders\u003c/em\u003e, 2020. p. 228-236. Doi:10.1016/j.semarthrit.2019.09.002.\u003c/li\u003e\n\u003cli\u003eLIN, Kueiyu Joshua; DVORIN, Evan; KESSELHEIM, Aaron S. Prescribing systemic steroids for acute respiratory tract infections in United States outpatient settings: a nationwide population-based cohort study. \u003cem\u003ePlos Medicine\u003c/em\u003e, 2020, 17.3: e1003058. Doi:10.1371/journal.pmed.1003058.\u003c/li\u003e\n\u003cli\u003eMOWAD, Christen M., et al. Allergic contact dermatitis: patient management and education. \u003cem\u003eJournal of the American Academy of Dermatology\u003c/em\u003e, 2016, 74.6: 1043-1054. DOI: 10.1016/j.jaad.2015.02.1144.\u003c/li\u003e\n\u003cli\u003eBOURKE, J.; COULSON, I.; ENGLISH, J. Guidelines for the management of contact dermatitis: an update. \u003cem\u003eBritish Journal of Dermatology\u003c/em\u003e, 2009, 160.5: 946-954. DOI: 10.1111/j.1365-2133.2009.09106.x.\u003c/li\u003e\n\u003cli\u003eSUNG, Calvin T., et al. Systemic treatments for allergic contact dermatitis. \u003cem\u003eDermatitis\u003c/em\u003e, 2019, 30.1: 46-53. DOI: 10.1097/DER.0000000000000435.\u003c/li\u003e\n\u003cli\u003eZUBERBIER, Torsten, et al. The international EAACI/GA\u0026sup2;LEN/EuroGuiDerm/APAAACI guideline for the definition, classification, diagnosis, and management of urticaria. \u003cem\u003eAllergy\u003c/em\u003e, 2022, 77.3: 734-766. DOI: 10.1111/all.15090.\u003c/li\u003e\n\u003cli\u003eGRATTAN, C. E. H.; HUMPHREYS, F.; BRITISH ASSOCIATION OF DERMATOLOGISTS THERAPY GUIDELINES AND AUDIT SUBCOMMITTEE. Guidelines for evaluation and management of urticaria in adults and children. \u003cem\u003eBritish Journal of Dermatology\u003c/em\u003e, 2007, 157.6: 1116-1123. DOI: 10.1111/j.1365-2133.2007.08283.x.\u003c/li\u003e\n\u003cli\u003eZUBERBIER, Torsten. A summary of the new international EAACI/GA2LEN/EDF/WAO guidelines in urticaria. \u003cem\u003eWorld Allergy Organization Journal\u003c/em\u003e, 2012, 5: S1-S5. dOI: 10.1186/1939-4551-5-S1-S1.\u003c/li\u003e\n\u003cli\u003eLAUGESEN, Kristina, et al. Fifteen-year nationwide trends in systemic glucocorticoid drug use in Denmark. \u003cem\u003eEuropean Journal of Endocrinology\u003c/em\u003e, 2019, 181.3: 267-273. DOI: 10.1530/EJE-19-0305.\u003c/li\u003e\n\u003cli\u003eMENZIES-GOW, Andrew N., et al. Trends in systemic glucocorticoid utilization in the United Kingdom from 1990 to 2019: a population-based, serial cross-sectional analysis. \u003cem\u003ePragmatic and Observational Research\u003c/em\u003e, 2024, 53-64. Doi: 10.2147/POR.S442959.\u003c/li\u003e\n\u003cli\u003eSEIBEL, Markus J.; COOPER, Mark S.; ZHOU, Hong. Glucocorticoid-induced osteoporosis: mechanisms, management, and future perspectives. \u003cem\u003eThe lancet Diabetes \u0026amp; endocrinology\u003c/em\u003e, 2013, 1.1: 59-70.doi: 10.1016/S2213-8587(13)70045-7.\u003c/li\u003e\n\u003cli\u003eCOMPSTON, Juliet. Glucocorticoid-induced osteoporosis: an update. \u003cem\u003eEndocrine\u003c/em\u003e, 2018, 61.1: 7-16. Doi: 10.1007/s12020-018-1588-2.\u003c/li\u003e\n\u003cli\u003eHUMPHREY, Mary Beth, et al. 2022 American College of rheumatology guideline for the prevention and treatment of glucocorticoid‐induced osteoporosis. \u003cem\u003eArthritis \u0026amp; Rheumatology\u003c/em\u003e, 2023, 75.12: 2088-2102. doi: 10.1002/art.42646.\u003c/li\u003e\n\u003cli\u003eSULLIVAN, Patrick W., et al. Oral corticosteroid exposure and adverse effects in asthmatic patients. \u003cem\u003eJournal of Allergy and Clinical Immunology\u003c/em\u003e, 2018, 141.1: 110-116. e7. doi: 10.1016/j.jaci.2017.04.009.\u003c/li\u003e\n\u003cli\u003eFARDET, Laurence, et al. Corticosteroid-induced adverse events in adults: frequency, screening and prevention. \u003cem\u003eDrug safety\u003c/em\u003e, 2007, 30: 861-881. DOI: 10.2165/00002018-200730100-00005.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"oral corticosteroids, prescribing trends, Korea, health insurance claims, dermatology, primary care, guideline adherence, long-term use","lastPublishedDoi":"10.21203/rs.3.rs-6706699/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6706699/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjectives\u003c/h2\u003e \u003cp\u003eTo investigate long-term trends in oral corticosteroid (OCS) prescribing among the adult population in South Korea and to evaluate variations in prescribing patterns across diagnoses, healthcare institution types, and clinical specialties using a comprehensive national claims database.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis population-based retrospective cohort study was conducted using the National Health Insurance Service\u0026ndash;National Sample Cohort (NHIS-NSC), a nationally representative administrative claims database comprising approximately 1\u0026nbsp;million individuals in South Korea, sampled in 2002 and followed longitudinally. Adults aged 20 years or older who received at least one prescription for oral corticosteroids (OCS) between January 1, 2003, and December 31, 2012, were included in the analysis. Individuals with incomplete demographic or prescription data or those who received only inhaled or topical corticosteroids during the study period were excluded. The primary outcome was the annual prevalence of OCS users, defined as individuals with at least one OCS prescription per year. Users were further classified by frequency into short-term (1\u0026ndash;2 prescriptions/year), mid-term (3\u0026ndash;5 prescriptions/year), and long-term (\u0026ge;\u0026thinsp;6 prescriptions/year) groups. Secondary outcomes included the most frequently associated diagnostic categories and subcategories based on ICD-10 codes, and the distribution of OCS prescriptions by healthcare institution type (clinics, hospitals, general hospitals) and clinical specialty. Particular attention was given to prescribing trends in dermatologic (L20\u0026ndash;L30), urticarial (L50), and respiratory (J00\u0026ndash;J99) conditions, given their high contribution to overall corticosteroid use and relevance to guideline-based prescribing.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eBetween 2003 and 2012, the proportion of OCS users increased from 20.8\u0026ndash;29.2%, representing a 40% relative rise. While the proportion of short-term users declined, mid- and long-term use increased steadily. Dermatologic and respiratory conditions were the leading causes of OCS prescriptions, particularly allergic contact dermatitis (L23) and urticaria (L50), which showed long-term use in 14.5% and 5.9% of users, respectively. Prescribing rates for these conditions were disproportionately high in clinic settings compared to hospitals and general hospitals. Cross-national comparisons revealed that South Korea has higher rates of long-term OCS use and more frequent use in conditions where systemic corticosteroids are not routinely recommended, as compared to countries such as France, the United Kingdom, Denmark, and Iceland.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003e OCS prescribing in South Korea has increased significantly over the past decade, particularly in primary care for dermatologic and allergic conditions that are not strongly supported by current clinical guidelines. The high prevalence of long-term use in mild-to-moderate conditions and in clinic-based care highlights the need for more rigorous prescribing protocols, expanded education on adverse effects, and broader implementation of alternative treatment strategies. These findings underscore the importance of national-level interventions to promote evidence-based corticosteroid use and mitigate the risk of unnecessary exposure in the general population.\u003c/p\u003e","manuscriptTitle":"Oral Corticosteroid Prescription Trends in South Korea: A 10-Year Nationwide Population-Based Study Using the NHIS-NSC","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-19 09:57:15","doi":"10.21203/rs.3.rs-6706699/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c57d8fbb-2192-4390-bc50-b22702a446b9","owner":[],"postedDate":"June 19th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-07-15T07:09:28+00:00","versionOfRecord":[],"versionCreatedAt":"2025-06-19 09:57:15","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6706699","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6706699","identity":"rs-6706699","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}