Duration of Use Guidance Published for Systemic Corticosteroids in Atopic Dermatitis Treatment

A new position paper published in the Journal of Investigative Dermatology addresses a persistent and concerning gap in atopic dermatitis (AD) management: the continued widespread use of systemic corticosteroids (SCS) despite clear clinical guidelines discouraging their routine application.¹

Mark Lebwohl, MD

Courtesy of Icahn School of Medicine, Mount Sinai

The paper, authored by leading dermatologists led by Mark Lebwohl, MD, dean for clinical therapeutics and chairman emeritus of the Kimberly and Eric J. Waldman Department of Dermatology at the Icahn School of Medicine at Mount Sinai, in New York, establishes critical evidence-based standards for SCS duration and transitions to safer systemic therapies, with authors emphasizing that “any SCS use constitutes a systemic therapy trial warranting transition to advanced systemic therapy options.”¹

The Scope of the Problem

According to the paper, nearly 1 in 5 adolescents (aged 12 years and older) and adults with AD in the United States receives systemic corticosteroid treatment, with oral corticosteroids accounting for approximately 80% of this usage.² Among those with SCS prescriptions, nearly one-third receive medium-to-long-term exposure extending beyond 30 days, directly contradicting established clinical guidelines.

This widespread use persists despite the availability of FDA-approved advanced systemic therapies, including biologics and Janus kinase (JAK) inhibitors, which are strongly recommended by guidelines from the American Academy of Dermatology. The fundamental issue, according to Lebwohl and colleagues: current clinical guidelines fail to define what constitutes "short-term" use, creating ambiguity that perpetuates harmful prescribing patterns and restrictive payer policies, including requirements for prolonged step therapy.¹

Evidence of Harm Even with Brief Exposure

Bunick, Lebwohl, et al provide a compelling analysis of risks associated with even brief corticosteroid exposure. The authors cite a large US population-based study³ revealing that short-term outpatient SCS prescriptions, with a median duration of just 6 days, were associated with significantly increased 30-day risks of sepsis, venous thromboembolism, and fractures. These risks persisted even at relatively low doses (less than 20 mg/day prednisone equivalent).³

The authors emphasize that "the assumption of safety with short-term use is unfounded," noting that moderate-dose oral prednisone courses of 2-3 weeks commonly used in dermatology have been linked to serious complications including avascular necrosis and adrenal suppression. The European Society of Endocrinology and US Endocrine Society guidelines warn that adrenal suppression risk begins within 3-4 weeks of daily SCS initiation.⁴

The “broad spectrum of toxicities” associated with prolonged SCS use confirmed by systematic reviews includes increased risk of hypertension, diabetes, osteoporosis, thrombosis, and rebound flares of AD. The position paper cites research that has found progressively increased risk of myocardial infarction, particularly beyond 90 days.⁵

Specific Parameters

The authors propose a fundamental shift in how clinicians and payers approach SCS use in AD. Drawing from the 2024 Endocrine Society guidelines, they establish specific parameters: short-term use is defined as treatment lasting less than 3-4 weeks, while any treatment exceeding this threshold with doses greater than physiologic replacement constitutes long-term use with its associated heightened risks.¹

Most significantly, they introduced the "systemic therapy trial" concept. The authors state unequivocally:

"Any SCS exposure, including single injections, brief tapers (eg, 6 days or less), or cumulative use under 4 weeks—constitutes a systemic therapy trial."

This framework means that completion of any SCS trial immediately qualifies patients for transition to advanced corticosteroid-sparing systemic therapies. Bunick and colleagues are emphatic that the recommended framework “does not endorse short-term SCS but establishes a strict, biologically grounded limit to prevent repetitive cycling and accelerate patient access to systemic therapies that provide effective long-term control.”¹

Transitioning to Evidence-Based Alternatives

The paper strongly advocates for oral JAK inhibitors and injectable biologic agents as well-suited and evidence-based next-step treatments following short-term SCS trials. Unlike SCSs, these agents have received regulatory approval based on rigorous randomized controlled trials with defined safety and efficacy endpoints. Further, they are now the foundation of “guideline-based corticosteroid-sparing strategies for patients who require systemic treatment,” the authors wrote.¹

The advanced oral and injectable medications offer both rapid onset of action, which mirrors the rationale for oral corticosteroid use in flares, and trial-confirmed sustained long-term efficacy. Lebwohl et al point out that their approval for both adolescents and adults allows effective treatment across a broad age spectrum, and in stark contrast with SCSs, their long-term safety profile has been established in trials with up to 5 years of exposure.

Injectable biologics, including IL-4 receptor antagonists and IL-13 inhibitors, are also important options, though the authors note their slower onset of action may limit effectiveness when prompt disease control is required. The JAK inhibitors with both rapid and sustained effects, are often the choice in these situations, they added.

The position paper draws support from a modified Delphi consensus panel of US dermatologists with expertise in moderate-to-severe AD, convened in June 2025. Although the expert consensus is pending final publication, the panel convened strongly endorsed 2 critical practice standards:

1. Short-term SCS use must be strictly limited to a maximum duration of 3-4 weeks, aligning with Endocrine Society risk thresholds
2. Any SCS exposure constitutes a systemic therapy trial, immediately qualifying patients for transition to advanced systemic therapies

Implications for Practice and Policy

The authors argue that implementing these evidence-based standards will replace arbitrary practices with a transparent, risk-informed framework. They call for health plans to adopt these duration thresholds as foundational safety standards and to formally recognize any SCS exposure as a qualifying systemic trial.

This approach addresses current insurance barriers where step therapy requirements inappropriately delay access to safer alternatives. By establishing that even a single corticosteroid injection or brief taper represents a failed trial of conventional therapy, the framework provides clear justification for advanced systemic therapy authorization.

Moving Forward

The position paper represents more than academic discourse—it provides practical tools for clinicians navigating the complex landscape of AD management while advocating for patient safety. As the authors note, "establishing a clear threshold for short-term use is clinically warranted to minimize patient harm."

For healthcare providers, this framework may potentially improve patient outcomes while reducing long-term complications. For payers, it provides clear, evidence-based criteria for therapy approvals that prioritize patient safety over cost considerations.

The paper ultimately calls for a fundamental shift in how the medical community approaches systemic treatment in AD, from reflexive corticosteroid use to evidence-based, guideline-concordant care that prioritizes both efficacy and long-term patient safety.

References

1. Burshtein J, Bunick CB, Vleugels RA, et al. Systemic corticosteroid use in atopic dermatitis: a position paper to inform safer clinical practice and policy. J Investigative Dermatol. Published online September 6, 2025. doi:10.1016/j.jid.2025.08.002

2. Bunick CB, Vleugels RA, Lebwohl, M, et al. Utilization and duration of systemic corticosteroid exposure in atopic dermatitis patients after the introduction of advanced therapies: a population-based study from the United States. Skin. 2024;8(6). doi:10.25251/skin.8.supp.448

3. Waljee AK, Rogers MA, Lin P, Singal AG, Stein JD, Marks RM, et al. Short term use of oral corticosteroids and related harms among adults in the United States: population-based cohort study. BMJ. 2017;357:j1415. doi: 10.1136/bmj.j1415

4. Beuschlein F, Else T, Bancos I, et al. European Society of Endocrinology and Endocrine Society Joint Clinical Guideline: diagnosis and therapy of glucocorticoid-induced adrenal insufficiency. Eur J Endocrinol 2024;190:G25-51. doi:10.1093/ejendo/lvae029.

5. Lebwohl M, Bunick C, Vleugels RA, et al. Cardiovascular and thrombosis risks of prolonged versus short-term use of oral corticosteroids among atopic dermatitis patients in the United States. Society for Investigative Dermatology Annual Meeting; May 7—10. San Diego, CA.