Despite longstanding guidelines discouraging systemic corticosteroid (SCS) use in atopic dermatitis (AD), the practice remains widespread. A new position paper sets forth clear thresholds for use and urges clinicians and payers alike to rethink the role of SCSs in managing patients with AD.

Nearly 1 in 5 adolescent and adult patients with AD in the US receives SCSs, most often oral prednisone, according to population-based data. The paper’s authors argue that this prescribing pattern persists because clinical guidelines have never clearly defined what constitutes “short-term” use.

“This ambiguity leads to repeat bursts and delayed access to safer, steroid-sparing options, and exposes patients to harm,” one of the paper’s authors, Christopher Bunick, MD, PhD, associate professor of dermatology at Yale School of Medicine, New Haven, Connecticut, told Medscape Dermatology. “Our core standard is simple: if SCSs are used at all, use the shortest duration possible with a maximum of 3-4 weeks, then immediately transition to advanced systemic therapy.”

Harm Even With Brief Exposure

In the paper, published online on September 6 in the Journal of Investigative Dermatology, the authors emphasized that “any SCS use constitutes a systemic therapy trial warranting transition to advanced systemic therapy options.” They noted that even short SCS courses can have serious consequences.

• Short-term risks: A large US study found median outpatient courses lasted only 6 days but were linked to markedly increased 30-day risks for sepsis (incidence rate ratio [IRR], 5.30), venous thromboembolism (IRR, 3.33), and fracture (IRR, 1.87).
• Irreversible harms: Conditions such as avascular necrosis, cataracts, and adrenal suppression may develop within weeks.
• Broad toxicities: Systematic reviews associate SCS exposure with metabolic disorders, hypertension, osteoporosis, mood and behavioral changes, rebound flaring, and cardiovascular events.

“Even brief courses are not benign,” Bunick said. “Short bursts are linked to bone fractures, blood clots, metabolic disturbances, glucose and blood pressure elevations, and rebound flares. The cumulative harm from repeat bursts is substantial yet often overlooked in routine practice.” The assumption that short courses are safe “is unfounded,” the study authors wrote.

Defining ‘Short-Term’ and the Systemic Trial Concept

To close this gap, the paper aligns dermatology practice with the 2024 Endocrine Society guideline on glucocorticoid-induced adrenal insufficiency.

• Short-term use: < 3-4 weeks
• Long-term use: ≥ 3-4 weeks at supraphysiologic doses

The authors stressed that “any SCS exposure — including single injections, brief tapers (eg, ≤ 6 days), or cumulative use under 4 weeks — constitutes a systemic therapy trial.” Completion of such a trial, they argued, “inherently qualifies the patient for transition to advanced corticosteroid-sparing systemic therapies.”

Bunick explained: “Any SCS exposure, including a single injection or even a 6-day prednisone taper, should be considered a completed systemic trial that triggers this transition.”

Where Steroids Still Fit 

According to Bunick, SCSs still have a role in rare, severe cases requiring immediate relief: “Reserve SCS for severe, or incapacitating flares when immediate relief is necessary and as a bridge to other approved and guideline-endorsed AD advanced systemic therapy,” he told Medscape Medical News. “Keep total exposure to the shortest duration possible with a maximum of 3-4 weeks. Plan the exit from day 1 by arranging rapid transition to an advanced systemic therapy.”

Moving Patients Toward Advanced Therapies

The authors highlight JAK inhibitors as particularly well-suited to replace corticosteroids in flares: they have a rapid onset of action, sustained disease control, and reassuring long-term safety data. Injectable biologics remain foundational, though they may have slower onset and narrower targeting, they noted.

Conventional immunosuppressants such as cyclosporine and methotrexate are reserved for settings where advanced therapies are unavailable or contraindicated, according to the authors.

Consensus and Policy Implications 

In June 2025, a modified Delphi consensus among US dermatologists experienced in treating moderate-to-severe AD reached two agreements regarding the use of SCS, with strong support for the following standards:

• Short-term SCS use must be limited to a maximum of 3-4 weeks.
• Any SCS exposure qualifies as a systemic trial, warranting transition to advanced therapies.

The authors call on payers to adopt these thresholds, recognizing any SCS exposure as sufficient to justify escalation. Without standardized policies, they warn, patients face unnecessary harm and delays in accessing safer, guideline-concordant care. (The expert consensus is pending final publication.)

Practical Guidance

Bunick said clinicians should adopt a “treat-to-target mindset” when counseling patients. “Set clear referral triggers — frequent or severe flares, inability to step down without relapse, or any need for systemic control beyond optimized topicals,” he advised. “Rapid itch relief, high-level skin clearance, and sustained long-term efficacy without dependence on steroids should be the goal.”

The consensus initiative was supported by an unrestricted grant from AbbVie, which had no role in topic selection, panel formation, consensus development, data interpretation, or content creation.

Bunick reported serving as an investigator and/or consultant for AbbVie, Almirall, Alumis, Amgen, Apogee, Arcutis, Botanix, Connect BioPharma, Daiichi Sankyo, Dermavant, Eli Lilly, EPI Health/Novan, Galderma, Incyte, LEO Pharma, Novartis, Ortho Dermatologics, Palvella, Pfizer, Regeneron, Sanofi, Sun Pharma, Takeda, Timber, Teladoc, Triveni, and UCB. Other study authors disclosed similar relationships with industry. Full disclosures are available in the published article.

Jennifer Lightowler is a Connecticut-based dermatology physician assistant and freelance medical writer.