Adam Friedman, MD, FAAD

 should center on intentional, purposeful use and on tracking cumulative exposure across topical, inhaled, systemic, and injectable routes, according to Adam Friedman, MD, professor and chair of dermatology at George Washington University School of Medicine and Health Sciences. Friedman spoke with 

 at the National Corticosteroid Stewardship Summit in Washington, DC, on September 22, 2026. He discussed at-risk patients, practical monitoring tools, and the role of steroid-sparing therapies.

Corticosteroid Stewardship Is Not Steroid Avoidance, With Adam Friedman, MD

Corticosteroid Stewardship and Cumulative Exposure in Dermatology

Friedman framed toxicity as a function of concentration and exposure rather than of any single ingredient or therapeutic class. He stressed stewardship does not mean avoiding corticosteroids, which remain life-saving in many settings.

"Steroids will always be an essential part of our therapeutic armamentarium," he said.

The first step, according to Friedman, is following the labeled indication. Topical corticosteroids are intended for acute use, typically two to three weeks at a time depending on the label, followed by discontinuation.

Patients often receive corticosteroids from several clinicians, including inhaled, systemic, and injectable formulations prescribed outside dermatology. Friedman called for an easy way to track cumulative exposure across practitioners without adding administrative hassle. Awareness of existing corticosteroid use could prompt a dermatologist to select an alternative, though no established tracking system exists yet.

The concern extends across specialties. A 2026 review linked repeated short courses of systemic corticosteroids and long-term high-dose inhaled corticosteroids to adverse health effects, and it outlined prescriber-level and health system approaches to stewardship.¹

Patients with chronic inflammatory skin diseases face the greatest risk of unrecognized overexposure, Friedman said. These patients may receive large-quantity refills, such as a 1-lb jar, repeatedly over years without follow-up. Comorbid conditions such as connective tissue diseases may also require corticosteroids by other routes.

How to Monitor Corticosteroid Exposure During Routine Visits

Friedman identified thorough medication reconciliation as the first practical tool, noting clinical assistants can help keep the medication list current. An accurate medication record is also a component of meaningful use of an electronic medical record system, he said.

Clinicians should also look for, and ask about, signs of overuse. Cutaneous signs include skin lightening, thinning, fragility, and easy bruising, while signs of systemic absorption include plethora and central obesity.

Topical exposure alone can produce systemic toxicity. A 2025 case report described a patient with Hailey-Hailey disease who applied topical clobetasol or betamethasone for more than 10 years at doses up to 50 g/day.² She developed Cushingoid features, metabolic abnormalities, and hypothalamic-pituitary-adrenal axis suppression, followed by adrenal insufficiency after tapering.²

Friedman described several basic questions as potential early predictors of excess exposure, particularly with higher-dose systemic corticosteroids. These questions address sleep, hunger, mentation, and whether patients feel more easily angered or stressed.

Where Do Steroid-Sparing Therapies Fit in Corticosteroid Stewardship?

Friedman described steroid-sparing therapies as companions to corticosteroids rather than replacements. In his view, corticosteroids best serve acute and emergency use, while nonsteroidal agents are better suited as the maintenance workhorse in chronic inflammatory skin diseases.

Real-world data reflect this overlap. In a 2026 prospective study of 688 patients with inflammatory diseases receiving biologic or targeted synthetic disease-modifying antirheumatic drugs, 17.4% reported active glucocorticoid use, with a mean therapy duration of 112 days.³

Integrating these options into practice is not simple, however. Friedman said access "is probably our greatest hurdle. It is the most toxic thing in healthcare today." He added access is even more limited in certain patient populations and demographics, and new options should not obscure the continued need for corticosteroids when used correctly.

As one change dermatologists can make this month, Friedman recommended written handouts on best-use practices. Patients may retain about 10% of what clinicians tell them, he said. A handout can reinforce consistent use for a set duration, including once- or twice-weekly maintenance when alternatives are inaccessible.

Friedman recalled patients reporting daily use of topical triamcinolone as a moisturizer, which he attributed to poor retention rather than a lack of counseling.

Written materials have supported stewardship in other settings. At 2 urgent care centers, a program combining clinician education, patient pamphlets, and peer comparison feedback reduced glucocorticoid prescribing for acute respiratory infections from 20.4 to 8.8 per 100 eligible visits (

Gallub V, Rogers L, Kim B. Corticosteroid stewardship in asthma: from individual prescribers to system-level change. Curr Opin Pulm Med. 2026;32(3):203-209. doi:10.1097/MCP.0000000000001254

Iwamoto Y, Komi M, Fushimi Y, et al. A case of Hailey-Hailey disease accompanied by Cushing's syndrome and adrenal insufficiency due to long-term usage of topical steroids with review of literature. Endocr J. 2025;72(12):1369-1376. doi:10.1507/endocrj.EJ25-0164

Lopez V, Ritenour A, Harmon K. Pharmacist-led steroid stewardship in inflammatory diseases: evaluating glucocorticoid use and patient outcomes. Am J Health Syst Pharm. Published online September 10, 2026. doi:10.1093/ajhp/zxag276

Patel D, Dubois T, Weston V, et al. Urgent care stewardship for glucocorticoid overuse in acute respiratory infections. JAMA Netw Open. 2026;9(4):e269261. doi:10.1001/jamanetworkopen.2026.9261

Videos

Friedman outlines how dermatologists can track cumulative corticosteroid exposure, identify at-risk patients, and improve patient adherence with handouts.

Corticosteroid Stewardship in Dermatology is Not Steroid Avoidance, With Adam Friedman, MD

Adam Friedman, MD, FAAD, is professor and chair of 

 at George Washington University School of Medicine & Health Sciences in Washington, DC. At 

, he built his table discussion around a skill he says rarely factors into clinical training: saying no.¹ LEADderm was founded to address what organizers call dermatology's missing curriculum, covering skills such as mentorship, negotiation, and practice management.¹

Friedman used his own struggle with overcommitment as the starting point for a broader conversation about protecting limited time. Dermatology remains one of medicine's most selective specialties.² Friedman says competitive pressure trains applicants to say yes to nearly everything long before residency even begins, and the habit persists into academic and practice leadership roles.

Friedman's table centers on practical tactics: delaying an answer, and weighing whether an opportunity serves a career goal or personal energy. He also invites the requester into a shared decision about feasibility, an approach modeled on shared decision-making in patient care. He is also delivering an unrehearsed product theater at the meeting, delegating slides in real time with a co-presenter he had not previously met.

Friedman spoke in this Q&A discussion with 

 on-site at LEADderm 2026 in Newport Beach, California, about managing competing career demands.

: Can you walk us through the theme of your table here at LEADderm 2026?

When I was asked to come up with a discussion point around the table I am positioned at with attendees of LEADderm 2026, the first thing that came to mind was the power of yes, and even more so, the power of saying no, which, full disclosure, I am absolutely terrible at. Part of this is not just educating those sitting with me, but also an opportunity to self-reflect on how I manage my time and consider when I say yes and when I say no.

I'm a firm believer that early in your career, you should say yes to literally everything. You have no idea what door will open from saying yes to something that seems seemingly simple and how it can propel your career forward very quickly. The problem is you get very used to saying yes, and as you ascend the ranks, whether in academia or in practice, there is only a finite amount of time. So what you end up doing is not multitasking, which is not a real thing; you end up diluting your efforts. If you say yes to everything, you are giving less time to each thing and not doing anything with your full attention, and that's when you start dropping balls and undermining your reputation.

I think the biggest issue for any of us full-on yes responders is we're afraid if we say no, the opportunities disappear. I can tell you that is absolutely not true, unless you say no in the wrong way, which is also very possible. So I'll provide some tips I've learned over the years for how to say no in a way that doesn't disenfranchise others from inviting you again.

First, when you're asked to do something, do not shoot from the hip. You do not need an answer that second. You can say, let me circle back, let me look at my schedule, let me see what I can do. What that allows you to do is step back and ask: do I need to do this? Do I need to do this right now, for career gain, for personal gain, for personal life? And even if I don't need to do it, is it something I enjoy that will fill my cup so it invigorates me to take on the other soul-crushing things in my career?

The other thing I've started doing recently is applying shared decision-making, the same concept we use in patient care, to yes-or-no requests. You can go back to someone and say, I would really love to do this, but here are the things on my plate right now. What do you think? How do you think I can do this? Now you've passed it back to the person asking, and they may say, you're right, your plate is too full, you probably shouldn't be doing this. And now you didn't have to say the negative word, no. No doesn't have to be negative, but it's often perceived that way.

Taking time to make the decision, and including the person who asked you, takes the pressure and anxiety off of you. Now you've shared that load, and the perception will be that you thought about it critically, that you do want to do it, but you also want to give it your all. You'll be better respected for it.

: What do you feel is the biggest contributor to dermatologists taking on too much?

 I think it actually starts before our training, given dermatology is one of the most competitive fields. Not to scare anyone watching this, but last year's match rate was 46%. When I went into dermatology, it was roughly around 60%. I think because of that competitive nature, we are pushed to say yes to everything because we have to. If we want to get to the promised land, we have to do as many things as possible.

Even during residency, even though we have our MD and training licenses and are seeing patients, we still have this mindset that you've got to say yes to be part of the club, and it's really hard to learn how to turn that off. Even where I am in my career, sometimes I still think of myself in that position of trying to get into that cool club, so to speak, and it gives you that little bit of anxiety that pushes you to say yes even when you probably shouldn't.

So I think taking a step back to evaluate whether what you're being asked to do is really important right now is something we've never really done, because we've always said say yes, say yes, say yes. Now you actually can say not right now, or I'd love to but I'm just not available. I don't think anyone has talked about that along the pathway. It's always been, if you want this, you've got to suck it up and just say yes. As you go through your career that changes, but no one has given us the green flag for when that can happen.

: Are there other key points you highlight in your LEADderm presentation?

 One of the things I get to do at LEADderm 2026 is a product theater, which is no different from any conference. What's unique here is I'm doing it with a fellow faculty member I've never met before, and to keep it a little spicy, we didn't prep whatsoever. The LEADderm twist is we are going to delegate slides to each other in real time, just like you would in the real world, with some negotiation around whether my partner wants to take a slide or not, and vice versa.

That kind of unique spin on something we see at every conference really makes you think critically about how to deliver a presentation in partnership with someone else, because that mirrors what we do in negotiation regardless of where we are in our careers. We might negotiate in real time with a medical assistant, a practice manager, a resident, a fellow attending, or even the C-suite. There isn't all this prep time before a conference; it has to happen often in real time, and that's why I'm excited to present in that manner. Who knows what's going to happen? It'll be a huge success, of course, but we'll see. TBD.

Editor's Note: This transcript has been edited for grammar and clarity using artificial intelligence tools. Friedman had no relevant disclosures of note.

LEADderm. About LEADderm: a new kind of dermatology conference. leadderm.org. Accessed September 13, 2026. 

Articles

Adam Friedman framed leadership development around the under-taught competency of declining requests without damaging relationships. Early-career reflexive “yes” behaviors, reinforced by dermatology’s hypercompetitive pipeline, can become maladaptive as responsibilities scale and time becomes the limiting reagent. He emphasized avoiding impulsive commitments, pausing to assess strategic fit, bandwidth, and intrinsic reward, and using a shared decision-making style to externalize constraints with the requester. A live, unprepped co-presented product theater illustrated real-time delegation and negotiation dynamics.

Adam Friedman, MD, breaks down how to say no strategically in dermatology, from delaying an answer to sharing the decision with the requester.

Q&A: Why Saying 'No' is a Career Skill as a Clinician, with Adam Friedman, MD

Adam Friedman, MD, professor and chair of 

 at the George Washington University School of Medicine & Health Sciences in Washington, DC, traces dermatology's yes-first culture back to residency competition, before trainees ever start their careers.

, held August 29-30 in Newport Beach, California, Friedman said the pressure to say yes takes root long before a dermatologist has any leadership responsibilities to manage.

Competition, Burnout, and the Cost of Always Saying 'Yes' as a Clinician

Friedman said dermatology's match rate has tightened since he entered the field, citing a rate of about 46% last year compared with roughly 60% when he applied. He said the competitive pressure conditions applicants, and later residents, to say yes to nearly everything just to be seen as part of the field's inner circle.

The mindset does not stop once residency begins. Friedman said residents who already hold an MD and a training license, and who are already seeing patients, still operate as though they need to prove they belong.

"Even where I am in my career, sometimes I think of myself still in that position of trying to get to that cool club, so to speak. It gives you a little bit of anxiety that pushes you to say yes, even when you probably shouldn't," Friedman said.

Friedman said no one ever hands trainees a green flag for when it becomes acceptable to slow down, since the message throughout training is simply to keep saying yes. He said the alternative is not always an outright no, but sometimes telling someone he would love to help, just not right now.

Friedman previewed a LEADderm 2026 product theater session built around the same skill: he will present alongside a faculty member he has never met, delegating slides to each other in real time with no advance rehearsal. He said the format mirrors real-world negotiation dermatologists face with medical assistants, practice managers, residents, and even C-suite executives, all without the luxury of preparation time. Friedman said the outcome is not scripted, calling the unpredictability part of what makes the exercise a genuine test of adaptability rather than a rehearsed showcase.

LEADderm. About LEADderm: the missing curriculum. leadderm.org.

Friedman A. Tips on Saying 'No' as a Dermatology Leader, With Adam Friedman, MD. HCPLive. August 29, 2026. 

https://www.hcplive.com/view/tips-saying-no-as-dermatology-leader-adam-friedman-md

Adam Friedman, MD, traces dermatology's yes-first culture to residency competition, previewing an unrehearsed LEADderm 2026 negotiation exercise.

, held August 29-30 in Newport Beach, California, Adam Friedman, MD, FAAD, professor and chair of 

 at the George Washington University School of Medicine & Health Sciences in Washington, DC, led a table discussion on a skill he says gets little attention in clinical training: saying no.

 at the meeting, Friedman spoke on how he built the session around what he calls the power of yes, and even more so, the power of no. He said the topic doubles as a chance for self-reflection, since he considers himself terrible at saying no himself.

Tips on Saying 'No' as a Dermatology Leader, With Adam Friedman, MD

LEADderm, founded by Jennifer Soung, MD, was designed to address what organizers call dermatology's missing curriculum, skills such as mentorship, negotiation, and practice management rarely covered in clinical training. Friedman built his table discussion around his own struggle with overcommitment as its starting point, framing career growth as a series of choices about where limited time goes.

"The biggest issue for any of us full-on yes responders is we're afraid if we say no, the opportunities disappear. I can tell you that is absolutely not true, unless you say no in the wrong way, which is also very possible," Friedman said.

Friedman said early-career dermatologists should say yes to nearly everything, since even small opportunities can open unexpected doors. As responsibilities and leadership roles accumulate, he said the same habit dilutes a person's attention across too many commitments and starts undermining their reputation. He added this is not multitasking, since real multitasking does not exist, only a gradual erosion of focus.

His first tip for saying no: never answer on the spot. Friedman recommends buying time to weigh whether an opportunity serves a career or personal goal, and whether it would energize rather than drain. His second approach borrows from shared decision-making in patient care, looping the person who made the request back into the decision instead of delivering an outright no.

Friedman said the approach shifts the burden of refusing away from the dermatologist alone, since the person asking often reaches the same conclusion independently. He added the payoff is being better respected for giving fewer commitments full attention, rather than spreading effort across too many and showing the request was considered seriously rather than dismissed.

Conference Preview: 2026 LEADderm Conference in Newport Beach, CA. HCPLive. 

https://www.hcplive.com/view/conference-preview-2026-leadderm-conference-newport-beach-ca

Adam Friedman, MD, discusses saying no strategically as a career skill in a LEADderm 2026 table talk on managing opportunities.