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

Corticosteroid stewardship in dermatology 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 HCPLive 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 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 (P < .001).⁴

References

1. 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

2. 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

3. 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

4. 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