Definition Established for Systemic Corticosteroid Use Duration in Atopic Dermatitis

A new position paper from the Journal of Investigative Dermatology has established an evidence-based definition for systemic corticosteroid (SCS) duration in patients with atopic dermatitis, highlighting that any SCS utilization constitutes a systemic therapy trial warranting transition to advanced systemics.1

This paper was authored by such investigators as Christopher G. Bunick, MD, PhD, associate professor of dermatology at the Yale University School of Medicine. Bunick et al noted that prior to this paper’s publication, SCSs have remained prevalent in the management of atopic dermatitis.

This, they highlighted, has occurred despite guideline recommendations urging against routine or prolonged implementation. The investigators added, however, that such persistence is the result of the lack of a clearly defined, evidence-based threshold for "short-term" utilization.2

“A precise, evidence-informed limit on SCS use is needed to protect patients and align clinical practice with modern treatment standards,” Bunick and coauthors wrote.1 “This position paper establishes an evidence-based definition for SCS duration in AD, emphasizing that any SCS use constitutes a systemic therapy trial warranting transition to advanced systemic therapy options.”

Position Paper Conclusions

The investigative team highlighted that close to 1 in 5 adolescents and adults in the US with atopic dermatitis receive SCSs, despite strong guidance urging against it. Among those prescribed, the team noted that 67.7% have short-term exposure (≥1 to <30 days), 8.5% are in the medium range (>30 to ≤90 days), and 23.9% are treated for more than 90 days. About 80% of SCS use is oral; the rest involves intramuscular injections.

This continued reliance is prevalent despite a variety of US Food and Drug Administration (FDA)-approved systemic options available, Bunick and collagues noted, such as biologics and Janus Kinase (JAK) inhibitors. Such options are recommended by the American Academy of Dermatology (AAD) as safer and more efficacious alternatives.

One driver is the lack of a clear definition of “short-term” use in guidelines related to management, the investigative team expressed. Without a threshold, they noted that payer policies commonly lead to prolonged SCS exposure prior to the granting of access to advanced treatment options. The team added that clinicians may then reflexively prescribe corticosteroids for flares. Such practices, they noted, can delay transitions in treatment while exposing patients to risk.

Bunick et al highlighted that such risks are substantial, noting that SCS toxicity is dose- and duration-dependent. The authors further suggest that complications can occur quickly. They also cited evidence suggesting even short bursts leading to metabolic disruption, infections, and even adrenal suppression. The assumption that “short-term” equals “safe” is unfounded, Bunick and coauthors wrote.

To close this gap, experts have suggested adopting the 2024 Endocrine Society’s evidence-based framework. The framework defines short-term therapy as less than 3–4 weeks and long-term as any utilization past that with doses exceeding physiologic replacement. By this standard, the investigators noted that any exposure should count as a systemic therapy trial and qualify a patient for corticosteroid-sparing treatments. Such an approach does not endorse routine SCS utilization but instead sets a biologically grounded limit.

Notably, while corticosteroids have been approved for severe, unresponsive atopic dermatitis, Bunick and colleagues suggest that they were never assessed within modern randomized controlled trials for this skin disease. In contrast, advanced therapies, including JAK inhibitors and biologic options, have been rigorously tested, with clear efficacy and safety profiles having been observed.

Oral JAK inhibitors may also provide a compelling next step, the team highlighted. Like corticosteroids, oral JAKs act rapidly, with itch relief and skin improvement taking place following flares. But unlike corticosteroids, oral JAK inhibitors also deliver long-term disease control, with safety data extending up to five years. Approved for both adolescents and adults, JAK inhibitors are now strongly recommended by multiple guidelines as corticosteroid-sparing and disease-modifying options.

Biologic agents, such as interleukin (IL)-4 receptor antagonists and IL-13 inhibitors, have also transformed systemic care for atopic dermatitis. Bunick et al highlighted that they can deliver durable improvements but may have slower onset and can fall short during acute flares or in difficult body areas. JAK inhibitors, with their dual rapid and sustained effects, were noted as often filling such a gap.

Barriers remain, the investigative team highlighted. Insurance restrictions, prior authorization requirements, and step therapy policies continue to delay access to advanced therapies. Traditional systemic immunosuppressants—cyclosporine, methotrexate, azathioprine, mycophenolate—can be used when biologics or JAK inhibitors are unavailable, but their off-label status, weaker evidence, and higher toxicity make them less favorable choices.

Overall, Bunick and colleagues' insights present a shift in the management of this inflammatory skin disease: minimizing corticosteroid implementation, adopting clear definitions to limit any potential harms, and prioritizing advanced therapies that align with both safety data and outcomes among patients with atopic dermatitis.

“In alignment with this emerging consensus, we urge clinicians to integrate these definitions and transition principles into clinical practice,” the investigators concluded.1 “Given the current absence of standardized SCS duration limits in payer policies, health plans must adopt the evidence-based SCS use duration thresholds as a foundational safety standard and formally recognize any SCS exposure as a qualifying systemic trial and ensure timely access to advanced systemic therapies after any SCS trial.”

References

1. Burshtein J, Bunick CG, Lebwohl M, et al. Systemic Corticosteroid Use in Atopic Dermatitis: A Position Paper to Inform Safer Clinical Practice and Policy. J Invest Dermatol. 2025 Sep 6:S0022-202X(25)02338-3. doi: 10.1016/j.jid.2025.08.002. Epub ahead of print. PMID: 40914897.

2. Bunick CG, 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. J of Skin. 2024;8(6):s448. doi:10.25251/skin.8.supp.448.