Understanding Short-Term Systemic Corticosteroids in Atopic Dermatitis Care

Balancing Relief and Risks in Atopic Dermatitis Treatment

Every clinician treating atopic dermatitis (AD) has encountered the same challenging dilemma. A patient walks in experiencing a severe flare-up, struggling to sleep, scratching incessantly, and desperately needing immediate relief.

While it is possible to enhance topical treatments and refine skin care regimens, the rapid effectiveness of systemic corticosteroids (SCS) is often tempting. A tapering dose of prednisone, a methylprednisolone dose pack, or an intramuscular injection can seem like the quickest way to restore normalcy.

However, this approach raises a significant concern. All too frequently, what begins as “quick relief” morphs into a cycle of “repeat relief.” One burst of SCS leads to another, and before long, a temporary solution evolves into an ongoing pattern of care. In the context of a chronic condition, this pattern is critical.

Addressing the AAD Guideline Gap

A recently published expert consensus addresses the role and associated risks of SCS in AD, crafted specifically with this real-world scenario in mind. It goes beyond reiterating the caution against routine SCS use; it provides much-needed operational guidance for clinicians and payers alike, delivering clear definitions and actionable next steps.

Historically, the American Academy of Dermatology (AAD) has advised against the routine use of SCS for managing AD. Most clinicians are aware of this recommendation.

However, a significant practical gap exists. The term “short-term” is frequently referenced within the broader AD context, but there has been no universally recognized duration threshold defining what constitutes “short-term” exposure to SCS in this condition. This ambiguity is problematic.

In clinical settings, vague terminology can be interpreted in various ways by different practitioners and systems. “Short-term” can extend from days to weeks or translate into repeated bursts spanning months. In payer policies, such ambiguity can lead to misinterpretation, viewing SCS exposure as a routine requirement rather than recognizing it as an indicator that a patient requires a steroid-sparing, sustainable systemic treatment plan.

The predictable consequences of these issues include therapeutic inertia, delays in accessing advanced therapies, and preventable cumulative harm. This is why the consensus is crucial; it fills a practical void by clearly defining “short-term,” specifying what qualifies as systemic exposure, and linking any exposure to a clinician-friendly escalation pathway.

The Prevalence and Risks of SCS Use in Atopic Dermatitis

The use of SCS in managing AD is relatively common in the United States. The consensus report highlights current real-world data indicating that nearly 20% of adolescents and adults with AD are treated with SCS. This occurs despite the availability of multiple advanced systemic therapies designed specifically for AD.

The safety concerns associated with SCS are not limited to long-term use. Clinicians frequently observe a clinical pattern characterized by rebound flares post-discontinuation, repeated rescue cycles, and cumulative toxicity. The existing evidence base substantiates these apprehensions.

Even short courses of SCS have been linked to serious adverse outcomes, while repeated bursts heighten the associated risks. The repercussions of SCS use can include infections, metabolic and cardiovascular complications, fractures, thromboembolic incidents, and adrenal suppression, particularly as exposure accumulates. Furthermore, in pediatric patients, chronic SCS use can negatively affect growth and stature due to the downregulation of growth hormone and its receptors in the growth plates of bones.

From Position Paper to Expert Consensus

A robust position paper published in the Journal of Investigative Dermatology has illuminated the ongoing issue of SCS use in AD, emphasizing how policy and access dynamics can inadvertently normalize steroid cycling. The new expert consensus serves as formal, practical guidance that operationalizes this crucial message.

Most importantly, this consensus is the first of its kind to define the duration of SCS exposure in the context of AD.

Defining Short-Term Exposure

The consensus establishes a straightforward threshold: Short-term SCS exposure is defined as less than 4 weeks.

Long-term exposure is categorized as 4 weeks or more. Additionally, it clarifies an essential aspect of continuity of care: intramuscular corticosteroid injections are counted as systemic therapy. Therefore, if a patient receives an injection at another facility, it constitutes systemic exposure in the framework of AD management.

This clarification provides clinicians with language that is straightforward to document, easy to communicate, and challenging to misinterpret.

Key Assertion: Treating Any SCS Exposure as a Systemic Therapy Trial

The most significant shift in practice is captured in a simple assertion: Any exposure to SCS, regardless of its duration, should be regarded as a trial of systemic therapy that necessitates transitioning to advanced systemic treatments, including injectable biologics and oral Janus kinase inhibitors.

This perspective reframes the role of SCS from being a recurring bridge to a clear indicator that the disease has progressed to a stage where a steroid-sparing systemic strategy is warranted.

Oral JAK Inhibitors as a Transition Option

When SCS are utilized in AD, it is usually due to the clinician’s need for rapid results. Patients demand quick relief from itching, swift control of inflammation, and a definitive plan that does not involve repeated steroid use.

Oral JAK inhibitors can fulfill this clinical requirement in many instances. Designed for systematic control of AD, they offer a rapid onset that aligns with the immediate needs clinicians aim to address when resorting to SCS.

FDA-approved oral JAK inhibitors, which are endorsed by AAD guidelines, now benefit from an extensive safety experience documented through long-term clinical trials extending up to 6 years. This provides a solid evidence base supporting the use of targeted, steroid-sparing systemic approaches over repeated rescue bursts. Alternatively, there are four FDA-approved biologic therapies available that also serve as effective options for treating AD without resorting to SCS cycling. While some patients may experience quicker relief from itching and skin issues with oral JAK inhibitors, biologics may require a longer duration to achieve optimal control of AD due to their mechanisms of action, albeit with less frequent dosing for those who prefer injectable methods.

Guidelines for Transitioning from SCS to Advanced Systemic Therapy

The consensus offers practical guidance on transitioning that clinicians can implement without introducing additional complexity. If SCS exposure lasts fewer than 3 weeks, tapering is generally unnecessary.

The recommendation is to complete the short course and promptly initiate the advanced systemic therapy (whether an oral JAK inhibitor or biologic) thereafter to avert rebound flares and maintain control. For SCS exposure of 3 weeks or longer at doses exceeding physiological replacement, advanced systemic therapy should be initiated during the tapering phase, followed by a gradual reduction of corticosteroids.

The clinical objective is clear: avoid abrupt discontinuation that could trigger a flare and prevent prolonged exposure that leads to cumulative harm.

Utilizing the Consensus for Coverage Support

AD treatment labels typically include language indicating their use in patients whose disease is not adequately managed with other systemic therapies (such as oral JAK inhibitors) or topical therapies (like biologics), or when those therapies are deemed inadvisable.

In the context of AD, SCS clearly fall into the category of “inadvisable” systemic therapy for routine management due to their risk profile, lack of durable disease control, and widely acknowledged concerns about repeated rescue bursts.

This consensus equips clinicians with a clear, defensible framework for documenting this rationale. Clinicians can use a straightforward template in their notes and prior authorization requests: “Patient has moderate to severe AD requiring systemic corticosteroid rescue. Expert consensus guidance defines short-term systemic corticosteroid exposure in AD as less than 4 weeks and emphasizes clinically relevant risks even with short courses. According to the consensus, any systemic corticosteroid exposure constitutes a systemic therapy trial, supporting the transition to advanced systemic therapy, which is appropriate for achieving rapid and sustained control while minimizing repeated systemic corticosteroid exposure.”

Conclusion for Clinicians

Systemic corticosteroids were intended to serve as a bridge in treatment.

However, they often become the endpoint. This consensus provides clinicians with an exit strategy by defining “short-term” exposure, reclassifying any SCS usage in AD as a systemic therapy trial, and advocating for a timely transition to advanced systemic therapies when rapid and long-term control is necessary.

Sources

1. Burshtein J, Bunick CG, Vleugels RA, et al. The role and risks of systemic corticosteroids in atopic dermatitis: an expert consensus. doi:10.1007/s00403-025-04502-6
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