In this video blog, Douglas DiRuggiero, PA-C summarizes his lecture, Corticosteroids: The Good, The Bad, The Ugly , on November 8, 2024, 5th Annual Elevate-Derm West Conference at the Westin Kierland Resort in Scottsdale, AZ.

In this video

DiRuggiero frames the history of dermatology as "BC and AC"—before and after corticosteroids—crediting the 1952 paper on topical steroids with changing the trajectory of the specialty. Steroids remain "extraordinarily beneficial," reducing inflammation and itch and remodeling skin, and translational data now show topicals modifying the same cytokine signatures our biologics target, just at a local surface level. But he cautions that dermatology tends to stay in its own silo, monitoring only the steroids it prescribes while patients also collect them from ERs, urgent care, and over the counter—unlike allergy colleagues who track cumulative steroid load across inhalers, nasal sprays, and oral tapers.

The risks of chronic topical use are, in his words, "a real eye opener": multiple studies, case reports, and case series link topical steroids alone—no oral tapers—to higher odds of fractures, HPA axis suppression, adrenal crisis, menstrual and endocrine abnormalities, plus the surface effects of striae, atrophy, and dyschromia. With effective, well-tolerated non-steroidal topicals now available—topical JAK inhibitors, PDE4 inhibitors, oral options, and improved TCIs—he argues it's not "throwing the baby out with the bathwater," but recognizing steroids as short-burst rescue and bridge therapy rather than something patients stay on for decades. The remaining hurdle, he notes, is access.

  • Topical corticosteroids are extraordinarily beneficial and modify local cytokine signatures much like biologics do systemically—but the "bad" isn't limited to oral steroids.
  • Cumulative steroid exposure adds up across sources dermatology often doesn't count: ER, urgent care, OTC, inhalers, nasal sprays, and oral tapers.
  • Chronic topical steroid use alone is associated in the literature with increased risk of fractures, HPA axis suppression, adrenal crisis, and endocrine and menstrual abnormalities.
  • Steroids remain appropriate as short-burst rescue and bridge therapy—patients don't need to stay on them for years, yet data show some using topicals for decades.
  • Non-steroidal topicals (JAK inhibitors, PDE4 inhibitors) and newer systemics now check the efficacy and tolerability boxes; the main barrier left is access.