What Stewardship Actually Means Chair-Side
PA Buchi Neita and PA Shanna Miranti open by asking their guest, Dr. Peter Lio, to define corticosteroid stewardship in pediatric patients. Lio suggests that most good clinicians already practice it intuitively: topical steroids remain a first-line tool for many inflammatory problems, but too much potency, too much volume, or too much duration leads to the side effects the field already knows about — plus some newer ones still being learned.
His central framing is that steroids are best used in 'rescue mode.' They can be used safely for a bit, but with frequent breaks. Lio's practical trigger to change course: if a patient needs more and more, or relapses the moment they stop, it's time to switch to something else.
The Parent Conversation and the Fear of Steroids
Lio notes his patient population sometimes skews toward families who don't want any medicines, and the most common misconception he encounters is that any steroid exposure is dangerous. He counters that the vast majority of patients can use steroids very safely — which is exactly why they persist as first-line therapy.
His reassurance script is memorable: 'I don't want you to worry about them; I'm going to worry about them.' He offers a two-part plan — a rescue medicine (usually the steroid) and a non-steroidal for when things improve — and follows up in four to six weeks. At that visit, he asks how often the steroid was needed; if it's more than half the time, he makes a change.
For families scared by topical steroid withdrawal (TSW) online or by a prior provider, Lio adapts. He underscores that it's almost impossible to get into trouble over a single month with close follow-up. And for those who simply can't bear the risk, he now has an answer he couldn't offer ten years ago: go steroid-free from the start with a non-steroidal option.
Choosing Potency, Vehicle, and Duration
Lio starts with the simplest formulation he can, and his go-to is ointment — fewer ingredients, more tolerable, and a bit of occlusive, barrier effect that helps push medicine in. If a patient won't use an ointment, he switches to a cream. For atopic dermatitis, he generally avoids lotions, foams, and gels.
On potency, he pushes back on the common 'two-to-three-week' advice, calling it under-treatment. His marker of the right potency is a steroid that gets the patient better in three to five days, then a break. He warns about the paradox of a too-mild agent used daily and never stopped — that isn't safe either. For little kids, he favors fluticasone ointment and mometasone (strong, but he can say a couple of days then break), while steering away from betamethasone or clobetasol as generally too strong in this group.
As Miranti summarizes, this flips the usual paradigm: instead of two weeks of therapy, it's hitting it hard for a few days and then tapering down.
Real Adverse Events and the TSW Uptick
Lio has seen a fair amount of dyspigmentation, skin thinning and atrophy, and striae (often in the groin or axillary areas). He's even seen babies using so much steroid that they were failing to thrive, likely absorbing enough corticosteroid to matter. He also flags that in some countries these agents are sold without a prescription, driving overuse.
The biggest change over the past decade, he says, has been a large uptick in TSW, including in pediatric patients — the subject of a review article he wrote. He describes the suffering he's seen in some of these patients as horrible, which is what motivates his stewardship approach.
The Non-Steroidal Toolbox
Lio says he loves having all of these options — 'every pot has a lid.' He's grateful for tacrolimus and pimecrolimus (the TCIs), though he notes they remain oddly expensive despite being generic and lacking coupons. Crisaborole, a PDE4, can sting or burn; his hard-won pearl is not to apply it to very acute eczema. Instead, he cools things down with a steroid for three to five days, then layers crisaborole on healed skin to maintain improvement.
Among the newer agents, he describes topical ruxolitinib (a JAK inhibitor) as able to punch at the weight of steroids, though it carries a boxed warning families need to hear about. He praises topical roflumilast (a PDE4 inhibitor) for its once-daily use, elegant base, and lack of propylene glycol, calling it a great, well-tolerated place to start—its only downside is that it can be too mild for some patients. Tapinarof, the first topical aryl hydrocarbon receptor agonist, is once-daily and holds promise for remittive effect, but he's seen some folliculitis and irritation in atopic dermatitis patients. He also mentions delgocitinib, a different JAK inhibitor recently approved for chronic hand eczema in a cream base without propylene glycol — useful for patients with propylene glycol contact allergy who can't use the ruxolitinib formulation.
On younger-age indications: crisaborole ointment is approved from three months of age and applied BID — currently the only topical FDA-approved under age two. Roflumilast, tapinarof, and ruxolitinib now have strengths indicated for ages two and up. Lio's dream, now realized, is a two-non-steroid plan: rescue with topical ruxolitinib and maintain with topical roflumilast for patients who want to avoid steroids entirely — with ruxolitinib's chronic non-continuous indication fitting that role.
The APP's Role and the End Goal
Asked how PAs and NPs can strengthen stewardship, Lio's answer is simple: address it head-on. Tell families steroids are powerful and transformative — he recalls his late teacher Dr. Sam Michelle describing pre-steroid 1960s dermatology as 'lots of petrolatum' — but commit to watching them closely and switching if they aren't working or aren't earning breaks. Beyond topicals, clinicians have phototherapy, biologics, and oral JAK inhibitors for patients heading down a troubled path.
His parting message: steroids aren't going anywhere as first-line therapy, and banning them would be a catastrophe for the many who use them safely. But if clinicians are good stewards, he believes TSW can become a historical footnote — 'remember when we had that weird epidemic of it, but then once we got back to following those guidelines of being careful, we never saw it again.'