Rethinking the Topical Steroid Reflex
Buchi Neita, PA-C, and Shanna Miranti, PA-C, open this episode by naming a habit most clinicians share: reaching first for the topical corticosteroid because it works fast. Miranti describes it as grabbing "the fire hose, to put out that fire quickly" — effective, familiar, and the default many providers were trained to use. But both hosts argue that in an era of corticosteroid stewardship, that reflex deserves a second look.
Part of the hesitation around non-steroidal topicals, Miranti notes, comes from baggage left by older TCIs and first-generation PDE4 inhibitors that left patients and providers underwhelmed. Neita adds that many of us simply don't carry the same confidence in non-steroids that we do in steroids. The through-line of the episode is that newer, targeted agents now have strong, fast itch data—enough to justify a mindset shift.
Neita grounds the conversation in a real visit from that day: a patient with chronic facial eczema who said, "everything burns, everything stings." Neita handed her a sample in the room; the patient applied it immediately, felt relief within minutes, and asked for more. The hosts use this to make a practical point — in-office samples create instant buy-in and shared decision-making.
The JAK Inhibitors: Ruxolitinib and Delgocitinib
Ruxolitinib cream (available September 2021) is a topical JAK1 and JAK2 inhibitor. In atopic dermatitis, it is FDA-approved for ages 2 and up as a 1.5% cream for mild to moderate disease only, with a body surface area cap of 20%—about 20 of the patient’s palms using the rule of palms. Neita flags the limitations: it cannot be combined with biologics, oral JAK inhibitors, or other oral immunosuppressants, and it still carries the class black box warning. Where it shines, she says, is speed: the trials captured statistically significant itch reduction at 15 minutes after the first application, with twice-daily dosing.
Delgocitinib, the newest agent (July 2025), is a pan-JAK inhibitor that hits JAK1, 2, 3, and TYK2 and is currently FDA-approved for chronic hand eczema. Neita cites the Delta 1 and 2 trial data showing a four-point or greater itch reduction in 47% of drug-arm patients versus 23% on placebo, with relief seen as early as day one. She stresses sticking to the on-label hand eczema use for now, but highlights how meaningful rapid relief is at such a high-impact, painful, often fissuring site.
The PDE4 and the AhR Agonist: Roflumilast and Tapinarof
Roflumilast cream (July 2024) is an advanced topical PDE4 inhibitor — not the old-school version, as Miranti emphasizes. It comes in 0.05% for ages two to five and 0.15% for ages six and up, with once-daily dosing and no BSA limitation. Neita cites the INTEGUMENT trials: 33.6% of patients achieved itch improvement by week four versus 20.7% on placebo in one trial, and 30.2% versus 12.4% in the other, with many patients improving within 24 hours of the first application. Miranti adds a formulation pearl: it contains no propylene glycol, so patients who've burned and stung on other products tend to tolerate it well, and the moisturizing vehicle can double as barrier support for patients averse to layering.
Tapinarof 1% cream (approved for AD December 2024) is the outlier mechanistically — an aryl hydrocarbon receptor agonist that turns on a pathway to downregulate TH2 cytokines, restore the skin barrier, and reduce oxidative stress. Miranti reminds listeners that sometimes turning a process on, not off, helps restore homeostasis. It's approved for ages two and up, once daily, with no contraindications or limitations of use on label. She highlights the ADORING trials' inclusive recruitment: more than 80% pediatric patients across defined age bands and more than 50% skin of color, with VIGA responses more than three times placebo. Because the trials skewed pediatric, itch was measured at different, often later time points rather than at 15 minutes, but still reached statistical significance.
Measure the Itch, Every Visit
The hosts close on their biggest call-out: clinicians don't feel what patients feel. Even when the skin looks better, and the provider is impressed, Miranti urges capturing itch scores at every visit — have the MA ask anyone over 12 for a 0-to-10 score, and for younger kids ask parents about lost sleep, daytime distraction, and the subtle signs only a parent notices, like scratching behind the ear or not sitting still at dinner.
Both hosts note you don't have to abandon steroids entirely — sometimes starting a short course alongside an advanced topical helps secure patient buy-in. But the advice is clear: don't keep refilling the corticosteroid. All four agents beat vehicle on itch, and patients are really after rapid relief.