A 75-Year History That Changed Dermatology
For the first-ever live recording of SkinSync at the Elevate-Derm Summer Conference in Park City, Utah, Neita and Miranti sat down with Douglas DiRuggiero, PA-C, for a fast-paced conversation on topical corticosteroid stewardship. DiRuggiero, who admits history is his "jam," traced the long human habit of putting things on skin—from tar in Egyptian times, to mercury salts for syphilis in the 1700s, to topical salicylic acid in the 1800s.
The turning point, in his view, came in 1952 when Marion Sulzberger compounded a hydrocortisone acetate powder and published on it. DiRuggiero argues this did more than any single agent to change dermatology’s trajectory. Notably, just a year earlier the Nobel Prize had recognized corticosteroids' use, and within a year the systemic problems—Cushingoid features, osteoporosis, weight gain, diabetes—were already being published. Sulzberger hypothesized that going topical would avoid those internal effects. DiRuggiero isn't convinced that assumption held up.
The Systemic Signal We've Been Ignoring
DiRuggiero framed the issue as a balance between steroid phobia and thoughtful stewardship. Because topical corticosteroids have low molecular weight, he explained, they are readily absorbed systemically—a point he and his daughter Margaret detail in their free JCAD article, "Beyond Skin Deep." As he put it, the real question after 75 years isn't what we've learned, but what we'll actually choose to change about our prescribing habits.
He pointed to a 2006 JAAD paper describing 40 pediatric cases developing Cushingoid syndrome and adrenal insufficiency after topical steroid use—often for a year or less on small body surface area. More recent data connect topical steroids to osteoporotic fracture, elevated ocular pressure, and cataract formation—even when the steroid isn't applied near the eyes.
He cited a nationwide Taiwan study (2017–2020) of roughly 130,000 osteoporosis cases with matched controls, isolating patients with only topical steroid exposure and no documented systemic steroids, prescribed for three or more years. Low-potency use carried an odds ratio of 2.2, medium-potency 2.6, and high-potency 3.4 for osteoporosis. DiRuggiero underscored the takeaway: even continual low-potency use appears to have systemic effects. He also shared a case of an 11-year-old who presented with a broken wrist after three years of intermittent topical betamethasone—never longer than three weeks at a time, about three flares a year—whose DEXA scan showed frank osteoporosis at -2.7. The paper's authors even suggested baseline DEXA scans for children on mid- or high-potency topicals, though DiRuggiero was careful to say he wasn't personally advocating that on the podcast.
The Double-Edged Sword: What Drives Absorption
When Neita asked what increases systemic absorption—location, potency, or formulation—DiRuggiero said, "all of the above." Occlusion increases absorption, as does application in skin folds. Vehicle still matters, though he noted that with modern technology, ointments are no longer automatically more potent than lotions.
Age is a major factor he now weighs more heavily. Having seen nearly 250,000 dermatology patients and written more topical steroids than most, DiRuggiero said he's "looking at the man in the mirror." He now pauses over the kyphotic elderly woman with new-onset psoriasis he might treat without knowing her bone status, or the patient with a strong diabetes history whose glucose he could be nudging upward. He's building a system in his office to track cumulative topical steroid exposure—something he notes allergy colleagues already do well across inhaled, nasal, and oral forms, and something dermatology has largely resisted.
A Stewardship Mindset—and Better Options
The point, DiRuggiero stressed, isn't to throw steroids under the bus—the group had just heard a lecture on the importance of not fearing high-potency steroids in the genital area. It's risk versus benefit, applied with more consciousness. He wants colleagues to move past worrying only about cutaneous effects—atrophy, striae, rosacea, acne, hypertrichosis, dyschromia—and open up to the possibility that internal effects deserve a monitoring mindset too.
What makes that shift feasible now is the arsenal of non-steroidal topicals. DiRuggiero traced the path from tacrolimus (launched December 2000) and pimecrolimus, through the first PDE4 inhibitors, to newer-generation agents like topical ruxolitinib, tapinarof, and roflumilast that he says finally deliver the efficacy clinicians wanted alongside strong safety. Their advantage: fewer complex, body-site-specific "red light, green light" paradigms. Aside from certain body-surface-area parameters, many can be used anywhere-eyelids, groin, hair-bearing skin-without worrying about whether the patient is applying them correctly.
Neita and Miranti closed by urging clinicians to pause before defaulting to a topical steroid, and to treat patients the way they'd want to be treated. As DiRuggiero noted, TikTok-driven steroid phobia has actually opened the door—many parents don't want their children on steroids—giving clinicians a natural opening to reach for the non-steroidal options now available.