Risks and Adverse Effects of Long-Term Topical Corticosteroid Use

The speaker discusses the challenging scenario of treating patients who experience topical steroid withdrawal (TSW). Despite patients’ resistance to using more steroids—since they feel steroids are the cause of the issue—steroids are often necessary for gradually tapering the patient off. This situation is analogous to how endocrinologists handle adrenal insufficiency, where steroids are slowly reintroduced in a controlled manner. Long-term steroid use can lead to adverse effects such as acne, skin fragility, increased risk of infections like herpes, and more, which makes it essential for clinicians to practice responsible stewardship of these medications.

Next, the speaker shifts to newer nonsteroidal topical treatments for atopic dermatitis. These are FDA-approved alternatives that are becoming more commonly used. However, due to the lack of head-to-head studies, comparative effectiveness remains difficult to assess. Some of the notable treatments include crisaborole ointment, a phosphodiesterase inhibitor that is greasy and applied twice daily; roflumilast cream, a more elegant formulation with a vehicle designed to avoid irritation, applied once daily; and ruxolitinib topical, a Janus kinas inhibitor that comes with boxed warnings and is expensive, priced higher than some biologics or chemotherapy treatments. This makes it less accessible for most patients.

Tapinarof, another newer medication, works through aryl hydrocarbon receptor modulation and is approved for use in both mild and severe cases of atopic dermatitis. It’s available for patients aged as young as 2 years and has been a welcome addition to the treatment landscape. Despite the availability of these newer treatments, challenges remain with access, especially given the high costs of some options like ruxolitinib. The speaker stresses the importance of understanding and considering these nonsteroidal therapies as part of a comprehensive approach to treating atopic dermatitis.