Navigating Corticosteroid Stewardship in Dermatology, With Kristina Derrick, MD

As the number of topical nonsteroidal agents grows, corticosteroid stewardship in dermatology is shifting from whether to prescribe corticosteroids to how to prescribe them well. The emphasis now falls on the lowest effective potency, a defined treatment duration, and awareness of exposure from other specialties. However, cost, formulary restrictions, and prior authorization requirements often stand between clinicians and steroid-sparing care.

Kristina Derrick, MD, addressed these challenges in an interview with HCPLive at the National Corticosteroid Stewardship Summit in Washington, DC, on September 22, 2026, where she served as a panelist on a multispecialty panel on cumulative exposure. She discussed steroid-sparing alternatives, documentation across care settings, and what multispecialty stewardship could look like in 5 years.

Balancing Corticosteroid Benefits and Long-Term Risks in Dermatology

"Corticosteroids are a crucial part of dermatology. We cannot practice without them," Derrick said. Because most dermatologic disease presents on the skin, topical formulations allow clinicians to limit systemic exposure, she explained, and the guiding principle remains the least potent agent for the shortest duration.

Putting this principle into practice is the challenge, given the scale of topical corticosteroid use in the US. An analysis of Medicare Part D data found topical corticosteroid prescriptions rose from 7.7 million in 2011 to 10.6 million in 2015, a 37.0% increase. Over the same period, annual Medicare spending on these agents climbed 226.5%, from $237.6 million to $775.9 million, driven largely by rising generic prices.¹

Topical Nonsteroidal Alternatives and Barriers to Reducing Corticosteroid Use

Derrick pointed to a growing list of topical nonsteroidal options, including established agents such as tacrolimus, pimecrolimus, and crisaborole, as well as newer agents such as roflumilast, tapinarof, and ruxolitinib. For acute conditions such as drug-induced hypersensitivity syndromes, Derrick noted oral or injectable steroid-sparing options may also play a role.

Tolerability and patient preference drive real-world use, she said. A greasy vehicle a patient dislikes will go unused, and clinicians need a clear rationale for when to transition from a corticosteroid to a steroid-sparing agent.

Derrick described 2 daily barriers. Patients may not understand the potential adverse effects of corticosteroids, particularly high-potency agents, which can clear a rash within days and invite continuous use. The second barrier is access, driven by cost, insurance coverage, pharmacy benefit managers, and formularies.

Even older topical nonsteroidals frequently require prior authorization, adding staffing demands for dermatology practices as well as primary care, emergency, hospital, and other specialty settings. Published data reflect this burden: in a single-center US review, prior authorization was required for 8.1% of all dermatology prescriptions, and patients with approved requests were more likely to improve than those with denials (71.1% vs 58.0%; P = .013).²

Documenting Corticosteroid Exposure and Building Multispecialty Stewardship

Documenting cumulative exposure is difficult, Derrick said, because patients may not know their full corticosteroid history and medical records are often fragmented. Exposure can come from topical agents, eye drops, oral medications, and injections.

US prescribing patterns reflect this multispecialty picture. In an analysis of National Ambulatory Medical Care Survey data from 2006 to 2015, family and general physicians were more likely to prescribe systemic corticosteroids for atopic dermatitis, and pediatricians were less likely.³

Derrick’s advice is to control your own setting: limit refills and document the agents and durations used over the past year. This documentation also supports prior authorization requests for topical nonsteroidals, which typically require a record of failed agents over a defined period or documented intolerances. She noted patients with poorly controlled diabetes or prior adverse effects such as striae are poor candidates for continued topical corticosteroid use.

Within 5 years, Derrick said she hopes to see stewardship efforts involving dermatologists, endocrinologists, neurologists, ophthalmologists, and rheumatologists, building on existing rheumatology guidelines. She called for collaboration focused on reducing long-term higher-dose systemic use, improving access, raising patient awareness, and strengthening monitoring while preserving clinician and patient choice.

"Just because a medication requires monitoring and can have side effects does not mean it's not safe," Derrick said. She emphasized the importance of maintaining access, individualizing treatment decisions, and empowering patients with information.

References

1. Song H, Adamson A, Mostaghimi A. Medicare Part D payments for topical steroids: rising costs and potential savings. JAMA Dermatol. 2017;153(8):755-759. doi:10.1001/jamadermatol.2017.1130

2. Popatia S, Flood KS, Golbari NM, et al. Examining the prior authorization process, patient outcomes, and the impact of a pharmacy intervention: a single-center review. J Am Acad Dermatol. 2019;81(6):1308-1318. doi:10.1016/j.jaad.2019.05.024

3. Fleischer AB. Guideline-based medicine grading on the basis of the guidelines of care for ambulatory atopic dermatitis treatment in the United States. J Am Acad Dermatol. 2019;80(2):417-424. doi:10.1016/j.jaad.2018.09.026