Risk of Systemic Adverse Effects From Topical and Oral Corticosteroids: Time for a Paradigm Shift?

Abstract

Introduction: Corticosteroids (CS) are commonly prescribed by dermatology practitioners and clinicians in other specialties to manage inflammatory conditions. In 2023 alone, >15 million prescriptions for topical CS (any indication) were filled in the US. Cutaneous adverse events (AEs) have traditionally been the primary acknowledged AE attributed to topical CS use, but growing evidence suggests that absorption may lead to a variety of systemic AEs. To better understand the data on CS and the risks associated with their use, a targeted literature search was performed.

Methods: PubMed was searched from 2010–2025 for English-language studies and meta-analyses using a variety of MeSH terms, including corticosteroids, topical, glucocorticoids, guidelines, and certain specific AEs; reference lists of selected articles were also searched.

Results: Topical CS: Cohort and case-control studies have shown that prolonged use of high-potency topical CS poses a modest, but clinically meaningful systemic risk of type 2 diabetes, osteoporosis/osteoporotic fractures, and hypothalamic-pituitary-adrenal (HPA) axis suppression. Some doses of highly potent topical CS (eg, 49 g of high potency topical CS for 2 weeks) have been described as exceeding published thresholds for HPA axis suppression. Oral CS: Short-term oral CS use (<30 days) is common, occurring in 21% of US adults across specialties and diseases. Findings from population-based studies and claims database analyses show that even short courses of oral CS (≤5 mg/day for ≤6 months) can contribute to hyperglycemia, elevated blood pressure, mood changes, sleep disturbance, sepsis, fracture, and venous thromboembolism.

Conclusions: Available data reveal that CS-related AEs may be more impactful than traditionally thought. This underscores the importance of a more discriminating approach to CS use, especially given the increasing availability of novel, effective alternatives. Judicious CS prescription should include individual patient risk assessment, routine safety monitoring, and use of the lowest effective dose for only the necessary duration. This review identifies an opportunity for a new era where non-CS therapies are used as replacements for topical CS to minimize patient risk without compromising treatment outcomes, especially in higher-risk patients and when the disease requires higher potencies, chronic use, and/or widespread topical application. Sponsored by Arcutis Biotherapeutics, Inc.