Your Insurance Card May Decide Whether You Get Steroid-Free Eczema Creams

For millions of people living with atopic dermatitis, the itchy, inflammatory skin condition that is the most common form of eczema, the past two decades have brought a genuine therapeutic revolution. Long before biologic injections and oral JAK inhibitors entered the conversation, dermatologists gained access to a family of nonsteroidal topical therapies: calcineurin inhibitors such as tacrolimus and pimecrolimus, the phosphodiesterase-4 inhibitor crisaborole, and, more recently, topical Janus kinase inhibitors like ruxolitinib cream. These agents suppress the inflammatory cascade in the skin without the cutaneous side effects of corticosteroids, notably skin atrophy, telangiectasia, and hypopigmentation, which matter enormously for patients who need long-term maintenance therapy on the face, eyelids, neck, and skin folds. Yet a new short report in the Archives of Dermatological Research suggests that the promise of these steroid-sparing options is not distributed evenly across the American health care landscape, and that the type of insurance a patient carries may be one of the strongest determinants of whether they ever receive them.

The study, led by Mihir M. Shah of Stanford University School of Medicine together with Arash Pour Mohammad, Mahi Bhatt, Justin M. Ko, and Gordon H. Bae of the Stanford Department of Dermatology, examined patterns of nonsteroidal topical prescribing for dermatitis across different insurance categories. Drawing on Epic Cosmos, one of the largest aggregated electronic health record databases in the United States, the researchers were able to compare how patients with public insurance, private commercial coverage, and other payer types fared when it came to access to these medications. The central finding is stark in its simplicity: insurance type is associated with reduced use of nonsteroidal topical therapies for dermatitis, meaning that patients covered by certain plans, particularly public programs, were less likely to have these treatments documented in their records than patients with other forms of coverage.

The technical rationale for why this matters begins with the biology of atopic dermatitis itself. The disease is driven by a dysregulated type 2 immune response, with elevated signaling through interleukin-4 and interleukin-13, impaired epidermal barrier function, and chronic activation of T cells in the skin. Topical corticosteroids remain the workhorse of therapy because they are broadly anti-inflammatory and inexpensive, but their long-term use is limited by well-characterized adverse effects. Calcineurin inhibitors work downstream of T cell receptor signaling, blocking the calcineurin–nuclear factor of activated T cells pathway and thereby reducing transcription of inflammatory cytokines. Crisaborole inhibits phosphodiesterase-4, elevating intracellular cyclic AMP and damping inflammatory mediator release. Topical JAK inhibitors interrupt cytokine signaling at the receptor level. Each of these mechanisms offers steroid-free control of flares, and clinical guidelines increasingly position them as first-line or maintenance options, especially for sensitive anatomical sites.

Access to these molecules, however, is mediated not by guidelines but by formularies. A companion analysis published in the same journal by Kim and colleagues in 2024 found that Medicaid coverage for nonsteroidal topical atopic dermatitis treatment is often restrictive and highly variable across the United States, with state-by-state differences in prior authorization requirements, step therapy mandates, and quantity limits. Step therapy, the practice of requiring patients to fail on cheaper agents before escalating, is particularly consequential in dermatology, because a patient may need to document inadequate response or adverse reaction to multiple topical corticosteroids before a nonsteroidal agent is approved. Prior authorization adds administrative delay, and in a relapsing condition like atopic dermatitis, delays during a flare translate directly into suffering, sleep loss, and, in children, potential developmental and psychosocial consequences.

The Stanford team’s findings fit into a broader and troubling literature on dermatologic health equity. A 2023 retrospective matched cohort study by Al-Obaydi, Craig, and Al-Shaikhly documented racial and ethnic disparities in the treatment of atopic dermatitis patients in the United States, showing that Black and Hispanic patients receive guideline-concordant therapy at lower rates than white patients. Because race, socioeconomic status, and insurance type are deeply intertwined in the American system, with Black and Hispanic populations disproportionately enrolled in Medicaid, insurance-based barriers to nonsteroidal topicals may function as a structural mechanism that perpetuates and amplifies racial disparities in eczema outcomes. A 2025 Kaiser Family Foundation analysis of health coverage by race and ethnicity from 2010 through 2023 underscores how unevenly coverage types are distributed across the population, making payer status a plausible and measurable proxy for structural disadvantage.

What makes the new report particularly valuable is its methodology. Epic Cosmos aggregates de-identified longitudinal records from hundreds of health care organizations participating in the Epic electronic health record network, giving researchers a window into real-world prescribing behavior across geographically and demographically diverse populations. Rather than relying on claims data, which capture prescriptions filled but not the clinical context in which they were considered, the electronic health record approach allows investigators to identify patients with dermatitis diagnoses and examine what therapies were actually documented in their care. The retrospective design is exempt from informed consent requirements and did not constitute human subjects research requiring institutional review board approval, and the authors declare no conflicts of interest and report no external funding, an increasingly rare transparency profile in dermatologic research that is often supported by pharmaceutical industry grants.

The study does have limitations inherent to its design and data source, and these deserve honest acknowledgment. Because the data are observational, the association between insurance type and nonsteroidal topical use cannot be interpreted as proof that coverage policies directly cause the prescribing gap; unmeasured confounders such as disease severity, patient preference, geographic access to dermatologists, and clinician practice patterns may contribute. The proprietary nature of the Epic Cosmos database, governed by data use agreements, means the underlying data cannot be shared publicly and access is restricted to authorized researchers affiliated with participating health care organizations, which limits independent replication. Nevertheless, the consistency of the finding with prior formulary analyses strengthens the biological and policy plausibility of the association: if Medicaid plans systematically restrict nonsteroidal topicals, lower documented use among Medicaid beneficiaries is exactly what one would expect to observe.

The clinical stakes of this prescribing gap are not trivial. Untreated or undertreated atopic dermatitis carries a heavy burden: chronic sleep disruption from nocturnal pruritus, increased risk of skin and systemic infections including eczema herpeticum, higher rates of anxiety and depression, and, in severe cases, associations with cardiometabolic and atopic comorbidities. The so-called itch–scratch cycle perpetuates barrier damage and inflammation, and early aggressive control of disease in childhood may influence the atopic march, the progression from eczema to food allergy, allergic rhinitis, and asthma. Denying or delaying access to effective steroid-sparing agents forces clinicians into a corner: either overuse topical corticosteroids in situations where nonsteroidal agents would be preferable, or under-treat the disease. Both paths carry costs, and both fall disproportionately on patients whose insurance makes the modern alternatives hardest to obtain.

The policy implications are equally clear. A 2024 evaluation by Loiselle and colleagues of prescription medication access in the atopic dermatitis population in the United States documented systemic barriers to reaching therapy, and the new findings add a specific, actionable target: harmonizing and relaxing Medicaid coverage criteria for nonsteroidal topical therapies. Because Medicaid is jointly administered by states and the federal government, reform could occur at multiple levels, from state Medicaid formulary committees revising prior authorization criteria to federal guidance encouraging uniform coverage of guideline-supported dermatologic therapies. Clinicians, meanwhile, can respond in the near term by documenting medical necessity meticulously, appealing denials, and using patient assistance programs where available. What the Stanford report ultimately exposes is a quiet form of rationing, one that operates not at the pharmacy counter but in the invisible machinery of formulary design, and one that patients with eczema pay for in sleepless nights and inflamed skin.

Subject of Research: Insurance-related disparities in access to nonsteroidal topical therapies for dermatitis

Article Title: Insurance type is associated with reduced use of dermatitis nonsteroidal topical therapies

Article References: Shah, M. M., Pour Mohammad, A., Bhatt, M., Ko, J. M., & Bae, G. H. (2026). Insurance type is associated with reduced use of dermatitis nonsteroidal topical therapies. Archives of Dermatological Research, 318(1), Article 478. https://doi.org/10.1007/s00403-026-04956-2

Image Credits: AI Generated

DOI: 10.1007/s00403-026-04956-2

Keywords: atopic dermatitis, dermatitis, nonsteroidal topical therapies, insurance, Medicaid, health disparities, calcineurin inhibitors, crisaborole, topical JAK inhibitors, electronic health records, health policy, dermatology