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

The trial compared 0.05 percent clobetasol propionate ointment, one of the strongest topical steroids in clinical use, with 0.1 percent tacrolimus ointment, a calcineurin inhibitor best known for treating atopic dermatitis. Twenty patients received each treatment. The question matters because early-stage mycosis fungoides is highly treatable with skin-directed therapies, yet the ideal first-choice agent has remained contested. Topical steroids are cheap, familiar, and fast, but long-term use carries the familiar toll of skin atrophy, striae, telangiectasia, and taper-dependent relapse. Tacrolimus offers a steroid-sparing alternative that suppresses T-cell activation without thinning the skin, but direct comparative evidence against clobetasol in lymphoma patients has been almost nonexistent until now.

On raw clearance rates, the verdict was lopsided. In the clobetasol group, 95 percent of patients achieved a complete clinical response, meaning their lesions resolved entirely, and the remaining 5 percent achieved a partial response. In the tacrolimus group, by contrast, only 60 percent reached complete clearance and 20 percent a partial response. The median time to complete response also favored the steroid, at two months versus three and a half months for tacrolimus, although that timing difference did not reach statistical significance. For clinicians and patients alike, the message of the first analysis is straightforward: clobetasol clears early patches and plaques faster and more often.

But the story changed when the researchers followed patients forward in time. Among those who achieved complete clearance, relapse occurred in 63.2 percent of the clobetasol-treated patients compared with just 25 percent of those treated with tacrolimus, a difference that approached but did not reach conventional statistical significance. Kaplan-Meier survival analysis, which tracks how long patients remain disease-free over months and years, showed a trend toward longer relapse-free survival in the tacrolimus group, with a log-rank p-value of 0.060. In a study of only forty patients, trends of this size are tantalizing rather than definitive, but they hint at a trade-off that clinicians have long suspected: steroids win the sprint while tacrolimus may hold ground longer in the marathon.

The biology behind that trade-off is worth unpacking. Mycosis fungoides is driven by clonal malignant T lymphocytes that home to the skin, and both drugs attack the inflammatory machinery these cells depend on, but by different routes. Clobetasol binds intracellular glucocorticoid receptors, broadly repressing transcription of inflammatory cytokines and inducing apoptosis in immune cells, a blunt but powerful instrument. Tacrolimus inhibits calcineurin, a phosphatase essential for activating the transcription factor NFAT in T cells, thereby blocking interleukin-2 production and T-cell proliferation with far greater selectivity. Because the steroid suppresses inflammation indiscriminately, it clears lesions dramatically, but once therapy stops or is tapered, the underlying malignant clone may rebound quickly. Calcineurin inhibition, gentler and more targeted, may leave residual disease control in place even as visible lesions fade more slowly.

Safety considerations sharpen the clinical calculus further. Prolonged use of super-potent steroids on thin skin, on the face, or in folds produces atrophy, striae, and secondary infection, and mycosis fungoides frequently affects these vulnerable sites and demands years of intermittent treatment. Tacrolimus ointment does not cause skin thinning, which is precisely why dermatologists have proposed it as a steroid-sparing option, and earlier work including a phase 2 trial of the related calcineurin inhibitor pimecrolimus published in The Lancet Haematology in 2022 demonstrated meaningful activity and tolerability in early-stage disease. One historical concern, a theoretical lymphoma risk from systemic absorption of calcineurin inhibitors, has been substantially allayed by large cohort studies such as the JOELLE investigations, which followed tens of thousands of users and found no convincing increase in lymphoma incidence, and pharmacokinetic studies showing minimal systemic exposure when tacrolimus is applied to intact skin.

The Istanbul team’s findings also sit within a growing evidence base for topical therapy in this lymphoma. Zackheim’s foundational work established patch-stage mycosis fungoides as responsive to potent topical corticosteroids, and a 2025 comparison from the same Turkish group, published in the Brazilian Annals of Dermatology, found clobetasol competitive with oral bexarotene in early disease. What has been missing is exactly the kind of direct steroid-versus-calcineurin-inhibitor comparison this study provides, even in retrospective form. The authors themselves caution that comparative data on topical therapies remain limited and that calcineurin inhibitors have been proposed as steroid-sparing alternatives largely on theoretical and indirect grounds.

The study’s limitations deserve honest weight. Forty patients divided into two groups of twenty, treated retrospectively rather than randomized, leave ample room for selection bias, confounding by disease severity or anatomical site, and underpowered statistics. Relapse definitions and follow-up duration are critical in a disease whose natural history is measured in decades, and differences that miss significance at p-values just above 0.05, as several here do, could easily prove real in a larger cohort or dissolve into noise. The authors do not claim that tacrolimus prevents relapse; they report trends. Still, in rare diseases, randomized trials are notoriously difficult to populate, and carefully collected comparative cohort data like this often guides practice for years before definitive evidence arrives.

For patients, the practical takeaway is a conversation rather than a prescription. Someone with extensive thin plaques on the face or flexures, or a history of steroid-induced skin damage, may reasonably begin with tacrolimus, accepting slower clearance and a somewhat lower chance of complete response in exchange for durability and skin preservation. Someone with thicker, widespread plaques and a need for rapid control may start with clobetasol, then consider rotating to or maintaining with a calcineurin inhibitor to hold the gains while sparing the skin. The pattern in this data, fast clearance with higher relapse on one side and slower, stickier remission on the other, maps neatly onto that sequential strategy, which many dermatologists already employ empirically.

What happens next is the familiar rhythm of clinical oncology: these findings need prospective confirmation, ideally in a randomized trial with standardized response criteria under the current ISCL-EORTC staging framework, longer follow-up to truly characterize relapse-free survival, and enough patients to convert suggestive p-values into conclusions. Until then, the Istanbul study earns its place as one of the few direct comparisons of the two most accessible topical treatments for early mycosis fungoides, and it reframes the question clinicians ask at the bedside. It is no longer simply which ointment clears the skin, but which ointment keeps it clear, and the answer may be that the humble immunomodulator cream, long relegated to second-line status, deserves a more prominent seat at the table for carefully selected patients facing this indolent lymphoma.

Subject of Research: Comparative efficacy of topical corticosteroid versus calcineurin inhibitor therapy in early-stage mycosis fungoides

Article Title: Comparison of the efficacy of topical 0.05% clobetasol propionate and topical 0.1% tacrolimus in the treatment of early-stage mycosis fungoides

Article References: Comparison of the efficacy of topical 0.05% clobetasol propionate and topical 0.1% tacrolimus in the treatment of early-stage mycosis fungoides. (n.d.). https://doi.org/10.1007/s00403-026-04958-0

Image Credits: AI Generated

DOI: 10.1007/s00403-026-04958-0

Keywords: mycosis fungoides, cutaneous T-cell lymphoma, clobetasol propionate, tacrolimus, topical therapy, dermatology, relapse-free survival, calcineurin inhibitors, skin-directed treatment, clinical research, Comparison, efficacy