Cushing's syndrome and adrenocortical insufficiency caused by topical steroids: misuse or abuse?
BACKGROUND
Prolonged application of topical steroids transiently suppresses the hypothalamic-pituitary-adrenal axis (HPA). Infants who are exposed to topical corticosteroids have greater risk for Cushing's syndrome or adrenocortical insufficiency caused by suppression of the HPA axis because glucocorticoids are highly absorbed through the diaper area. Here, we report six infants (four girls, two boys) aged between 3 and 8 months who were exposed to potent topical corticosteroids (clobetasol propionate and diflucortolone valerate) by the mother's application without prescription.


METHODS
We examined the HPA axis and other side effects of the potent glucocorticoid therapy in these infants. After stopping the topical corticosteroid, serum AST, ALT, lipids, morning cortisol and ACTH levels were measured. A low dose ACTH stimulation test was carried out. Hydrocortisone was started for the prevention of glucocorticoid withdrawal syndrome and the dose was gradually decreased. Abdominal ultrasonography was performed to investigate hepatosteatosis.


RESULTS
The ACTH stimulation test showed suppression of the HPA axis in these infants. Hepatomegaly was found in all infants and three of them had hepatosteatosis. Liver transaminase levels were elevated in five infants. Five patients have been followed for 6-14 months. One infant died due to generalized Cytomegalovirus infection.


CONCLUSIONS
We emphasize that physicians should be alert for the dangerous side-effects of topical steroids and they should avoid long-term use. Furthermore, parents should be informed about the side-effects when topical steroid treatment is chosen.
Güven
Ayla
A
Department of Pediatric Endocrinology, Ondokuz Mayis University Medical Faculty, Turkey. aylaguven@yahoo.com
Gülümser
Ozlem
O
Ozgen
Tolga
T
D000287:Administration, Topical; D000309:Adrenal Insufficiency / Q000097:blood / Q000139:chemically induced* / Q000175:diagnosis; D000324:Adrenocorticotropic Hormone / Q000097:blood; D000893:Anti-Inflammatory Agents / Q000008:administration & dosage / Q000009:adverse effects*; D019963:Clinical Chemistry Tests; D002990:Clobetasol / Q000009:adverse effects*; D000075202:Contraindications; D003480:Cushing Syndrome / Q000097:blood / Q000139:chemically induced* / Q000175:diagnosis; D003963:Diaper Rash / Q000097:blood / Q000188:drug therapy / Q000473:pathology; D004060:Diflucortolone / Q000008:administration & dosage / Q000009:adverse effects / Q000031:analogs & derivatives*; D062787:Drug Overdose; D017809:Fatal Outcome; D005260:Female; D005938:Glucocorticoids / Q000008:administration & dosage / Q000009:adverse effects*; D006801:Humans; D006854:Hydrocortisone / Q000097:blood; D007030:Hypothalamo-Hypophyseal System / Q000187:drug effects / Q000503:physiopathology; D007223:Infant; D008297:Male; D010913:Pituitary-Adrenal System / Q000187:drug effects / Q000503:physiopathology
D000893:Anti-Inflammatory Agents; D005938:Glucocorticoids; C013486:diflucortolone valerate; D000324:Adrenocorticotropic Hormone; D002990:Clobetasol; D004060:Diflucortolone; D006854:Hydrocortisone