Fatal iatrogenic Cushing's syndrome

European Society of Endocrinology and Endocrine Society Joint Clinical Guideline: Diagnosis and Therapy of Glucocorticoid-induced Adrenal Insufficiency

Glucocorticoids are widely prescribed as anti-inflammatory and immunosuppressive agents. This results in at least 1% of the population using chronic glucocorticoid therapy, being at risk for glucocorticoid-induced adrenal insufficiency. This risk is dependent on the dose, duration and potency of the glucocorticoid, route of administration, and individual susceptibility. Once glucocorticoid-induced adrenal insufficiency develops or is suspected, it necessitates careful education and management of affected patients. Tapering glucocorticoids can be challenging when symptoms of glucocorticoid withdrawal develop, which overlap with those of adrenal insufficiency. In general, tapering of glucocorticoids can be more rapidly within a supraphysiological range, followed by a slower taper when on physiological glucocorticoid dosing. The degree and persistence of HPA axis suppression after cessation of glucocorticoid therapy are dependent on overall exposure and recovery of adrenal function varies greatly amongst individuals. This first European Society of Endocrinology/Endocrine Society joint clinical practice guideline provides guidance on this clinically relevant condition to aid clinicians involved in the care of patients on chronic glucocorticoid therapy.

European Society of Endocrinology and Endocrine Society Joint Clinical Guideline: Diagnosis and therapy of glucocorticoid-induced adrenal insufficiency

Glucocorticoids are widely prescribed as anti-inflammatory and immunosuppressive agents. This results in at least 1% of the population using chronic glucocorticoid therapy, being at risk for glucocorticoid-induced adrenal insufficiency. This risk is dependent on the dose, duration and potency of the glucocorticoid, route of administration, and individual susceptibility. Once glucocorticoid-induced adrenal insufficiency develops or is suspected, it necessitates careful education and management of affected patients. Tapering glucocorticoids can be challenging when symptoms of glucocorticoid withdrawal develop, which overlap with those of adrenal insufficiency. In general, tapering of glucocorticoids can be more rapidly within a supraphysiological range, followed by a slower taper when on physiological glucocorticoid dosing. The degree and persistence of HPA axis suppression after cessation of glucocorticoid therapy are dependent on overall exposure and recovery of adrenal function varies greatly amongst individuals. This first European Society of Endocrinology/Endocrine Society joint clinical practice guideline provides guidance on this clinically relevant condition to aid clinicians involved in the care of patients on chronic glucocorticoid therapy.

Glucocorticoid induced adrenal insufficiency

Synthetic glucocorticoids are widely used for their anti-inflammatory and immunosuppressive actions. A possible unwanted effect of glucocorticoid treatment is suppression of the hypothalamic-pituitary-adrenal axis, which can lead to adrenal insufficiency. Factors affecting the risk of glucocorticoid induced adrenal insufficiency (GI-AI) include the duration of glucocorticoid therapy, mode of administration, glucocorticoid dose and potency, concomitant drugs that interfere with glucocorticoid metabolism, and individual susceptibility. Patients with exogenous glucocorticoid use may develop features of Cushing's syndrome and, subsequently, glucocorticoid withdrawal syndrome when the treatment is tapered down. Symptoms of glucocorticoid withdrawal can overlap with those of the underlying disorder, as well as of GI-AI. A careful approach to the glucocorticoid taper and appropriate patient counseling are needed to assure a successful taper. Glucocorticoid therapy should not be completely stopped until recovery of adrenal function is achieved. In this review, we discuss the factors affecting the risk of GI-AI, propose a regimen for the glucocorticoid taper, and make suggestions for assessment of adrenal function recovery. We also describe current gaps in the management of patients with GI-AI and make suggestions for an approach to the glucocorticoid withdrawal syndrome, chronic management of glucocorticoid therapy, and education on GI-AI for patients and providers.

Outcomes of oral lichen planus and oral lichenoid lesions treated with topical corticosteroid

OBJECTIVE

To determine corticosteroid treatment effectiveness in patients with oral lichen planus/oral lichenoid lesions (OLP/OLL).

MATERIAL AND METHODS

Twenty-one patients with OLP and eighty-one patients with OLL received 0.05% clobetasol propionate (CP) or 0.05% triamcinolone acetonide (TA) in aqueous solution (AS) or orabase (OB), evaluating responses to treatment and follow-up compliance.

RESULTS

Lesions were atrophic (72 of 102; 70.6%), extensive (58 of 100; 58%), producing eating difficulties (62 of 102; 60.8%), and spontaneous pain (30 of 102; 29.4%); 50 patients (49%) received CP-AS. The mean ± SD percentage of follow-ups attended was 43 ± 32%. Symptom remission was achieved in 46% of patients receiving CP-AS, 36.36% of those receiving TA-AS, 20% of those receiving CP-OB, and 25% of those receiving TA-OB. Follow-up compliance was poor in 66.7% of patients. Among 51 patients with continuous symptoms, 64.7% evidenced total remission at treatment completion; among 33 with intermittent symptoms, 73.1% had outbreaks 2-3 times/year and 51.5% controlled outbreaks with <6 corticosteroid applications. Adverse effects were observed in seven patients (6.8%) (moon face, hirsutism, capillary fragility) in induction stage, subsiding with dose; among 15 patients under maintenance treatment for >6 months, one showed hypothalamic-pituitary-adrenal (HPA) axis inhibition but not adrenal insufficiency.

CONCLUSIONS

Our treatment proved highly effective and safe. Recall programs are desirable to enhance follow-up compliance.

Exogenous Cushing's syndrome due to topical corticosteroid application: case report and review literature

Prolonged use of topical corticosteroids causes systemic adverse effects including Cushing's syndrome and hypothalamic-pituitary-adrenal (HPA) axis suppression, which is less common than that of the oral or parenteral route. At least 43 cases with iatrogenic Cushing syndrome from very potent topical steroid usage (Clobetasol) in children and adult have been published over the last 35 years particularly in developing countries. In children group (n = 22), most are infants with diaper dermatitis and two cases who had started topical application at a very early age and died from severe disseminated CMV infection. For the adult group (n = 21), the most common purpose of steroid use was for treatment of Psoriasis. The recovery period of HPA axis suppression was 3.49 ± 2.92 and 3.84 ± 2.51 months in children and adult, respectively. We report on an 8-month-old female infant who developed Cushing's syndrome and adrenal insufficiency after diaper dermatitis treatment through the misuse of Clobetasol without doctor's prescription. Physiologic dose of hydrocortisone was prescribed to prevent an adrenal crisis for 3 months and discontinued when HPA axis recovery was confirmed by normal morning cortisol and ACTH levels.

HPA-suppressive effects of aqueous clobetasol propionate in the treatment of patients with oral lichen planus

BACKGROUND

Oral topical corticosteroids have potential to produce inhibition of the hypothalamus-pituitary-adrenal (HPA) axis.

OBJECTIVE

To assess whether clobetasol propionate (CP) in aqueous solution causes HPA inhibition.

PATIENTS AND METHODS

Sixty-two patients with oral lichen planus or oral lichenoid lesions presenting with severe lesions were treated with topical oral 0.05% CP plus 100,000 IU/cm(3) nystatin in aqueous solution. Initial treatment of three 5-min mouthwashes (10 mL) daily was reduced, when the response was deemed complete or excellent, to a maintenance treatment of one 5-min mouthwash on alternate days for 6 months; treatment was then withdrawn and patients were followed up for 1 year. HPA function was assessed by plasma cortisol measurement and adrenocorticotropin (ACTH) stimulation at the end of the initial and maintenance treatment regimens.

RESULTS

The HPA axis was more frequently inhibited during initial (53/62; 85.5%) vs. maintenance (2/49; 4%) regimens of aqueous CP.

LIMITATIONS

In patients with morning plasma cortisol levels between 3 and 18 microg/dL, a normal result for the ACTH stimulation test only moderately reduces the possibility that a patient has secondary adrenal insufficiency. This can be considered a minor limitation in our study, as only three patients required additional assessment with the ACTH stimulation test.

CONCLUSIONS

Hypothalamus-pituitary-adrenal inhibition is substantial during initial treatment with aqueous CP three times daily.

Inappropriate use of potent topical glucocorticoids in infants

Topical therapy with glucocorticoids (GCs) is used commonly in chronic dermatoses. Side effects are less common compared to systemic use; however, newer potent preparations may have serious side effects. A potential danger is their inappropriate use. Three infants who developed iatrogenic Cushing's syndrome and prolonged adrenal suppression in the course of GC therapy for simple diaper dermatitis are described. One patient also developed steatohepatitis which is uncommon with local GCs.

High-potency steroid use in children with vitiligo: A retrospective study

BACKGROUND

Data on efficacy and safety of treatments in children with vitiligo are limited.

OBJECTIVE

We sought to describe the clinical outcomes and safety of children with vitiligo treated with high-potency topical corticosteroids.

METHODS

Clinical improvement and laboratory data were retrospectively analyzed in 101 children (0-18 years) with vitiligo treated with moderate- to high-potency topical corticosteroids.

RESULTS

Of patients, 64% (45 of 70) had repigmentation of the lesions, 24% (17 of 70) showed no change, and 11% (8 of 70) were worse than at the initial presentation. Local steroid side effects were noted in 26% of patients at 81.7 +/- 44 days of follow-up. Cortisol levels were abnormal in 29% of patients (21 of 73). Two children with low cortisol levels were given the diagnosis of steroid-induced adrenal suppression. Children with normal and abnormal cortisol levels were not significantly different by sex, age of onset, potency of the corticosteroid use, or family history. However, children with head and/or neck affected areas were 8.36 times more likely to have an abnormal cortisol level compared with children affected in other body areas (RR 95% confidence interval: 1.19, 58.60, P = .003, n = 72). Of patients, 8% (6 of 74) had an abnormal thyrotropin test result.

LIMITATIONS

The retrospective design of this study presents inherent limitations.

CONCLUSION

Moderate- to high-potency topical corticosteroids are efficacious in children with vitiligo, but may be associated with systemic absorption.

Adverse effects of topical glucocorticosteroids

Topical corticosteroids were introduced into medicine about 50 years ago. They represent a significant milestone in dermatologic therapy. Despite encouragement to report observed adverse drug reactions, the clinical practice of reporting is poor and incomplete. Likewise, adverse effects and safety of topical corticosteroids are neglected in the medical literature. The authors provide an updated review of their adverse-effect profile. Children are more prone to the development of systemic reactions to topically applied medication because of their higher ratio of total body surface area to body weight. Cutaneous adverse effects occur regularly with prolonged treatment and are dependent on the chemical nature of the drug, the vehicle, and the location of its application. The most frequent adverse effects include atrophy, striae, rosacea, perioral dermatitis, acne, and purpura. Those that occur with lower frequency include hypertrichosis, pigmentation alterations, delayed wound healing, and exacerbation of skin infections. Of particular interest is the rate of contact sensitization against corticosteroids, which is considerably higher than generally believed. Systemic reactions such as hyperglycemia, glaucoma, and adrenal insufficiency have also been reported to follow topical application. The authors provide an updated review of local and systemic adverse effects upon administration of topical corticosteroids, including the latest FDA report on the safety of such steroids in children.

LEARNING OBJECTIVE

At the completion of this learning activity, participants should be familiar with topical corticosteroids and their proper use.

Treatment of patch-stage mycosis fungoides with topical corticosteroids

Experience at the University of California, San Francisco (UCSF), in the management of patch-stage mycosis fungoides (MF) with topical, predominantly high-potency, corticosteroids is reviewed. The technique of applications is discussed in detail. Approximately 200 patients have been treated. The results are very favorable. The response rate is over 90%. Side-effects are minor. Topical clobetasol is the first-line treatment for early stage MF at UCSF.

Topical corticosteroid-induced adrenocortical insufficiency: clinical implications

Topical corticosteroids are often prescribed for the treatment of dermatological disorders. However, systemic adrenal insufficiency may result from their overuse. Current literature detailing both laboratory and clinical findings was analyzed, in the hopes of evaluating the health-risk potential of topical corticosteroids in producing adrenal insufficiency. Risk factors identified in this report included use of high potency corticosteroids, occlusive or prolonged treatment application, and use in thin-skinned areas. Other patients at risk for development of adrenal suppression include infants and those with damaged skin barriers. Several diagnostic tests may be utilized to measure adrenal function, though each has its limitations. The most common tests include measurement of plasma total cortisol, 24-hour steroid, adrenocorticotrophin hormone stimulation and insulin tolerance. The report finds strong laboratory evidence of adrenal hypofunction. Additionally, clinical reversible adrenal insufficiency has been observed on rare occasions. Therefore, topical corticosteroids should be used with an increased awareness of the potential for systemic adrenal suppressive effects. However, since nonreversible clinical secondary adrenocortical-insufficiency disease has not been clearly documented with even class I topical corticosteroids, native adrenal supplementation in periods of stress appears unnecessary; rare exceptions cannot be excluded.

Treatment of psoriasis. Part 1. Topical therapy and phototherapy

New developments in the topical therapy and phototherapy of psoriasis have greatly improved our ability to safely and effectively treat this debilitating disease. Topical corticosteroids remain the most commonly prescribed agents for psoriasis, but they are frequently prescribed with other agents. Investigations of corticosteroids claiming an improved benefit/risk ratio have yielded promising results, but more work is needed. Use of anthralin and tar has declined with the availability of the noncorticosteroids calcipotriene and tazarotene. Other experimental topical therapies are in various stages of development. Broadband ultraviolet B (UVB) remains the most commonly used phototherapy light source, but many patients are being treated with a new form of ultraviolet light, narrowband UVB. Although PUVA remains one of the most effective psoriasis treatments, its use is declining because of its association with cutaneous malignancies. New radiation sources such as lasers have been added to our armamentarium of available therapies and even newer light source-based treatments are being examined.

LEARNING OBJECTIVE

At the conclusion of this learning activity, participants should be familiar with the varying topical treatments for psoriasis as well as the different modalities of phototherapy. Participants should also have a better understanding of side effects associated with each treatment, which should help in determining options for therapy.

Super potent topical corticosteroid use associated with adrenal suppression: clinical considerations

The potential for a variety of local and systemic side effects from the use of potent topical corticosteroids has long been recognized. However, adrenal suppression has only rarely been documented. We describe two patients with profound hypothalamic-pituitary-adrenal axis suppression resulting from the unregulated use of super potent topical corticosteroids.