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

Topical Corticosteroid Phobia among Danish Pharmacy Staff

INTRODUCTION

Topical corticosteroid (TCS) phobia may negatively impact treatment adherence. Currently, there are few studies exploring trust and knowledge of TCS use among pharmacy staff. The objective of this work was to examine TCS knowledge and possible phobia among Danish pharmacy staff.

METHODS

A questionnaire, based on Topical Corticosteroid Phobia (TOPICOP©) questionnaire, was developed and rephrased to fit pharmacy staff. The questions were Likert scales and numerical rating scales (NRS) (0-10). In October/November 2021, 64 pharmacies were invited. If the pharmacies agreed to participate, a researcher visited the pharmacies and distributed the questionnaires.

RESULTS

A total of 244 pharmacy workers from 59 pharmacies participated. The majority (95.4%) responded that they were aware of side effects of TCS; however, misconceptions regarding side effects were found in up to 34% of participants. Regarding TCS use, 40% sometimes advised the patients to wait as long as possible before initiating treatment with TCS. Confidence in dispensing TCS to patients was high, with a mean of 8.45 (NRS).

CONCLUSION

Danish pharmacy staff generally reported high confidence in TCS use. Misconceptions regarding side effects were common, and there was a tendency to giving advices on TCS treatment that may indicate low confidence in TCS. Thorough education of pharmacy staff is needed to improve the knowledge of TCS.

Perioperative Evaluation and Management of Patients on Glucocorticoids

Myriad questions regarding perioperative management of patients on glucocorticoids (GCs) continue to be debated including which patients are at risk for adrenal insufficiency (AI), what is the correct dose and duration of supplemental GCs, or are they necessary for everyone? These questions remain partly unanswered due to the heterogeneity and low quality of data, studies with small sample sizes, and the limited number of randomized trials. To date, we know that although all routes of GC administration can result in hypothalamic-pituitary-adrenal (HPA) axis suppression, perioperative adrenal crisis is rare. Correlation between biochemical testing for AI and clinical events is lacking. Some of the current perioperative management recommendations based on daily GC dose and duration of therapy may be difficult to follow in clinical practice. The prospective and retrospective studies consistently report that continuing the daily dose of GCs perioperatively is not associated with a higher risk for adrenal crises in patients with GC-induced AI. Considering that oral GC intake may be unreliable in the early postoperative period, providing the daily GC plus a short course of IV hydrocortisone 25 to 100 mg per day based on the degree of surgical stress seems reasonable. In patients who have stopped GC therapy before surgery, careful assessment of the HPA axis is necessary to avoid an adrenal crisis. In conclusion, our literature review indicates that lower doses and shorter duration of supplemental GCs perioperatively are sufficient to maintain homeostasis. We emphasize the need for well-designed randomized studies on this frequently encountered clinical scenario.

Strategies for using topical corticosteroids in children and adults with eczema

BACKGROUND

Eczema is a common skin condition. Although topical corticosteroids have been a first-line treatment for eczema for decades, there are uncertainties over their optimal use.

OBJECTIVES

To establish the effectiveness and safety of different ways of using topical corticosteroids for treating eczema.

SEARCH METHODS

We searched databases to January 2021 (Cochrane Skin Specialised Register; CENTRAL; MEDLINE; Embase; GREAT) and five clinical trials registers. We checked bibliographies from included trials to identify further trials.

SELECTION CRITERIA

Randomised controlled trials in adults and children with eczema that compared at least two strategies of topical corticosteroid use. We excluded placebo comparisons, other than for trials that evaluated proactive versus reactive treatment.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods, with GRADE certainty of evidence for key findings. Primary outcomes were changes in clinician-reported signs and relevant local adverse events. Secondary outcomes were patient-reported symptoms and relevant systemic adverse events. For local adverse events, we prioritised abnormal skin thinning as a key area of concern for healthcare professionals and patients.

MAIN RESULTS

We included 104 trials (8443 participants). Most trials were conducted in high-income countries (81/104), most likely in outpatient or other hospital settings. We judged only one trial to be low risk of bias across all domains. Fifty-five trials had high risk of bias in at least one domain, mostly due to lack of blinding or missing outcome data. Stronger-potency versus weaker-potency topical corticosteroids Sixty-three trials compared different potencies of topical corticosteroids: 12 moderate versus mild, 22 potent versus mild, 25 potent versus moderate, and 6 very potent versus potent. Trials were usually in children with moderate or severe eczema, where specified, lasting one to five weeks. The most reported outcome was Investigator Global Assessment (IGA) of clinician-reported signs of eczema. We pooled four trials that compared moderate- versus mild-potency topical corticosteroids (420 participants). Moderate-potency topical corticosteroids probably result in more participants achieving treatment success, defined as cleared or marked improvement on IGA (52% versus 34%; odds ratio (OR) 2.07, 95% confidence interval (CI) 1.41 to 3.04; moderate-certainty evidence). We pooled nine trials that compared potent versus mild-potency topical corticosteroids (392 participants). Potent topical corticosteroids probably result in a large increase in number achieving treatment success (70% versus 39%; OR 3.71, 95% CI 2.04 to 6.72; moderate-certainty evidence). We pooled 15 trials that compared potent versus moderate-potency topical corticosteroids (1053 participants). There was insufficient evidence of a benefit of potent topical corticosteroids compared to moderate topical corticosteroids (OR 1.33, 95% CI 0.93 to 1.89; moderate-certainty evidence). We pooled three trials that compared very potent versus potent topical corticosteroids (216 participants). The evidence is uncertain with a wide confidence interval (OR 0.53, 95% CI 0.13 to 2.09; low-certainty evidence). Twice daily or more versus once daily application We pooled 15 of 25 trials in this comparison (1821 participants, all reported IGA). The trials usually assessed adults and children with moderate or severe eczema, where specified, using potent topical corticosteroids, lasting two to six weeks. Applying potent topical corticosteroids only once a day probably does not decrease the number achieving treatment success compared to twice daily application (OR 0.97, 95% CI 0.68 to 1.38; 15 trials, 1821 participants; moderate-certainty evidence). Local adverse events Within the trials that tested 'treating eczema flare-up' strategies, we identified only 26 cases of abnormal skin thinning from 2266 participants (1% across 22 trials). Most cases were from the use of higher-potency topical corticosteroids (16 with very potent, 6 with potent, 2 with moderate and 2 with mild). We assessed this evidence as low certainty, except for very potent versus potent topical corticosteroids, which was very low-certainty evidence.  Longer versus shorter-term duration of application for induction of remission No trials were identified. Twice weekly application (weekend, or 'proactive therapy') to prevent relapse (flare-ups) versus no topical corticosteroids/reactive application Nine trials assessed this comparison, generally lasting 16 to 20 weeks. We pooled seven trials that compared weekend (proactive) topical corticosteroids therapy versus no topical corticosteroids (1179 participants, children and adults with a range of eczema severities, though mainly moderate or severe). Weekend (proactive) therapy probably results in a large decrease in likelihood of a relapse from 58% to 25% (risk ratio (RR) 0.43, 95% CI 0.32 to 0.57; 7 trials, 1149 participants; moderate-certainty evidence). Local adverse events We did not identify any cases of abnormal skin thinning in seven trials that assessed skin thinning (1050 participants) at the end of treatment. We assessed this evidence as low certainty. Other comparisons  Other comparisons included newer versus older preparations of topical corticosteroids (15 trials), cream versus ointment (7 trials), topical corticosteroids with wet wrap versus no wet wrap (6 trials), number of days per week applied (4 trials), different concentrations of the same topical corticosteroids (2 trials), time of day applied (2 trials), topical corticosteroids alternating with topical calcineurin inhibitors versus topical corticosteroids alone (1 trial), application to wet versus dry skin (1 trial) and application before versus after emollient (1 trial). No trials compared branded versus generic topical corticosteroids and time between application of emollient and topical corticosteroids.

AUTHORS' CONCLUSIONS

Potent and moderate topical corticosteroids are probably more effective than mild topical corticosteroids, primarily in moderate or severe eczema; however, there is uncertain evidence to support any advantage of very potent over potent topical corticosteroids. Effectiveness is similar between once daily and twice daily (or more) frequent use of potent topical corticosteroids to treat eczema flare-ups, and topical corticosteroids weekend (proactive) therapy is probably better than no topical corticosteroids/reactive use to prevent eczema relapse (flare-ups). Adverse events were not well reported and came largely from low- or very low-certainty, short-term trials. In trials that reported abnormal skin thinning, frequency was low overall and increased with increasing potency. We found no trials on the optimum duration of treatment of a flare, branded versus generic topical corticosteroids, and time to leave between application of topical corticosteroids and emollient. There is a need for longer-term trials, in people with mild eczema.

Efficacy and Safety of Novel Formulation of Clobetasol Propionate 0.025% Cream in Indian Moderate-to-Severe Psoriasis Patients: Phase-2a, Randomized 3-Arm Study

INTRODUCTION

Clobetasol propionate (0.05% standard dose formulation), a topical corticosteroid, leads to systemic side-effects like hypothalamic-pituitary-adrenal (HPA) axis suppression at doses as low as 2 g/day. The aim of this study was to evaluate HPA axis suppression, efficacy, and safety of clobetasol propionate (0.025%, formulation 5 and 13) versus currently marketed 0.05% cream in Indian patients with moderate-to-severe psoriasis.

METHODS

In this phase 2a investigator-blinded study, patients aged ≥ 18 years with moderate-to-severe psoriasis were randomized 1:1:1 to receive clobetasol propionate 0.025% formulation 5, or 13, or 0.05% cream; twice daily for 28 days. Safety endpoints included adrenocorticotropic hormone (ACTH) test results at day 28 (primary), and local tolerability at each visit (burning/stinging/pruritus, secondary). Efficacy endpoints included Psoriasis Global Assessment (PGA) score.

RESULTS

Overall, 88 patients received clobetasol propionate 0.025% formulation 5 and 13 (n = 29 for both) and 0.05% cream (n = 30). At day 28, the proportion of patients with an abnormal ACTH stimulation test (cortisol levels ≤ 18 µg/dl) was numerically lower in 0.025% formulations: 5 (20.7%) and 13 (17.2%) compared with 0.05% cream (30.0%), (p = 0.320). Decrease in burning/stinging /pruritus scores were comparable in all treatment groups and PGA success rates were higher with 0.025% formulations: 5 (38.9%) and 13 (36.8%) compared with 0.05% cream (30.8%).

CONCLUSION

Clobetasol propionate 0.025% could be an effective treatment for moderate-to-severe psoriasis compared with 0.05% cream, demonstrating comparable efficacy with a better systemic safety profile.

TRIAL REGISTRATION NUMBER

REF/2018/01/016779.

Reference values for salivary cortisol in healthy young infants by liquid chromatography-tandem mass spectrometry

BACKGROUND

Sampling of salivary cortisol is non-invasive and important for the evaluation of the hypothalamic-pituitary-adrenal axis function and stress levels. However, the reference values for salivary cortisol measured by liquid chromatography-tandem mass spectrometry (LC-MS/MS) in healthy infants are unclear. The aim of this study was to establish the reference values for salivary cortisol levels in healthy infants.

METHODS

This study was a prospective observational cohort study following the participants until the age of 6 months. We analyzed 71 healthy, full-term infants at age 1 month between December 2017 and March 2018. We repeated saliva sampling every month, measured the salivary cortisol levels in the early morning by LC-MS/MS, and took the subjects' medical history by questionnaire.

RESULTS

The minimum, 25th, 50th, 75th percentile, and maximum salivary cortisol levels were 0.08, 1.11, 2.21, 5.18, and 30.35 nmol/L, respectively.

CONCLUSIONS

We established the reference values for salivary cortisol in young infants using LC-MS/MS.

Breaking the Itch-Scratch Cycle: Topical Options for the Management of Chronic Cutaneous Itch in Atopic Dermatitis

Chronic itch is an unpleasant sensation that triggers a desire to scratch that lasts for six weeks or more. It is a major diagnostic symptom of myriad diseases, including atopic dermatitis for which it is the most prominent feature. Chronic itch can be hugely debilitating for the sufferer, damaging in terms of both the monetary cost of treatment and its socioeconomic effects, and few treatment options exist that can adequately control it. Corticosteroids remain the first line treatment strategy for atopic dermatitis, but due to the risks associated with long-term use of corticosteroids, and the drawbacks of other topical options such as topical calcineurin inhibitors and capsaicin, topical options for itch management that are efficacious and can be used indefinitely are needed. In this review, we detail the pathophysiology of chronic pruritus, its key features, and the disease most commonly associated with it. We also assess the role of the skin and its components in maintaining a healthy barrier function, thus reducing dryness and the itch sensation. Lastly, we briefly detail examples of topical options for the management of chronic pruritus that can be used indefinitely, overcoming the risk associated with long-term use of corticosteroids.

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.

The Efficacy and Tolerability of Clobetasol Propionate Foam 0.05% in the Treatment of Mild to Moderate Plaque-Type Psoriasis of Nonscalp Regions

Background:

Clobetasol propionate foam 0.05% (Connetics Corporation, Palo Alto, CA) is approved by the United States Food and Drug Administration for the treatment of corticosteroid-responsive scalp dermatoses, but there is only limited data available for its efficacy and tolerability in treating dermatoses which affect nonscalp sites.

Objective:

The efficacy and tolerability of clobetasol propionate foam (clobetasol foam) in treating psoriatic lesions at nonscalp sites was evaluated in a multicenter, randomized, double-blinded, placebo-controlled study of 279 patients with mild to moderate plaque-type psoriasis.

Methods:

The patients applied clobetasol foam or placebo to the psoriatic lesions twice daily for two weeks. In addition to receiving clinical evaluations, the study patients completed a questionnaire evaluating various characteristics of the foam formulation, including their preference for its use and their projected likelihood to comply with similar therapy in a nonstudy environment.

Results:

At Week 2 (or end of treatment), 68% (94/139) of patients who received clobetasol foam had a Physician's Static Global Assessment score of 0 (clear, except for minor residual discoloration) or 1 (majority of lesions have individual scores for plaque thickness, erythema, and scaling that averages 1). This was significantly more than the 21% (30/140) observed in the placebo group ( P < 0.0001). Similar results were obtained for the Patient's Global Assessment score at Week 2 and in changes (from Baseline to Week 2) in the scores for the signs of psoriasis at a target lesion and for pruritus. Adverse effects were generally limited to mild and transient burning or other application site reactions in only a few patients in each treatment group. In the patient's poststudy questionnaire (completed at Week 2, or end of treatment) a majority of patients rated the characteristics of the foam formulation very highly. The patients ranked the foam formulation as superior to other topical formulations based on factors impacting their quality of life and indicated they would be more likely to comply with a recommended course of therapy with the foam formulation than with other topical formulations.

Conclusion:

Clobetasol propionate foam 0.05% is safe and effective for the treatment of plaque-type psoriasis on scalp and nonscalp areas, when applied twice daily for two weeks. As it is understood that patient dissatisfaction with select topical formulations affects their compliance with therapy, which necessarily affects the effectiveness of the therapy, the results of the patient's poststudy questionnaire suggest that there are multiple and integrated benefits for the use of clobetasol foam in the treatment of psoriasis of nonscalp sites.

Ethical use of topical corticosteroids

Dermatologists rely very heavily on corticosteroids for treating many common dermatoses. Concerns about their incorrect use are widely expressed both in lay public and specialist discourse. From the point of view of medical ethics, issues of autonomy, beneficence and non-maleficence are all raised frequently when we prescribe topical corticosteroids to our patients. We need to be aware of situations when conflicts between these issues arise and have a clear thought process about resolving them. This can only be achieved if we have a thorough understanding of the skin disease being treated coupled with expertise in the use of the varied potencies and available dosage forms of topical corticosteroids. A good understanding of human psychology and effective communication is also needed to use these agents optimally.

Cushing's syndrome: hidden risk in usage of topical corticosteroids

Iatrogenic Cushing's syndrome in children may occur as a result of the application of exogenous steroids. Prolonged use of powerful corticosteroids suppresses adrenal functions and iatrogenic Cushing's syndrome may develop particularly in infants who are given topical corticosteroids. We report here a case on three infants having Cushing's syndrome with similar clinical presentations due to overuse of topical steroids for diaper dermatitis. The importance of exercising caution during the use of topical steroids is underlined in this study.

Maximal Usage Trial: An Overview of the Design of Systemic Bioavailability Trial for Topical Dermatological Products

Dermatologic diseases can present in varying forms and severity, ranging from the individual lesion and up to almost total skin involvement. Pharmacokinetic assessment of topical drug products has previously been plagued by bioanalytical assay limitations and the lack of a standardized study design. Since the mid-1990's the US Food and Drug Administration has developed and implemented a pharmacokinetic maximal usage trial (MUsT) design to help address these issues. The MUsT design takes into account the following elements: the enrollment of patients rather than normal volunteers, the frequency of dosing, duration of dosing, use of highest proposed strength, total involved surface area to be treated at one time, amount applied per square centimeter, application method and site preparation, product formulation, and use of a sensitive bioanalytical method that has been properly validated. This paper provides a perspective of pre-MUsT study designs and a discussion of the individual elements that make up a MUsT.

Role of the ACTH test and estimation of a safe dose for high potency steroids in vitiligo: A prospective randomized study

BACKGROUND

Topical corticosteroids are used as first line of therapy for vitiligo, although side effects such as adrenal insufficiency are possible.

OBJECTIVES

To establish the role of ACTH test before, during, and after treatment with high potency topical steroids; to determine if adrenal insufficiency occurs secondary to the use of high potency topical steroids in patients with vitiligo and intact cutaneous barrier; and also to determine response to treatment and side effects.

MATERIALS AND METHODS

Forty-four adults with non-segmental vitiligo affecting 20% or less of the body surface area were included and randomized to receive topical clobetasol propionate 0.05% cream (group 1) or placebo (group 2) for 12 weeks, with a maximum dose of 50 g per week. The placebo group was crossed over after week 6 and started on clobetasol until completion of the study. Serum cortisol levels with the 1 μg ACTH test were determined at baseline and on weeks 6 and 12.

RESULTS

No adrenal insufficiency was detected nor statistical significance was achieved when comparing cortisol levels between and within the groups at baseline and weeks 6 and 12. Group 1 had a better response to therapy but with more side effects.

CONCLUSIONS

Doses of 50 g or less per week of clobetasol during a period of 12 weeks are safe on adult vitiligo patients, although local side effects are possible. Repigmentation rates were incomplete with single steroid therapy, making combined therapy a better option.

Intralesional injection versus mouth rinse of triamcinolone acetonide in oral lichen planus: a randomized controlled study

OBJECTIVE

To compare the efficacy, relapse, and adverse effects between intralesional injection and mouth rinse of triamcinolone acetonide (TA) in patients with oral lichen planus (OLP).

STUDY DESIGN

A randomized controlled study.

SETTING

College medical center.

SUBJECTS AND METHODS

Forty consecutive patients, who had been diagnosed with OLP, were recruited. Participants were randomly divided into 2 groups using intralesional injection or mouth rinse of TA. The severity of pain and burning sensation on a 10-cm visual analog scale (VAS) and the Oral Health Impact Profile-14 (OHIP-14) were assessed at weeks 0, 1, 2, 3, 4, and 6. The signs of OLP were quantified using a special scoring system for OLP. The rate of relapse and the adverse effects were compared between both groups.

RESULTS

The VAS scores for pain and burning mouth sensation and objective scoring for OLP were significantly improved at 1, 2, 3, 4, and 6 weeks in both groups. The changes in the VAS for burning mouth sensation, OHIP-14, and objective scoring for OLP were similar between both groups. The change in the VAS for pain from baseline to week 1 in the intralesional injection group was significantly higher than in the mouth rinse group. The rate of adverse effects was significantly higher in the mouth rinse group than in the intralesional injection group (44.4% vs 5.0%).

CONCLUSION

The efficacies of both treatments were similar. The rate of adverse effects was significantly lower for intralesional injection of TA than mouth rinse of TA.

Rational and ethical use of topical corticosteroids based on safety and efficacy

Topical corticosteroids (TC) have greatly contributed to the dermatologist's ability to effectively treat several difficult dermatoses. The available range of formulations and potency gives flexibility to treat all groups of patients, different phases of disease, and different anatomic sites. However, the rapid rise in incidence of improper use of these drugs by dermatologists, general physicians, and patients threatens to bring disrepute to the entire group of these amazing drugs. Responsibility to disseminate proper knowledge regarding when, where, and how to use TC both to internists and patients rests primarily with the dermatologist. Benefits of rational and ethical use and the harm of overuse and misuse for nonmedical, specially for cosmetic purposes, should be clearly conveyed before penning a prescription involving TC. Simultaneous efforts to use political, legal, and other institutions to prevent misuse of these drugs by rationing their availability only through proper prescriptions will greatly help the cause. This will hopefully bring down both the extremes of ever increasing cases of steroid-induced dermatoses on one hand and the irrational fears of using TC in well justified indications on the other.

Evaluation of the atrophogenic potential of topical corticosteroids in pediatric dermatology patients

We conducted a cross-sectional observational study to determine the atrophogenic potential of TCS in children with dermatitis requiring long-term TCS suppression. Children who were able to achieve good disease control, with a maximum Eczema Area and Severity Index score of 1.0, using TCS were examined for adverse effects of treatment. Cutaneous atrophy was assessed using a validated dermoscopic technique. Cutaneous sites exposed to TCS were compared with nonexposed sites in all patients. There was no significant atrophy in 70 TCS-exposed and 22 TCS-naïve children. Mild grade 1 telangiectasia of the cubital fossa was observed in 3.3% of the test group and 3.1% of the control group (p > 0.99). We conclude that routine, appropriate, long-term use of TCS in children with dermatitis does not cause skin atrophy. These data do not support the widely held belief that routine use of TCS will "thin the skin." Parents, pharmacists, and health practitioners should be confident about the safety of using this treatment.

Management of hemangiomas and other vascular tumors

Vascular tumors of childhood are typically benign. The 4 most common types are infantile hemangioma (IH), congenital hemangioma (CH), kaposiform hemangioendothelioma (KHE), and pyogenic granuloma (PG). Vascular tumors must be differentiated from vascular malformations. Although tumors and malformations may appear as raised, blue, red, or purple lesions, their management differs significantly.

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.

Widespread use of toxic skin lightening compounds: medical and psychosocial aspects

Hyperpigmentation disorders and skin lightening treatments have a significant impact on the dermatologic, physiologic, psychologic, economic, social, and cultural aspects of life. Skin lightening compounds, such as hydroquinone and topical corticosteroids, are often used to treat hyperpigmentation disorders, such as melasma, or lighten skin for cosmetic purposes. Despite their established effectiveness, a multitude of dermatologic and systemic complications have been associated with these agents. Regulatory agencies have also recognized the adverse effects of skin lighteners and many countries around the world now forbid the production and sale of these compounds, although this prohibition has not significantly curtailed distribution. Dermatologists and users of cosmetic products should be aware of the various components in bleaching compounds, their potential adverse effects, and alternative options for skin lightening.

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.

Scleroderma renal crisis following widespread application of topical triamcinolone

A 52-year-old patient with early diffuse scleroderma (Scl) developed scleroderma renal crisis (SRC) following exposure to topical steroid cream. She had applied a larger-than-prescribed quantity of triamcinolone acetonide 0.1% cream all over her body for 3 months, the absorption of the cream being the equivalent of 7.5 mg of oral prednisone per day. Her SRC was subsequently managed successfully with aggressive antihypertensive therapy and hemodialysis, and she was discharged home. High-dose corticosteroids (CS) have long been implicated in the development of SRC, but topical and low-dose CS until now have not. In our opinion, low-dose CS and a predisposing clinical setting appeared sufficient to provoke SRC and may broaden the proscription against CS in Scl.

Role of topical calcineurin inhibitors in the treatment of seborrheic dermatitis: a review of pathophysiology, safety, and efficacy

Seborrheic dermatitis (SD) is characterized by erythematous pruritic patches and plaques with greasy scale that occur in sebaceous areas. It is common, affecting up to 3% of the population. Past treatments have relied on a wide variety of anti-inflammatory and antifungal agents, but corticosteroids have limited use because of long-term adverse effects. Topical calcineurin inhibitors provide a safe alternative for the treatment of SD, as these drugs block the inflammatory cascade involved in the disease process and pose no risk of skin atrophy. Studies of topical pimecrolimus and tacrolimus in the treatment of SD have found that improvement occurred within 2 weeks, and if SD recurred after stopping treatment, it was significantly less severe. There have been no studies of the comparative efficacy of pimecrolimus versus tacrolimus for the treatment of SD. Common adverse effects of mild burning and irritation have been associated with the use of both of these agents. Safety profile studies are limited to studies of atopic dermatitis, which show no increase in infection rate, photocarcinogenicity, or signs of immunosuppression in patients using topical calcineurin inhibitors for long-term treatment. This article reviews the clinical trials of pimecrolimus and tacrolimus in the treatment of SD, focusing on efficacy and safety.

Steriods in the treatment of lichen planus: a review

Steroids have been found to be effective in treating symptomatic oral lichen planus (OLP) by reducing pain and inflammation. In fact, systemic corticosteroids should be reserved for acute exacerbation, and multiple or widespread lesions. They may be indicated in patients whose condition is unresponsive to topical steroids. However, various potent topical steroids have been reported to be effective in the treatment of symptomatic OLP. They can be used as the first line drugs in the treatment of OLP with no serious side-effects. During the therapy, candidiasis was commonly found and in addition, bad taste, nausea, dry mouth, sore throat and swollen mouth may occur as minor side-effects from some topical steroids. Because OLP is a chronic disorder that requires long-term treatment, topical steroids are recommended for the treatment OLP because of minimal side-effects and the cost benefit. This manuscript reviews the use of steroids, especially its topical application, in the treatment of OLP.

Cushing's Syndrome Induced by Misuse of Moderate- to High-Potency Topical Corticosteroids

Objective:

To report a case of Cushing's syndrome caused by continuous use of moderate- to high-potency topical corticosteroids over several months.

Case Summary:

An 11-month-old patient with atopic dermatitis received uninterrupted treatment with moderate- to high-potency topical corticosteroids. He presented with several food allergies and was admitted to the hospital after atopic dermatitis worsened. Signs of growth retardation, which had begun at 6 months of age, were also noted during the child's hospital stay. An endocrinologist concluded that a lower-than-normal bone density scan and growth retardation on both weight and growth curves were due to suppression of the hypothalamic–pituitary–adrenal (HPA) axis and a multifactorial failure to thrive.

Discussion:

This is a case of an infant overexposed to topical corticosteroid treatment who developed Cushing's syndrome within a few months. Local treatment of atopic dermatitis is classically based on the use of topical corticosteroids in combination with an emollient or other drugs. To limit local and general damaging effects, the choice of topical corticosteroid must be made in terms of patient age, severity and site of the rash, and the extent of skin involvement. Several factors influence the systemic absorption of topical corticosteroids. While our literature review indicated the possibility of a multifactorial origin of the child's growth retardation, the use of topical corticosteroids was shown to have contributed to suppression of the HPA axis. Application of the Naranjo probability scale indicated a probable relationship between the continuous and sustained administration of topical corticosteroids over several months and suppression of the HPA axis. Although topical corticosteroids are widely used and can be perceived by parents and patients to be safe, daily documentation of agents used and body surfaces exposed should be done during long-term treatment.

Conclusions:

Continuous use of moderate- to high-potency topical corticosteroids over several months can contribute to Cushing's syndrome. Growth and development as well as cortisol levels should be monitored in children on long-term topical corticosteroid treatment.

Two cases of Cushing's syndrome due to overuse of topical steroid in the diaper area

Topical use of corticosteroids may cause immunosuppression and iatrogenic Cushing's syndrome via hypothalamic-pituitary-adrenal axis. We report two cases with iatrogenic Cushing's syndrome with different clinical outcomes due to abuse of same potent topical steroid clobetasol propionate. One of them died because of fatal disseminated cytomegalovirus infection. The other patient recovered completely. Physicians and parents should be informed about the adverse effects of such potent topical corticosteroids and physicians should prescribe less potent agents, especially during infancy.

Effect of immunosuppression on patients undergoing bariatric surgery

BACKGROUND

Immunocompromised patients are at high risk of medical complications. Immunosuppression might be a relative contraindication to bariatric surgery. We describe our experience with immunosuppressed patients undergoing bariatric surgery and review the safety, efficacy, results, and outcomes.

METHODS

We performed a retrospective review of prospectively collected data. All patients taking long-term immunosuppressive medications or with a diagnosis of an immunosuppressive condition were included in this study. Data on weight loss, co-morbidities, complications, and postoperative immunosuppression were collected.

RESULTS

From July 1999 to February 2008, 1566 patients underwent bariatric surgery. Of these 1566 patients, 61 (3.9%) were taking immunosuppressive medications or had an immunosuppressive condition. Of these 61 patients, 49 were taking immunosuppressive medications for asthma, autoimmune disorders, endocrine deficiency, or chronic inflammatory disorders. The medications included oral, inhaled, and topical glucocorticoids for 39 patients and other immunosuppressive or disease-modifying antirheumatic drugs for 24 patients. The bariatric procedures included laparoscopic Roux-en-Y gastric bypass in 55, laparoscopic revisional procedures in 5, and laparoscopic sleeve gastrectomy in 1. No patient died perioperatively. A total of 26 complications occurred in 20 patients. The average percentage of excess weight loss was 72% (range 20-109%) at 1 year postoperatively. At a median postoperative follow-up of 18 months (range 2-68.6), 25 (51%) of 49 patients no longer required immunosuppressive medications owing to improvement of their underlying disease. Obesity-related health problems (diabetes mellitus, hypertension, obstructive sleep apnea, gastroesophageal reflux disease, asthma) had resolved or improved in 80-100% of patients.

CONCLUSION

The results of our study have shown that immunocompromised patients can safely undergo bariatric surgery with good weight loss results and improvement in co-morbidities. A large percentage of patients were able to discontinue immunosuppressive medications postoperatively.

Low basal serum cortisol in patients with severe atopic dermatitis: potent topical corticosteroids wrongfully accused

BACKGROUND

Topical corticosteroids are used extensively to treat inflammatory skin disorders including atopic dermatitis (AD). Several studies have described temporary reversible suppression of hypothalamic-pituitary-adrenal function. However, sound evidence of permanent disturbance of adrenal gland function is lacking.

OBJECTIVES

To relate basal cortisol levels to prior use of topical corticosteroids and disease activity in patients with moderate to severe AD and to investigate the effect on basal serum cortisol levels of topical corticosteroid treatment during hospitalization.

METHODS

Two groups of patients with AD were evaluated: 25 inpatients with severe AD who required hospitalization (group 1) and 28 outpatients with moderate to severe AD (group 2). In group 1, morning basal serum cortisol levels were measured twice, at admission and at discharge; in group 2, morning basal serum cortisol levels were measured once. Use of topical corticosteroids in the 3 months prior to the cortisol measurement was recorded and disease activity was monitored using the Six Area, Six Sign Atopic Dermatitis (SASSAD) score and serum thymus and activation-regulated chemokine (TARC) levels.

RESULTS

On admission, basal cortisol levels in group 1 were significantly (P < 0.001) decreased in 80% of the patients. In group 2, the basal cortisol levels were normal in all but three patients. Comparing the two groups, group 1 on admission had a significantly lower cortisol level than that of group 2 (P < 0.001). Disease activity in group 1 on admission was significantly higher than that of group 2 (P < 0.001). There was no difference in use of topical corticosteroids in the 3 months before cortisol measurement. At discharge in group 1 there was a significant increase (P < 0.0001) of basal cortisol levels and a significant (P < 0.001) decrease in disease activity reflected by the decrease in serum TARC levels and SASSAD score.

CONCLUSIONS

Disease activity, rather than the use of topical corticosteroids, is responsible for the low basal cortisol values in patients with severe AD.