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Monge Chacón AG, Wang C, Waqar D, Syeda SA, Kumar R, Meghana DR. Long-Term Usage of Oral Glucocorticoids Leading to Adrenal Insufficiency: A Comprehensive Review of the Literature. Cureus 2023; 15:e38948. [PMID: 37309331 PMCID: PMC10257969 DOI: 10.7759/cureus.38948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/09/2023] [Indexed: 06/14/2023] Open
Abstract
Systemic glucocorticoid therapy is used worldwide by one to three percent of the general population and 0.5-1.8% on long-term oral glucocorticoid use. It is widely used in conditions such as inflammation, autoimmune diseases, and cancer to inhibit inflammatory responses. One of the possible undesirable side effects of exogenous corticosteroid treatment is adrenal suppression upon discontinuation of the medication and adrenal insufficiency after utilizing the supraphysiologic doses for more than one month. To prevent patients from the unwanted signs and symptoms of adrenal insufficiency, including fatigue, gastrointestinal upset, anorexia/weight loss, etc., better management of the quantity and frequency of exogenous corticosteroid use, as well as better education before starting its use, is needed. For patients actively on exogenous corticosteroids, a close follow-up must be in place to avoid adrenal suppression after the eventual discontinuation of their use. This review article summarizes the important studies to date on this subject, especially oral glucocorticoid use, and analyzes risks such as dose, duration of exposure, and comorbidities of adrenal insufficiency associated with oral glucocorticoid use. We comprehensively include information on those with primary adrenal insufficiency and pediatric patients, hoping to provide better insight and clinical reference.
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Affiliation(s)
| | - Chen Wang
- Medicine, China Medical University, Taichung, TWN
| | - Danish Waqar
- Internal Medicine, Nephrology, Loyola University Medical Center, Chicago, USA
| | | | - Rohan Kumar
- Medicine, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, IND
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Matejek N, Hoos J, Holterhus PM, Bettendorf M, Choukair D. Topical glucocorticoid application causing iatrogenic Cushing's syndrome followed by secondary adrenal insufficiency in infants: two case reports. J Med Case Rep 2022; 16:455. [PMID: 36476353 PMCID: PMC9730575 DOI: 10.1186/s13256-022-03659-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 10/25/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Iatrogenic Cushing's syndrome induced by oral and parenteral glucocorticoid administration is a well-known complication. Immediate withdrawal from exogenous steroids can lead to life-threatening adrenal insufficiency. However, Cushing's syndrome caused by topical treatment with glucocorticoids, such as dexamethasone eye drops or dermal application, is rarely recognized. Young infants in particular are at high risk of suffering from iatrogenic Cushing's syndrome when treated with highly potent topical glucocorticoids. CASE PRESENTATION We present a 6-month-old Syrian boy with cushingoid face after dermal clobetasol cream treatment and a 2-year-old Iranian girl with severe growth retardation after application of dexamethasone eye drops. Both families have a migration background and language barriers. In both cases no endogenous cortisol secretion was initially detected in serum and in 24-hour collected urine. After dose reduction of glucocorticoids, severity of symptoms was reversible and serum cortisol was detectable. DISCUSSION AND CONCLUSION Young infants are at high risk of developing Cushing's syndrome from topically applied highly potent glucocorticoids. Precise recommendations of treatment dosage, duration, and frequency must be given to the parents, and if necessary, with the help of an interpreter. Monitoring of height and weight as well as regular pediatric follow-ups should be scheduled. Physicians should be aware of potential adrenal insufficiency following withdrawal from long-term topical glucocorticoid treatment, and hydrocortisone treatment should be considered.
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Affiliation(s)
- Nicola Matejek
- Paediatric Endocrinology and Diabetes, Children’s Department Klinikum Worms, Worms, Germany
| | - Johannes Hoos
- grid.5253.10000 0001 0328 4908Division of Paediatric Endocrinology and Diabetes, Department of Paediatrics, University Children’s Hospital Heidelberg, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
| | - Paul Martin Holterhus
- grid.412468.d0000 0004 0646 2097Division of Paediatric Endocrinology and Diabetes, Department of Pediatrics I, University Hospital of Schleswig Holstein, UKSH, Campus Kiel, Kiel, Germany
| | - Markus Bettendorf
- grid.5253.10000 0001 0328 4908Division of Paediatric Endocrinology and Diabetes, Department of Paediatrics, University Children’s Hospital Heidelberg, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
| | - Daniela Choukair
- grid.5253.10000 0001 0328 4908Division of Paediatric Endocrinology and Diabetes, Department of Paediatrics, University Children’s Hospital Heidelberg, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
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Katsura M, Sato T, Morita K, Ishii T, Kishi K, Hasegawa T. Iatrogenic Cushing syndrome due to topical corticosteroids after skin graft surgery for giant nevus: A case report. Pediatr Dermatol 2022; 39:147-148. [PMID: 34989020 DOI: 10.1111/pde.14910] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 12/03/2021] [Accepted: 12/21/2021] [Indexed: 11/28/2022]
Abstract
Iatrogenic Cushing syndrome (ICS) may be caused by exposure to corticosteroid therapy. We report a case of ICS caused by topical corticosteroids applied to the skin after skin graft surgery. We presume that the development of ICS, in this case, was attributed to a combination of skin barrier disruption, usage of high-potency corticosteroids, broad application area/ large quantity of the corticosteroid, and the extended treatment period. Patients may be at risk for ICS after extensive skin graft surgery if large amounts of very potent topical corticosteroids are applied for an extended period to prevent scar formation or relieve itching.
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Affiliation(s)
- Minori Katsura
- Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan
| | - Takeshi Sato
- Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan
| | - Kumiko Morita
- Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan
| | - Tomohiro Ishii
- Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan
| | - Kazuo Kishi
- Department of Plastic and Reconstructive Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Tomonobu Hasegawa
- Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan
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Kanthagnany SK, Lane LC, Wood C, Sachdev P, Drake AJ, Cheetham T. Fifteen-minute consultation: An approach to the child receiving glucocorticoids. Arch Dis Child Educ Pract Ed 2021; 106:130-135. [PMID: 32769084 DOI: 10.1136/archdischild-2019-317812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 05/04/2020] [Accepted: 06/30/2020] [Indexed: 11/03/2022]
Abstract
Glucocorticoids (GC) are used in paediatric practice for a broad range of conditions and all paediatricians will prescribe GC, in some form, during their career. A wide variety of GC formulations, doses and administration routes are used for periods of time ranging from days to years. Exposure to exogenous GC can result in hypothalamic-pituitary-adrenal axis suppression-otherwise known as adrenal suppression (AS). Patients with AS may be well most of the time but if GC therapy is reduced or stopped or if additional endogenous GC cannot be generated during illness, then an absolute or relative lack of GC can result in severe illness or death. Here, we highlight the relevance of AS to all paediatricians by providing an overview of the background and discussing the presentation and approaches to the management of this clinical entity.
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Affiliation(s)
| | - Laura C Lane
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK.,Department of Paediatric Endocrinology, Great North Children's Hospital, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - Claire Wood
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK.,Department of Paediatric Endocrinology, Great North Children's Hospital, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - Pooja Sachdev
- Paediatrics, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Amanda Jane Drake
- University/BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Timothy Cheetham
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK .,Department of Paediatric Endocrinology, Great North Children's Hospital, Royal Victoria Infirmary, Newcastle upon Tyne, UK
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5
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Goldbloom EB, Ahmet A. Screening practices for paediatric asymptomatic adrenal suppression in Canada: Are we addressing this important risk? Paediatr Child Health 2019; 25:389-393. [PMID: 34163543 DOI: 10.1093/pch/pxy174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Accepted: 09/28/2018] [Indexed: 11/13/2022] Open
Abstract
Background Children with adrenal suppression (AS), a potential side effect of glucocorticoids (GCs) may be asymptomatic, present with nonspecific signs and symptoms or with adrenal crisis. Asymptomatic AS (AAS) can only be diagnosed through screening. Identifying and treating asymptomatic patients before symptoms develop may reduce morbidity. Screening guidelines for AS are lacking. Consequently, screening practices are highly variable. Objective To assess (1) the screening practices for and recognition of paediatric AAS among clinicians in Canada and (2) the educational impact of a 2-year surveillance program of symptomatic AS cases. Methods Before and after a 2-year Canadian Paediatric Surveillance Program (CPSP) study of symptomatic AS, participants were surveyed through the CPSP. The prestudy survey was sent to 2,548 participants in March 2010 and the poststudy survey was sent to 2,465 participants in April 2013. Results Response rates were 32% for the prestudy survey and 21% for the poststudy survey. Between the pre- and poststudy surveys, the percentage of physicians who reported routinely screening patients on GCs for AS increased from 10% to 21% and the percentage who reported having a screening policy in their office/centre increased from 6% to 11%. There was no significant change in the percentage of physicians who had diagnosed a child/youth with AAS in the preceding year. Conclusion Frequency of screening for AAS increased following the 2-year study but remains low. Development of a clinical practice guideline should increase both awareness of asymptomatic AS among Canadian paediatricians and the identification of AAS, before symptoms develop.
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Affiliation(s)
- Ellen B Goldbloom
- Department of Pediatrics (Endocrinology), Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario
| | - Alexandra Ahmet
- Department of Pediatrics (Endocrinology), Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario
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Wood Heickman LK, Davallow Ghajar L, Conaway M, Rogol AD. Evaluation of Hypothalamic-Pituitary-Adrenal Axis Suppression following Cutaneous Use of Topical Corticosteroids in Children: A Meta-Analysis. Horm Res Paediatr 2018; 89:389-396. [PMID: 29898449 DOI: 10.1159/000489125] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Accepted: 04/09/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/AIMS A meta-analysis was performed to determine the likelihood of hypothalamic-pituitary-adrenal (HPA) axis suppression following short-term cutaneous treatment of atopic dermatitis with topical corticosteroids (TCS) in pediatric patients. METHODS All published pediatric clinical trials evaluating TCS use with pre- and post-treatment HPA axis assessment by cosyntropin stimulation testing were included. RESULTS Of 128 eligible trials, 12 were selected for meta-analysis with a total of 522 participants. There were 20 observed cases of HPA axis suppression (3.8%, 95% CI 2.4-5.8). The percentage of HPA axis suppression with low- (classes 6-7), medium- (classes 3-5) and high-potency (classes 1-2) TCS use was 2% (3 of 148 patients, 95% CI 0.7-5.8), 3.1% (7 of 223 patients, 95% CI 1.5-6.3), and 6.6% (10 of 151 patients, 95% CI 3.6-11.8), respectively. CONCLUSION There is a low rate of reversible HPA axis suppression with the use of mid- to low-potency TCS compared to more potent formulations. In pediatric clinical practice, the limited use of mid- to low-potency TCS is rarely associated with clinically significant adrenal insufficiency or adrenal crisis. In the absence of signs and symptoms of adrenal insufficiency, there is little need to test the HPA axis of these patients.
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Affiliation(s)
- Lauren K Wood Heickman
- Department of Pediatrics, Division of Endocrinology, University of Virginia, Charlottesville, Virginia, USA
| | - Ladan Davallow Ghajar
- Department of Pediatrics, Division of Endocrinology, University of Virginia, Charlottesville, Virginia, USA
| | - Mark Conaway
- Department of Public Health Sciences, University of Virginia, Charlottesville, Virginia, USA
| | - Alan D Rogol
- Department of Pediatrics, Division of Endocrinology, University of Virginia, Charlottesville, Virginia, USA
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Özgüç Çömlek F, Örüm S, Aydın S, Tütüncüler F. Exogenous Cushing syndrome due to misuse of potent topical steroid. Pediatr Dermatol 2018; 35:e121-e123. [PMID: 29315782 DOI: 10.1111/pde.13409] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
We report an infant with exogenous Cushing syndrome after being treated for 2 months with a potent topical corticosteroid via the mother's application of topical clobetasol for diaper rash without a prescription. We emphasize that potent topical steroids should be used with great caution, especially when used under occlusion (e.g., diaper area) and that parents should be warned about potential side effects of these medications, particularly when used in infants.
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Affiliation(s)
- Fatma Özgüç Çömlek
- Division of Pediatric Endocrinology, School of Medicine, Trakya University, Edirne, Turkey
| | - Sevim Örüm
- Department of Pediatrics, School of Medicine, Trakya University, Edirne, Turkey
| | - Salih Aydın
- Department of Pediatrics, School of Medicine, Trakya University, Edirne, Turkey
| | - Filiz Tütüncüler
- Division of Pediatric Endocrinology, School of Medicine, Trakya University, Edirne, Turkey
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8
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Goldbloom EB, Mokashi A, Cummings EA, Abish S, Benseler SM, Huynh HQ, Watson W, Ahmet A. Symptomatic adrenal suppression among children in Canada. Arch Dis Child 2017; 102:338-339. [PMID: 28320817 DOI: 10.1136/archdischild-2016-311223] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Revised: 10/11/2016] [Accepted: 10/13/2016] [Indexed: 01/21/2023]
Abstract
BACKGROUND Adrenal suppression (AS) is an under-recognised side effect of glucocorticoid (GC) use. AS may go undetected until a physiological stress precipitates an adrenal crisis. The incidence of AS has not been established. We sought to estimate the minimum national incidence and presenting features of paediatric symptomatic AS. METHODS Through the established methodology of the Canadian Paediatric Surveillance Program, over 2500 paediatricians were surveyed monthly for 2 years (April 2010-March 2012) to report new cases of symptomatic AS. RESULTS Forty-six cases of symptomatic AS were confirmed. The estimated annual incidence is 0.35/100 000 children aged 0-18 years (95% CI 0.26 to 0.47). The most common presentations were growth failure (35%), non-specific symptoms (28%) or both (13%). Adrenal crisis occurred in six cases (13%). Thirty-seven children (80%) had received inhaled corticosteroid (ICS) alone or in combination with other GC forms. Many children received high but commonly prescribed doses of ICS. CONCLUSIONS AS is responsible for significant morbidity in children, including susceptibility to adrenal crisis. The minimal estimated incidence reported is for the entire paediatric population and would be much higher in the at-risk group (ie, children treated with GCs). Close monitoring of growth and possible symptoms of AS, which may be non-specific, are important in children on all forms of GC therapy including ICS. To reduce the risk of AS, physicians must be aware of the risk of AS, revisit GC doses frequently and use the lowest effective dose.
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Affiliation(s)
- Ellen B Goldbloom
- Department of Pediatrics (Endocrinology), Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
| | - Arati Mokashi
- Department of Pediatrics (Endocrinology), IWK Health Centre, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Elizabeth A Cummings
- Department of Pediatrics (Endocrinology), IWK Health Centre, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Sharon Abish
- Department of Pediatrics (Hematology Oncology), Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Susanne M Benseler
- Department of Pediatrics (Rheumatology), Alberta Children's Hospital, University of Calgary, Calgary, Alberta, Canada
| | - Hien Q Huynh
- Department of Pediatrics (Gastroenterology), Stollery Children's Hospital, University of Alberta, Edmonton, Alberta, Canada
| | - Wade Watson
- Department of Pediatrics (Allergy), IWK Health Centre, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Alexandra Ahmet
- Department of Pediatrics (Endocrinology), Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
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Orton S, Censani M. Iatrogenic Cushing's Syndrome Due to Intranasal Usage of Ophthalmic Dexamethasone: A Case Report. Pediatrics 2016; 137:peds.2015-3845. [PMID: 27244810 DOI: 10.1542/peds.2015-3845] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/17/2016] [Indexed: 11/24/2022] Open
Abstract
Iatrogenic Cushing's syndrome (ICS) is caused by exogenous corticosteroid administration with suppression of the hypothalamic-pituitary-adrenal axis. It has been commonly described with oral and topical steroid use, but scarce reports have documented intranasal steroid usage as the etiology in infancy. In this article, we describe a case of a 4-month-old infant who developed ICS after 6 weeks of intranasal dexamethasone ophthalmic solution administration for nasal obstruction. To our knowledge, this is the youngest patient reported with ICS due to intranasal use of a prescribed dose of an ophthalmic steroid. His hypothalamic-pituitary-adrenal axis recovered fully 4.5 months after steroid discontinuation. Because of the small body surface area and supine position during administration, infants are particularly susceptible to ICS. Given that intranasal steroids are commonly prescribed to infants and children for a variety of diagnoses, this case highlights the risks inherent in the use of intranasal steroid drops, particularly in young infants, for both adrenal suppression and linear growth deceleration, even with short-term use. Close monitoring of these patients' height and weight should occur while on steroid treatment, with every effort made to decrease or discontinue steroid use when possible.
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Affiliation(s)
- Sarah Orton
- Division of Pediatric Endocrinology, Department of Pediatrics, Weill Cornell Medicine, New York Presbyterian Hospital, New York, New York
| | - Marisa Censani
- Division of Pediatric Endocrinology, Department of Pediatrics, Weill Cornell Medicine, New York Presbyterian Hospital, New York, New York
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Glavas-Dodov M, Simonoska-Crcarevska M, Sulevski V, Slaveska Raicki R, Starova A. Assessment of attitudes towards the use of topical corticosteroids among patients, prescribers and pharmacists in the Republic of Macedonia. MAKEDONSKO FARMACEVTSKI BILTEN 2016. [DOI: 10.33320/maced.pharm.bull.2016.62.01.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Apart from the time-proven, gold standard treatment of many topical conditions with corticosteroids, the phobia of using topical corticosteroids (TCs) is a phenomenon unveiled among groups of patients, parents, as well as health professionals. Health professionals’ attitude to TCs could have a significant impact on the trend of TCs-phobia among patients. Therefore, it is essential to address this issue as TCs-phobia is something which could also have important implications in medication adherence and compliance to prescribed treatment. Bearing in mind that no survey had been conducted to investigate this matter in Republic of Macedonia (RM), a self-completed questionnaire has been created to assess attitudes and their prevalence associated with TCs-phobia among patients and health professionals with aim to describe the attitude, explore the reasons behind revealed phenomenon and define directions for future interventions needed to advance the healthcare in this field. Our findings show that the TCs-phobia is present among surveyed population (21.6 and 34.22% of all responders expressed negative attitudes or fear of TCs use, respectively). It is also concluded that ~27% of patients on TCs-therapy admitted that they feared of using the medication. However, there is a higher frequency of negative attitudes regarding the use of TCs among the health professionals (~39%) than among patients, where the TCs-phobia is more prominent among non-dermatologists than dermatologists. Moreover, negative attitude and fear of TCs use is universal among paediatricians (73.91%). Portrayed interventions needed to identify and manage the TCs-phobia can lead to improvement of adherence and predicted responsiveness of TCs-therapy.
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Mooney E, Rademaker M, Dailey R, Daniel BS, Drummond C, Fischer G, Foster R, Grills C, Halbert A, Hill S, King E, Leins E, Morgan V, Phillips RJ, Relic J, Rodrigues M, Scardamaglia L, Smith S, Su J, Wargon O, Orchard D. Adverse effects of topical corticosteroids in paediatric eczema: Australasian consensus statement. Australas J Dermatol 2015; 56:241-51. [DOI: 10.1111/ajd.12313] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Accepted: 01/08/2015] [Indexed: 11/30/2022]
Affiliation(s)
- Emma Mooney
- Department of Paediatric Dermatology; Royal Children's Hospital; Melbourne Victoria
| | - Marius Rademaker
- Department of Dermatology; Waikato Hospital; Hamilton New Zealand
| | | | - Ben S Daniel
- Department of Paediatric Dermatology; Royal Children's Hospital; Melbourne Victoria
| | - Catherine Drummond
- Department of Dermatology; Canberra Hospital; Canberra Australian Capital Territory
- Australian National University; Canberra Australian Capital Territory
| | - Gayle Fischer
- Department of Dermatology; Royal North Shore Hospital; Sydney New South Wales
- Sydney Medical School; University of Sydney; Sydney New South Wales
| | - Rachael Foster
- Department Paediatric Dermatology; Princess Margaret Hospital for Children; Perth Western Australia Australia
| | - Claire Grills
- Department of Paediatric Dermatology; Royal Children's Hospital; Melbourne Victoria
| | - Anne Halbert
- Department Paediatric Dermatology; Princess Margaret Hospital for Children; Perth Western Australia Australia
| | - Sarah Hill
- Department of Dermatology; Waikato Hospital; Hamilton New Zealand
| | - Emma King
- Department of Paediatric Dermatology; Royal Children's Hospital; Melbourne Victoria
| | - Elizabeth Leins
- Department of Paediatric Dermatology; Royal Children's Hospital; Melbourne Victoria
| | - Vanessa Morgan
- Department of Paediatric Dermatology; Royal Children's Hospital; Melbourne Victoria
- Department of Dermatology; Royal Melbourne Hospital; Melbourne Victoria
| | - Roderic J Phillips
- Department of Paediatrics; Monash University; Melbourne Victoria
- Department of Vascular Biology; Royal Children's Hospital; Melbourne Victoria
- Murdoch Children's Research Institute; Melbourne Victoria
| | - John Relic
- Department of Dermatology; Royal Newcastle Centre; Newcastle New South Wales
| | - Michelle Rodrigues
- Department of Paediatric Dermatology; Royal Children's Hospital; Melbourne Victoria
- Department of Dermatology; St Vincent's Hospital; Melbourne Victoria
| | - Laura Scardamaglia
- Department of Paediatric Dermatology; Royal Children's Hospital; Melbourne Victoria
- University of Melbourne; Melbourne Victoria
- Department of Dermatology; Royal Melbourne Hospital; Melbourne Victoria
- Department of Dermatology; Western Hospital; Melbourne Victoria
| | - Saxon Smith
- Department of Dermatology; Royal North Shore Hospital; Sydney New South Wales
- Sydney Medical School; University of Sydney; Sydney New South Wales
| | - John Su
- Department of Paediatric Dermatology; Royal Children's Hospital; Melbourne Victoria
- University of Melbourne; Melbourne Victoria
- Department of Dermatology, Eastern Health; Murdoch Children's Research Institute; Melbourne Victoria
- Monash University; Melbourne Victoria
- Murdoch Children's Research Institute; Melbourne Victoria
| | - Orli Wargon
- Department Paediatric Dermatology; Sydney Children's Hospital; Sydney New South Wales
| | - David Orchard
- Department of Paediatric Dermatology; Royal Children's Hospital; Melbourne Victoria
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12
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Cushing syndrome after bilateral lensectomy. Eur J Pediatr 2015; 174:399-401. [PMID: 25535172 DOI: 10.1007/s00431-014-2477-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2014] [Revised: 12/09/2014] [Accepted: 12/10/2014] [Indexed: 10/24/2022]
Abstract
UNLABELLED Iatrogenic Cushing syndrome induced by oral and parenteral corticosteroid administration is a well-known complication, and necessary precautions have to be taken. Cushing syndrome, however, following treatment with glucocorticoid-containing eye drops is a very rare complication. To the best of our knowledge, there have been only four reported cases in the literature. Herein, we present an infant boy who developed Cushing syndrome after receiving dexamethasone-containing eye drops after bilateral cataract extraction to prevent postoperative inflammatory complications. At the age of 5 months, after approx. 3 months of dexamethasone therapy, the patient presented with cushingoid facies, nephrocalcinosis and failure to grow. Iatrogenic Cushing syndrome was diagnosed and dexamethasone-containing eye drops were reduced and eventually stopped. Follow-up examinations revealed catch-up growth. CONCLUSION Ocularly administered corticosteroids may have substantial systemic side effects in infants.
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Farahani LA, Ghobadzadeh M, Yousefi P. Comparison of the effect of human milk and topical hydrocortisone 1% on diaper dermatitis. Pediatr Dermatol 2013; 30:725-9. [PMID: 23600719 DOI: 10.1111/pde.12118] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Diaper dermatitis is one of the most common skin problems in infants and children, affecting between 7% and 35% of infants. This randomized clinical trial compared the efficacy of hydrocortisone 1% ointment with that of human breast milk in treating acute diaper dermatitis in infants ages 0 to 24 months. Infants with diaper rash were treated with either hydrocortisone 1% ointment (n = 70) or human breast milk (n = 71) for 7 days. Improvement in the rash from baseline was seen in both treatment groups on days 3 and 7; there was no significant difference in total rash scores on days 3 and 7. Treatment with human breast milk was as effective as hydrocortisone 1% ointment alone. Human breast milk is an effective and safe treatment for diaper dermatitis in infants.
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Affiliation(s)
- Leila Amiri Farahani
- Department of Midwifery, School of Nursing and Midwifery, Arak University of Medical Sciences, Arak, Iran
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14
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Levin E, Gupta R, Butler D, Chiang C, Koo JYM. Topical steroid risk analysis: Differentiating between physiologic and pathologic adrenal suppression. J DERMATOL TREAT 2013; 25:501-6. [DOI: 10.3109/09546634.2013.844314] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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Begriche K, Massart J, Robin MA, Borgne-Sanchez A, Fromenty B. Drug-induced toxicity on mitochondria and lipid metabolism: mechanistic diversity and deleterious consequences for the liver. J Hepatol 2011; 54:773-94. [PMID: 21145849 DOI: 10.1016/j.jhep.2010.11.006] [Citation(s) in RCA: 365] [Impact Index Per Article: 28.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2010] [Revised: 11/05/2010] [Accepted: 11/09/2010] [Indexed: 02/08/2023]
Abstract
Numerous investigations have shown that mitochondrial dysfunction is a major mechanism of drug-induced liver injury, which involves the parent drug or a reactive metabolite generated through cytochromes P450. Depending of their nature and their severity, the mitochondrial alterations are able to induce mild to fulminant hepatic cytolysis and steatosis (lipid accumulation), which can have different clinical and pathological features. Microvesicular steatosis, a potentially severe liver lesion usually associated with liver failure and profound hypoglycemia, is due to a major inhibition of mitochondrial fatty acid oxidation (FAO). Macrovacuolar steatosis, a relatively benign liver lesion in the short term, can be induced not only by a moderate reduction of mitochondrial FAO but also by an increased hepatic de novo lipid synthesis and a decreased secretion of VLDL-associated triglycerides. Moreover, recent investigations suggest that some drugs could favor lipid deposition in the liver through primary alterations of white adipose tissue (WAT) homeostasis. If the treatment is not interrupted, steatosis can evolve toward steatohepatitis, which is characterized not only by lipid accumulation but also by necroinflammation and fibrosis. Although the mechanisms involved in this aggravation are not fully characterized, it appears that overproduction of reactive oxygen species by the damaged mitochondria could play a salient role. Numerous factors could favor drug-induced mitochondrial and metabolic toxicity, such as the structure of the parent molecule, genetic predispositions (in particular those involving mitochondrial enzymes), alcohol intoxication, hepatitis virus C infection, and obesity. In obese and diabetic patients, some drugs may induce acute liver injury more frequently while others may worsen the pre-existent steatosis (or steatohepatitis).
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Affiliation(s)
- Karima Begriche
- Department of Metabolism and Aging, The Scripps Research Institute, Jupiter, FL 33458, USA
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Tempark T, Phatarakijnirund V, Chatproedprai S, Watcharasindhu S, Supornsilchai V, Wananukul S. Exogenous Cushing's syndrome due to topical corticosteroid application: case report and review literature. Endocrine 2010; 38:328-34. [PMID: 20972726 DOI: 10.1007/s12020-010-9393-6] [Citation(s) in RCA: 72] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2010] [Accepted: 08/24/2010] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Therdpong Tempark
- Division of Dermatology, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand
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Affiliation(s)
- Lisa-Ann Fraser
- Department of Medicine, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario
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Messina MF, Valenzise M, Aversa S, Arrigo T, De Luca F. Iatrogenic Cushing syndrome caused by ocular glucocorticoids in a child. BMJ Case Rep 2009; 2009:bcr11.2008.1224. [PMID: 21686405 DOI: 10.1136/bcr.11.2008.1224] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A boy aged 7.6 years presented to our Unit of Paediatric Endocrinology for evaluation of obesity. Progressive weight gain (10 kg) started 6 months earlier after an accidental penetrating orbital injury on the right eye. During this period the child has been treated with oral betamethasone (0.5 mg/day) for 1 month and dexamethasone 2% ocular drops (2 hourly by day) for 6 months. Physical examination showed he was 113.5 cm in height (-1.5 SD), weight 36.0 kg, blood pressure 110/90 mmHg (90th centile), body mass index 28 (+5 SD), truncal obesity, buffalo hump, "moon-face", increased lanugo hair and supraclavicular fullness. Endocrinological work-up revealed undetectable levels of basal adrenocorticotropic hormone (ACTH), basal and ACTH-stimulated cortisol and 24 h urine excretion cortisol, confirming the diagnosis of iatrogenic Cushing syndrome. The abrupt withdrawal of ocular glucocorticoids by the parents evoked two adrenal crises; 4 months later the patient recovered. In conclusion, we would alert doctors that every formulation of glucocorticoids, no ocular drops excluded, can determine severe systemic side effects and iatrogenic Cushing syndrome.
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Affiliation(s)
- Stephen Lowis
- Department of Paediatric and Adolescent Oncology, Bristol Royal Hospital for Children, Bristol, UK.
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Coureau B, Bussières JF, Tremblay S. Cushing's Syndrome Induced by Misuse of Moderate- to High-Potency Topical Corticosteroids. Ann Pharmacother 2008; 42:1903-7. [DOI: 10.1345/aph.1l067] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
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.
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Affiliation(s)
| | - Jean-François Bussières
- Pharmacy Department, Centre Hospitalier Universitaire Sainte-Justine; Faculty of Pharmacy, University of Montreal, Quebec, Canada
| | - Stéphanie Tremblay
- Pharmacy Department, Centre Hospitalier Universitaire Sainte-Justine; Faculty of Pharmacy, University of Montreal
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Bibliography. Current world literature. Adrenal cortex. Curr Opin Endocrinol Diabetes Obes 2008; 15:284-299. [PMID: 18438178 DOI: 10.1097/med.0b013e3283040e80] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Bibliography. Current world literature. Growth and development. Curr Opin Endocrinol Diabetes Obes 2008; 15:79-101. [PMID: 18185067 DOI: 10.1097/med.0b013e3282f4f084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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