Topical corticosteroid-induced adrenocortical insufficiency: clinical implications

Higher cumulative dose of topical corticosteroids is associated with osteoporosis and major osteoporotic fracture: A nationwide case-control study

BACKGROUND

Connections between long-term use of topical corticosteroids (TCSs) of varying potency and osteoporosis and major osteoporotic fracture (MOF) are unclear. Susceptibility to adverse bone effects of TCSs in different sex, age and ethnic groups is unknown too.

OBJECTIVES

To demonstrate the association between cumulative dose of TCSs of varying potency and osteoporosis and MOF in Taiwanese population, with stratified analysis of sex and age.

METHODS

We conducted a nationwide case-control study and obtained data from Taiwan National Health Insurance Research Database. Cumulative TCS doses in different exposure periods were calculated, and the potency of TCSs was converted to prednisolone equivalent. Adjusted odds ratios (ORs) with 95% confidence intervals (CIs) were calculated for osteoporosis and MOF associated with TCS use.

RESULTS

From 2017 to 2020, 129,682 osteoporosis cases and 34,999 MOF cases were selected and randomly matched with 518,728 and 139,996 controls by sex and age. We found clear dose-response relationships between long-term TCS exposure and osteoporosis and MOF. For example, compared to no TCS use, adjusted ORs of osteoporosis were 1.216 (95% CI 1.189-1.243), 1.260 (95% CI, 1.241-1.280) and 1.341 (95% CI, 1.314-1.369) for exposure to low, medium and high cumulative TCS doses, respectively, over 5 years. Adjusted ORs of MOF were 1.118 (95% CI 1.069-1.170), 1.191 (95% CI, 1.156-1.227) and 1.288 (95% CI, 1.238-1.340) for exposure to low, medium and high cumulative TCS doses, respectively, over 5 years. Stratified analysis showed women had higher ORs of osteoporosis and MOF compared to men. Younger people (<50 years) had highest OR of osteoporosis compared to other age groups.

CONCLUSIONS

Higher cumulative TCS dose was associated with increased risk of osteoporosis and MOF. Long-term use of TCSs should be cautious, especially in susceptible populations such as women and young people.

Clinical and Laboratory Differences between Steroid-associated and Non-steroid-associated Rosacea: A Retrospective Study

Abstract is missing (Short communication)

Adrenal Insufficiency after Long-term use of Topical Glucocorticoids in Patients with Advanced Cutaneous T-cell Lymphomas: A Case Series

Abstract is missing (Short communication)

The effect of biopolymer gel derived from sugarcane on healing of traumatic oral ulcers: an experimental study

PURPOSE

The extracellular polysaccharide (EPS) is produced by the bacterium Zoogloea sp. and plays a positive role in tissue repair. The purpose of this study was to clinically and histologically compare the effects of EPS in the healing of traumatic oral ulcers in rats with the effects of triamcinolone.

METHODS

Ulcers were induced in the oral mucous of 45 male Wistar rats, divided into three groups: control group, treated with triamcinolone, and treated with biopolymer gel. In the clinical evaluation, we considered the weight variation of the animals and the size of the lesion area, at baseline and on treatment days 1, 3 and 7. The histological parameters evaluated were the type and intensity of the inflammatory infiltration, the presence of necrosis and foreign body granuloma and the degree of re-epithelialization of the lesion.

RESULTS

The reduction of the lesion area was greater in the animals treated with EPS, with no difference in the intensity of the inflammatory infiltration between the groups on days 3 and 7 of treatment.

CONCLUSIONS

The results suggest that topical application of EPS in traumatic oral ulcers of rats promotes faster repair than triamcinolone ointment, without increasing the intensity of inflammatory infiltration under the lesion.

Novel tactile bottle neck adaptor facilitates eye drop adherence in visually impaired patients

PURPOSE

To test the use of Ring-IT, a novel 3D tactile bottle neck adaptor in topical eye drop adherence in visually impaired patients.

METHODS

Bottle neck ring adaptors with either one, two or three protrusions with cube or sphere endings were designed. In phase 1, low vision was simulated in healthy subjects (n=20) with a 20/200 vision simulator; while in phase 2, visually impaired patients (n=26; 20/70 or worse) were recruited. Subjects were randomised to six combinations of varying protrusions and shapes on medication bottles and asked to identify these traits at different presentations. Responses and time to identify were recorded.

RESULTS

Phase 1: 98.3% of subjects correctly identified the number of protrusions. Mean time to identify was 4.5±6.1 s. Identification success for cube and sphere end pieces were 91.7% and 73.3%, with average time for identification of 9.9±7.6 and 10.9±9.0 s. In phase 2, 92.3% of subjects correctly identified the number of protrusions. Mean time to identify was 6.0±3.0 s. Identification success for cube and sphere end pieces were 78.2% and 74.4%; with average time for identification of 7.5±4.8 and 8.5±5.6 s, respectively.

CONCLUSIONS

Ring-IT was identified with accuracy and speed by both low vision simulated subjects, and by patients with true limited visual capabilities. These tactile bottle neck ring adaptors can be used as an assistive low vision aid device and may increase eye drop regimen adherence in visually impaired patients.

Current Screening Strategies for the Diagnosis of Adrenal Insufficiency in Children

Adrenal insufficiency can arise from a primary adrenal disorder, secondary to adrenocorticotropic hormone deficiency, or by suppression of hypothalamic-pituitary-adrenal axis due to exogenous glucocorticoids. Diagnosis of adrenal insufficiency is usually delayed because the initial presentation is often subtle and nonspecific. Clinician awareness and recognition is crucial for timely diagnosis to avoid adrenal crisis. Current screening strategies for the diagnosis of adrenal insufficiency in children in various clinical situations are discussed in this review.

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.

Pathogenesis, multi-omics research, and clinical treatment of psoriasis

Psoriasis is a common inflammatory skin disease involving interactions between keratinocytes and immune cells that significantly affects the quality of life. It is characterized by hyperproliferation and abnormal differentiation of keratinocytes and excessive infiltration of immune cells in the dermis and epidermis. The immune mechanism underlying this disease has been elucidated in the past few years. Research shows that psoriasis is regulated by the complex interactions among immune cells, such as keratinocytes, dendritic cells, T lymphocytes, neutrophils, macrophages, natural killer cells, mast cells, and other immune cells. An increasing number of signaling pathways have been found to be involved in the pathogenesis of psoriasis, which has prompted the search for new treatment targets. In the past decades, studies on the pathogenesis of psoriasis have focused on the development of targeted and highly effective therapies. In this review, we have discussed the relationship between various types of immune cells and psoriasis and summarized the major signaling pathways involved in the pathogenesis of psoriasis, including the PI3K/AKT/mTOR, JAK-STAT, JNK, and WNT pathways. In addition, we have discussed the results of the latest omics research on psoriasis and the epigenetics of the disease, which provide insights regarding its pathogenesis and therapeutic prospects; we have also summarized its treatment strategies and observations of clinical trials. In this paper, the various aspects of psoriasis are described in detail, and the limitations of the current treatment methods are emphasized. It is necessary to improve and innovate treatment methods from the molecular level of pathogenesis, and further provide new ideas for the treatment and research of psoriasis.

Experimental and clinical trial investigations of phyto-extracts, phyto-chemicals and phyto-formulations against oral lichen planus: A systematic review

ETHNOPHARMACOLOGICAL RELEVANCE

Bio-assay guided phytoextracts and derived phytoconstituents reported having multipotent biological activities and nearly 60-80% of the global population still using natural regimens as an alternative therapeutic source. This study focused on the ethnopharmacological and experimental evidence of natural remedies that are effective in treating oral lichen planus (OLP), a chronic T-cell mediated autoimmune disease that is associated with oral cancer transmission.

AIM OF THE REVIEW

A number of studies have shown that antioxidants and antiinflammatory phytoextracts and phyto-constituents are effective against OLP. In this systematic review, we summarize the details of experimentally assessed ancient Traditional Chinese Medicine (TCM), Indian Ayurveda or Ayurvedic Medicine, and Japanese Kampo Medicine (JKM) regimens (crude extracts, individual phytochemicals, and phyto-formulations) that reduce oral lesion, severity index and pain associated with OLP based on studies conducted in vivo, in vitro, and in randomized controlled trials (RCTs).

MATERIALS AND METHODS

Experimental, clinical and RCT investigation reports were gathered and presented according to PRISMA-2020 format. Briefly, the information was obtained from PubMed, ScienceDirect, Wiley journal library, Scopus, Google Scholar with ClinicalTrials.gov (a clinical trial registry database operated by the National Library of Medicine in the United States). Further, individual phytochemical structures were verified from PubChem and ChemSpider databases and visualized by ChemDraw 18.0 software.

RESULTS

We summarized 11 crude phytoextracts, 7 individual phytochemicals, 9 crude formulations, 8 specific TCM and JKM herbal cocktails, and 6 RCTs/patents corroborated by multiple in vitro, in vivo and enzyme assay methods. Briefly, plants and their family name, used plant parts, reported phytochemicals and their chemical structure, treatment doses, and duration of each experiment were presented more concisely and scientifically.

CONCLUSION

Documentation of evidence-based natural ethnomedicines or remedies could be useful for promoting them as potential, cost-effective and less toxic alternatives or as complementary to commonly prescribed steroids towards the control of OLP.

In search of disambiguation: development of eye drop bottle sleeves to aid in identification and survey among possible users. A cross-sectional study

BACKGROUND

Considerable numbers of individuals present low vision, blindness, illiteracy and other conditions that could possibly impair their identification of medications, such as eye drops. Through helping these individuals to identify their eye drops, they can achieve greater autonomy. Misidentification can be avoided through use of multisensory sleeves that can be adapted to most eye drop bottles. Correct use of eye drops is important for preventing progression of diseases like glaucoma that could potentially lead to blindness.

OBJECTIVE

To develop bottle sleeves to aid in identification of eye drops and then interview a group of possible users to evaluate the acceptance of the solution.

DESIGN AND SETTING

Cross-sectional survey performed at an ophthalmological clinic in São Paulo (SP), Brazil.

METHODS

We describe the development of multisensory sleeves to assist in identification of eye drops. To assess the acceptance of this solution, we interviewed 18 patients who were currently using three or more types of eye drops.

RESULTS

We developed four prototypes for eye drop bottle sleeves and conducted an acceptance test on them. Most of the patients who answered the survey about the sleeves were elderly. Most (95%) reported believing that the sleeves would help reduce the risk of mixing up eye drops with other medications that also dispense drops. They also believed that these would increase their autonomy in using eye drops.

CONCLUSION

The solution presented was well accepted and may help increase safety in using eye drops through preventing misidentification.

Prevalence of Adrenal Insufficiency and Glucocorticoid Use in Pediatric Pseudotumor Cerebri Syndrome

BACKGROUND

The pathophysiology underlying pseudotumor cerebri syndrome (PTCS) is complex and not well understood. There are clear differences between PTCS in adults and pediatrics. Few and isolated case reports have suggested that adrenal function may be involved, yet no large cohort study has examined this relationship.

METHODS

We conducted a retrospective single-center study of children who presented with a diagnosis of PTCS and had cortisol testing measured between January 2010 and September 2019. We included all subjects meeting the revised PTCS diagnostic criteria after the chart review. Based on morning, random or 1-μg cosyntropin stimulated cortisol levels, adrenal functioning was classified as: (1) insufficient (peak cortisol <16 μg/dL and AM cortisol <5 μg/dL), (2) at risk (peak cortisol 16-20 μg/dL, AM cortisol 5-13 μg/dL, or random <13 μg/dL), or (3) sufficient (peak cortisol >20 μg/dL and AM or random cortisol >13 μg/dL).

RESULTS

A total of 398 individuals were reviewed, and 64 were included for analysis. Of these, 40.6% were men, of mixed race and ethnicity with a mean age of 10.5 (SD 4.7) years. Of these, 23% and 52% had insufficient or at-risk cortisol levels. The majority of those in the insufficient (70%) or at-risk (80%) groups were exposed to topical, nasal, or inhaled glucocorticoids but not systemic. Only 60% and 12% of those with PTCS with insufficient or at-risk cortisol testing, respectively, underwent definitive testing with a stimulation test.

CONCLUSIONS

Glucocorticoid use and hypocortisolism are prevalent in PTCS and need consideration as a potential underlying cause. Most children had insufficient or at-risk cortisol levels, and many did not undergo further testing/workup. Children who present with PTCS, particularly young, males should be evaluated for adrenal insufficiency and its risk factors, including nonsystemic steroids. Prospective studies are necessary to further evaluate the effect of cortisol in relation to pediatric PTCS.

Novel Predictive Model for Adrenal Insufficiency in Dermatological Patients with Topical Corticosteroids Use: A Cross-Sectional Study

Purpose

This study aimed to identify predictive factors and to develop a predictive model for adrenal insufficiency (AI) related to topical corticosteroids use.

Methods

The research was conducted using a cross-sectional design. Adult patients with dermatological conditions who had been prescribed topical steroids for at least 12 months by the dermatology outpatient departments of the Faculty of Medicine, Chiang Mai University from June through October 2020 were included. Data on potential predictors, including baseline characteristics and laboratory investigations, were collected. The diagnoses of AI were based on serum 8AM cortisol and low-dose ACTH stimulation tests. Multivariable logistic regression was used for the derivation of the diagnostic score.

Results

Of the 42 patients, 17 (40.5%) had AI. The statistically significant predictive factors for AI were greater body surface area of corticosteroids use, age <60 years, and basal serum cortisol <7 µg/dL. In the final predictive model, duration of treatment was added as a factor based on its clinical significance for AI. The four predictive factors with their assigned scores were: body surface area involvement 10–30% (20), >30% (25); age <60 years old (15); basal serum cortisol of <7 µg/dL (30); and duration of treatment in years. Risk of AI was categorized into three groups, low, intermediate and high risk, with total scores of <25, 25–49 and ≥50, respectively. The predictive performance for the model was 0.92 based on area under the curve.

Conclusion

The predictive model for AI in patients using topical corticosteroids provides guidance on the risk of AI to determine which patients should have dynamic ACTH stimulation tests (high risk) and which need only close follow-up (intermediate and low risk). Future validation of the model is warranted.

Adrenocortical corticotropic insufficiency secondary to the use of cosmetic dermocorticoids

Voluntary depigmentation or artificial depigmentation for cosmetic purposes is a very widespread phenomenon in Africa. The prevalence reported by several authors varies from 26 to 67%. The complications linked to their use are numerous and less known by the population. We report two cases of acute adrenocortical insufficiency secondary to the use of cosmetic dermocorticoids in diabetic patients aged 40 and 53 years respectively. They were admitted with signs of ketoacidosis decompensation which were similar to signs of acute adrenal insufficiency. The cases’ history revealed that they were using dermocorticoids. The clinical examination identified in both patients a systemic inflammatory response syndrome and general depigmentation. The 40-year-old patient had erysipelas of the left leg and the 53-year-old patient had a diabetic foot with a neuropathic and infectious mechanism. Laboratory tests revealed hyperglycemia, massive acetonuria and a low 8-hour cortisol. The clinical outcome was favorable after hydro-electrolytic rehydration, hourly intravenous insulin therapy, hydrocortisone and antibiotic therapy. Corticotropic insufficiency secondary to voluntary depigmentation by dermocorticoids is a complication that should be systematically sought in any subject using dermocorticoids. Hydrocortisone substitution should be done without delay in the event of confirmed corticotropic insufficiency.

Pharmacological Management of Common Soft Tissue Lesions of the Oral Cavity

Soft tissue lesions commonly seen in the oral cavity tend to overlap in their onset, presentation, and location making it difficult to appreciate their etiology. In some instances, common oral soft tissue lesions can create confusion due to similar clinical appearance or unusual presentation; therefore, proper diagnosis of the lesion is key in pharmacologic management. In ulcerative conditions, topical steroids can decrease the symptoms and improve healing time, but do not affect the recurrence rate. Always be suspicious of soft tissue lesions that are nonresolving or recurrent lesions as they may warrant further investigation to rule out malignancy or associated systemic conditions. This article discusses key clinical presentations and the proper topical and systemic pharmacologic treatments.

The Effect of Mouthrinse with 0.05% Dexamethasone Solution on the Oral Bacterial Community of Oral Lichen Planus Patients: Prospective Pilot Study

Few studies have already been performed to assess oral bacteria during steroid therapy for oral lichen planus (OLP). Thus, the aim of our study was to analyze the effect of dexamethasone mouthrinse treatment on the oral bacteria of OLP patients. This prospective study was conducted on patients who were diagnosed with OLP and treated with 0.05% dexamethasone mouthrinse twice per day for 4 weeks. Using unstimulated saliva of the patients before and after treatment, the qualitative and quantitative changes in oral bacteria were analyzed using quantitative real-time polymerase chain reaction (qPCR). The qPCR results were analyzed using Wilcoxon signed-rank test to the quantitative changes with dexamethasone mouthrinse. The statistical significance was considered at a level of 0.05. In total, 20 patients were enrolled in this study, wherein all were noted to show improved symptoms of OLP. Fifteen patients (75%) had a qualitative change in the oral microbial species and an improved relative periodontitis risk score (from 26.1 ± 10.7 to 20.9 ± 9.2; p = 0.008). However, quantitative changes in all species were determined to be not statistically different before and after the treatment. Most OLP patients had a changed microbial community composition after 0.05% dexamethasone mouthrinse for 4 weeks. In particular, the composition of the periodontopathic bacteria was improved after the treatment.

[Cushing's syndrome with subsequent tertiary adrenocortical insufficiency after simultaneous multiple intra-articular local glucocorticoid treatment : Keep an eye on hormone deficiency conditions requiring treatment after multiple administrations of local steroids]

Eine 4‑jährige Patientin mit neu diagnostizierter polyartikulärer juveniler idiopathischer Arthritis (JIA) entwickelte nach simultaner multipler Lokaltherapie mit Glukokortikoiden an 46 Stellen zunächst ein Cushing-Syndrom, gefolgt von einer schleichenden Zustandsverschlechterung und schließlich einem akuten hochfieberhaften Harnwegsinfekt. Dabei wurde eine iatrogene Nebennierenrindeninsuffizienz nach der multiplen intraartikulären Glukokortikoidgabe diagnostiziert. Die Möglichkeit schwerer systemischer Glukokortikoidnebenwirkungen nach ausgedehnten Lokaltherapien sollte in das reguläre Management der JIA-Patienten einbezogen werden.

Safety and Effectiveness of Copaiba Oleoresin (C. reticulata Ducke) on Inflammation and Tissue Repair of Oral Wounds in Rats

In traditional communities of the Brazilian Amazon, the copaiba oleoresin (C. reticulata Ducke) is widely known for its therapeutic activity, especially its wound healing and anti-inflammatory actions. Our study aimed to evaluate these effects in oral lesions and the safety of the dosage proposed. A punch biopsy wound was induced on the ventral surface of the tongue of forty-five male Wistar rats under anesthesia. Animals were randomly allocated to one of three groups based on the treatment: control, corticoid and copaiba. A daily dose of each treatment and vehicle was administrated by oral gavage for three consecutive days. Sample collections took place on the third, seventh and 15th days post-wounding for clinical and histopathological analyses. Blood was collected on the third and seventh days for kidneys and liver function tests. Semi-quantitative analyses were performed based on scores of inflammation and reepithelization. Tissue collagen deposition was detected by PicroSirius red staining. Copaiba-treated wounds revealed a smaller wound area, decreased of acute inflammatory reaction and enhanced reepithelization. The levels of kidney and liver function tests did not reveal presence of damage post-treatments. Our findings suggest that copaiba oleoresin is a safe and effective alternative therapy for inflammation and tissue repair of oral wounds in this animal model.

Red Grape Polyphenol Oral Administration Improves Immune Response in Women Affected by Nickel-Mediated Allergic Contact Dermatitis

BACKGROUND

Our previous findings demonstrated that in vitro supplementation of polyphenols, extracted from seeds of red grape (Nero di Troia cultivar), to peripheral lymphomonocytes from patients affected by allergic contact dermatitis (ACD) to nickel (Ni) could reduce the release of proinflammatory cytokines and nitric oxide (NO), while increasing the levels of interleukin (IL)-10, an anti-inflammatory cytokine.

OBJECTIVE

To assess whether an intervention with oral administration of polyphenols leads to a reduction of peripheral biomarkers in ACD patients.

METHODS

At T0, 25 patients affected by ACD to Ni were orally administered with 300 mg polyphenols prodie extracted from seeds of red grape (Nero di Troia cultivar) (NATUR-OX®) for 3 months (T1). The other 25 patients affected by ACD to Ni received placebo only for the same period of time. Serum biomarkers were analyzed at T0 and T1. In both groups, seven dropouts were recorded.

RESULTS

At T1 in comparison to T0, in treated patients, values of interferon-γ, IL-4, IL-17, pentraxin 3 and NO decreased, while IL-10 levels increased when compared with T0 values. Conversely, in placebo- treated patients, no modifications of biomarkers were evaluated at T1.

CONCLUSION

Present laboratory data rely on the anti-oxidant, anti-inflammatory and anti-allergic properties of polyphenols.

Safety and efficacy of fixed-dose combination calcipotriol (50 μg/g) and betamethasone dipropionate (0.5 mg/g) cutaneous foam in adolescent patients (aged 12 to <17 years) with plaque psoriasis: results of a phase II, open-label trial

Background

Fixed‐dose combination of calcipotriol (50 μg/g; Cal) and betamethasone dipropionate (0.5 mg/g; BD) foam is approved for plaque psoriasis treatment in adults, with a paucity of data supporting use in adolescents.

Objectives

To evaluate safety of 4 weeks’ treatment with Cal/BD foam in adolescent patients with psoriasis, and additional safety outcomes in patients with more severe disease (HPA‐axis cohort). Primary objectives included treatment‐emergent adverse events (TEAEs) and systemic calcium levels in the overall population, and HPA‐axis function, change in calcium excretion and the calcium:creatinine ratio in the HPA‐axis cohort. Secondary objectives included exploratory efficacy endpoints [treatment success: change in Psoriasis Area and Severity Index (PASI)]. Systemic exposure to Cal/BD was also assessed.

Methods

A phase II, open‐label, study (NCT02387853) in patients (12 to <17 years) with at least mild psoriasis, to evaluate Cal/BD foam applied once daily for ≤4 weeks.

Results

In patients assigned to treatment (n = 106), 32 TEAEs occurred in 22 patients (20.8%). All but two TEAEs were mild; none led to study withdrawal or death. Changes (0–4 weeks) in albumin‐corrected serum calcium (overall population) and urinary calcium excretion (HPA‐axis cohort) were small, transient and not considered clinically relevant. In the HPA‐axis cohort, no change in urinary calcium:creatinine ratio was observed and responses to adrenocorticotropic–hormone (ACTH) challenge did not suggest disruption of the HPA‐axis. Prespecified treatment success on the body and scalp was achieved by 71.8% and 75.7% of the overall population, respectively. Mean PASI decreased by 82.0% vs. baseline at Week 4. Systemic exposure to Cal/BD was minimal.

Conclusions

Cal/BD foam was well tolerated in adolescent patients with body/scalp psoriasis. There was no evidence for dysregulation of the HPA‐axis nor calcium homoeostasis in patients with more severe disease. Exploratory efficacy data in the overall population were encouraging.

Safety and efficacy of topical, fixed-dose combination calcipotriene (0.005%) and betamethasone (0.064% as dipropionate) gel in adolescent patients with scalp and body psoriasis: a phase II trial

Background

Psoriasis is a disease that commonly manifests in adolescence. Up to half of adults with psoriasis develop it before the age of 20. Topical formulations containing corticosteroids and/or vitamin D3 analogs are recommended for treatment.

Objective

This phase II study aimed to evaluate the safety, including any potential effect on the hypothalamic–pituitary–adrenal axis and calcium metabolism, and efficacy of fixed‐dose combination calcipotriene (0.005%) and betamethasone (0.064% as dipropionate) (Cal/BD) gel in adolescents with psoriasis.

Methods

Patients aged 12 to <17 years, with at least mild psoriasis on the body and scalp, received topical Cal/BD gel once daily for ≤8 weeks. Safety response criteria included adverse drug reactions [ADRs; any adverse event (AE) possibly or probably related to treatment as determined by the investigator; a primary response criterion] and AEs (a secondary response criterion). Only treatment‐emergent AEs (events that occurred after the first application of Cal/BD gel or events which started before this and increased in intensity after the first application of Cal/BD gel) are presented here. Efficacy response criteria included controlled disease, by physician's global assessment of disease severity (PGA), following Cal/BD gel treatment.

Results

A total of 107 patients (median age 14 years; range 12–16) were enrolled and treated. Eight ADRs were observed in 7 (7%) patients and 38 (36%) patients experienced ≥1 AE. The most common AEs were headache [6 (6%) patients], nasopharyngitis [6 (6%) patients] and blood parathyroid hormone increased [4 (4%) patients]. One severe AE was reported (attempted suicide) but was considered unrelated to treatment. At the end of treatment, 58% of patients had controlled disease on the body and 69% on the scalp according to PGA.

Conclusion

In this uncontrolled phase II study, Cal/BD gel was well tolerated and effective for treating scalp and body psoriasis in adolescents.

Association Between Topical Corticosteroid Use and Type 2 Diabetes in Two European Population-Based Adult Cohorts

OBJECTIVE

Topical corticosteroids (CSs) are commonly used to treat inflammatory skin conditions including eczema and psoriasis. Although topical CS package inserts describe hyperglycemia and glycosuria as adverse drug reactions, it is unclear whether topical CS use in real life is also associated with an increased risk of type 2 diabetes (T2D).

RESEARCH DESIGN AND METHODS

Two matched case-control studies and one cohort study were conducted using routinely collected health care data from Denmark and the U.K. A total of 115,218 and 54,944 adults were identified as case subjects with new-onset T2D in the Danish and U.K. case-control study, respectively. For the Danish cohort study, 2,689,473 adults were included. The main exposure was topical CSs, and the outcome was incident T2D.

RESULTS

Topical CS was significantly associated with T2D in the Danish (adjusted odds ratio [OR] 1.25 [95% CI 1.23-1.28]) and U.K. (adjusted OR 1.27 [95% CI 1.23-1.31]) case-control studies. Individuals who were exposed to topical CSs had significantly increased risk of incident T2D (adjusted hazard ratio 1.27 [95% CI 1.26-1.29]). We observed significant dose-response relationships between T2D and increasing potency of topical CSs in the two Danish studies. The results were consistent across all sensitivity analyses.

CONCLUSIONS

We found a positive association between topical CS prescribing and incident T2D in Danish and U.K. adult populations. Clinicians should be cognizant of possible diabetogenic effects of potent topical CSs.

Multi-class determination of steroid hormones and antibiotics in fatty hotpot ingredients by pressurized liquid extraction and liquid chromatography-tandem mass spectrometry

Due to the misuse of hormones and antibiotics resulting in drug residues in meat products, serious concerns have arisen regarding to the potential risks for human health. In this paper, a simple and efficient method was developed to simultaneously quantify six steroid hormones and six antibiotics in fatty foods by combining pressurized liquid extraction (PLE) with ultra-high performance liquid chromatography-tandem mass spectrometry (UHPLC-MS/MS). Adsorbents, extraction temperature, extraction time, recycle time and several other parameters were optimized in current investigation. The optimized PLE method was employed by using n-hexane-methanol-acetonitrile (2:1:1, v/v/v) as extraction solvent, silica gel as lipid sorbent, and the optimum parameters were 60 °C, 1500 psi and 10 min, respectively. Under the optimal conditions, the recoveries of spiked samples ranged from 82.2% to 115.0%. The limits of quantifications (LODs) were from 0.4 to 25.0 μg/kg. The developed PLE method was successfully applied to analyze steroid hormones and antibiotics in 27 fatty foods of hotpot ingredients without any additional clean-up steps. The results showed that the residues of estradiol benzoate (EB) and enrofloxacin (EN) in some matrices were much higher than maximum residue limits (MRLs) value, especially EB in fish, which exceeded 176.7 μg/kg. The results demonstrated that the developed method was sensitive and efficient in testing hotpot ingredients, and was an excellent analytical tool for monitoring residues of steroid hormones and antibiotics in fatty foods.

Low Risk of Adrenal Insufficiency After Use of Low- to Moderate-Potency Topical Corticosteroids for Children With Atopic Dermatitis

Our objective was to assess the risk of adrenal insufficiency (AI) with short-term use of low- to moderate-potency topical corticosteroids (TCS) for treatment of atopic dermatitis. Our systematic literature search revealed 9 studies (n = 371) that evaluated AI using adrenocorticotropic hormone stimulation testing, with measures of serum cortisol levels at baseline and following at least 2 weeks of TCS application. Biochemical AI was defined by a stimulated cortisol level of ≤18.0 µg/dL (~500 nmol/L). The overall proportion of AI with low-to-moderate TCS use was 2.7% (95% confidence interval = 1.47% to 4.89%). None of the children showed any clinical evidence of AI or adrenal crisis. Short-term use of low- to moderate-potency TCS for the treatment of atopic dermatitis is associated with a low risk of adrenal suppression. General practitioners do not need to test these patients for adrenal suppression in the absence of concerning signs and symptoms of AI.

Evaluation of Hypothalamic-Pituitary-Adrenal Axis Suppression following Cutaneous Use of Topical Corticosteroids in Children: A Meta-Analysis

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.

The unresolved riddle of glucocorticoid withdrawal

Glucocorticoid (GC) therapy is the most common cause of adrenal insufficiency (AI). The real prevalence of AI after GC is unknown but it could involve more than 30% of patients. Some gene variation has been associated with the variability of hypothalamic-pituitary-adrenal (HPA) axis and this issue could contribute to the individual variation of adrenal function after GC treatment. Symptoms and signs of AI are nonspecific and frequently the diagnosis is delayed. Dosage, duration of treatment, administration route and serum cortisol value are not completely useful to predict AI. Clinical estimation of HPA suppression is difficult and biochemical testing is needed to confirm the diagnosis of AI. The different tapering regimens are based on a very low quality of evidence and considering the sizable individual variation, it is improbable that future research will find a secure GC tapering schedule for all patients. The aim of this review is to address the most important aspects in management of GC withdrawal in light of current knowledge.

Prevention of Flares in Children with Atopic Dermatitis with Regular Use of an Emollient Containing Glycerol and Paraffin: A Randomized Controlled Study

BACKGROUND/OBJECTIVES

Emollients are part of the standard treatment for atopic dermatitis (AD), although there is limited evidence that regular use of emollients as management therapy reduces the frequency of flares and corticosteroid consumption. The objective of this study was to evaluate the benefit of emollient use in the management of mild to moderate AD in children by assessing the ability of two different emollients (particularly V0034CR) to prevent flares and to reduce the use of corticosteroids.

METHODS

In this randomized, open-label study, patients with a current flare were treated with a potent topical corticosteroid. After flare resolution, patients were centrally randomized to V0034CR emollient, reference emollient, or no emollient (1:1:1 ratio) for 12 weeks. New flares were medically assessed before being treated with a moderately potent corticosteroid.

RESULTS

A total of 335 children 2 to 6 years of age were randomized. At 12 weeks, the percentage of patients with one or more flares was statistically significantly lower with V0034CR (35.1%) than without emollient (67.6%; p < 0.001). Fewer patients treated with V0034CR required any corticosteroids or immunosuppressants (23.6%) than patients with no emollient (43.3%) at 12 weeks. The difference was significant at all time points (p = 0.002). Patients treated with emollients had a longer time to first flare, fewer flares, higher complete remission rates, less corticosteroid consumption, lower Investigator Global Assessment scores, and lower Scoring Atopic Dermatitis scores than those who were not. V0034CR was well tolerated, with no specific safety concerns.

CONCLUSION

Regular emollient use in children with mild to moderate AD reduces flares and corticosteroid consumption.

Exogenous Cushing's syndrome due to a Chinese herbalist's prescription of ointment containing dexamethasone

Eczema in children is a chronic disabling condition. The impact of this condition on the lives of families is often underestimated by conventional physicians. As a consequence parents may investigate complementary treatment options. Close monitoring by a paediatrician is essential, considering that a variety of adverse effects can occur during the use of complementary treatment. We present a 5-year-old girl with eczema. She visited a Chinese herbalist who prescribed an ointment. The parents noticed that the eczema resolved fast, itching decreased and she was finally sleeping well. However, her behaviour changed and appetite increased. Undetectable levels of serum cortisol were found, which was indicative of exogenous Cushing's syndrome. Analysis of the ointment revealed the presence of dexamethasone. Hydrocortisone substitution and subsequently a reduction schedule were implemented, after which endogenous cortisol production recovered after 4 months. Physicians should be aware that unregistered herbal medicine can contain potent drugs such as glucocorticoids.

The effect of diode laser and topical steroid on serum level of TNF-alpha in oral lichen planus patients

Background

Oral lichen planus (OLP) is a common chronic inflammatory mucosal disease with a multifactorial etiology. It is a T-cell mediated autoimmune disease in which the cytotoxic CD8+T cells trigger apoptosis of the basal cells of oral epithelium. Various treatment regimens have been employed for management of symptomatic OLP. This study was carried out to evaluate the effect of topical steroids as well as laser on the clinical signs and symptoms detected by reticular, atrophic, erosive score (RAE score) and tumor necrosis factor- α (TNF-α) level in the serum of patients with symptomatic OLP.

Material and Methods

The study was conducted on twenty-four patients (18 females and 6 males) with symptomatic OLP that were allocated into two groups. Each included twelve patients. The first group treated either with diode laser (970nm SIROLaser Advance class IIIb, SIRONA The Dental Company, Germany) twice weekly with maximum of ten sessions while the second group were treated with topical corticosteroids (0.1% triamcinolone acetonide orabase, Kenacort-A Orabase Pomad, DEVA HOLDING A.Ș, Istanbul, Turkey) for four weeks.

Results

Corticosteroids group showed less clinical signs and symptoms of reticular, atrophic, erosive RAE score (p=0.02) and TNF-α serum level (p=0.028) than diode laser group with no reported therapy side effects or complications in any of the treated patients.

Conclusions

Topical steroids reduce pain, reticular, atrophic, erosive RAE score and TNF-α serum level more than laser treatment. Moreover, laser treatment can be used as an alternative treatment when steroids are contraindicated for the treatment of symptomatic OLP.

Key words:Oral lichen planus, diode laser, topical steroid, RAE score, TNF-α.

The risks of overlooking the diagnosis of secreting pituitary adenomas

Secreting pituitary adenomas that cause acromegaly and Cushing’s disease, as well as prolactinomas and thyrotroph adenomas, are uncommon, usually benign, slow-growing tumours. The rarity of these conditions means that their diagnosis is not familiar to most non-specialist physicians. Consequently, pituitary adenomas may be overlooked and remain untreated, and affected individuals may develop serious comorbidities that reduce their quality of life and life expectancy. Because many signs and symptoms of pituitary adenomas overlap with those of other, more common disorders, general practitioners and non-endocrinology specialists need to be aware of the “red flags” suggestive of these conditions. A long duration of active disease in patients with secreting pituitary adenomas is associated with an increased risk of comorbidities and reduced quality of life. Appropriate treatment can lead to disease remission, and, although some symptoms may persist in some patients, treatment usually reduces the incidence and severity of comorbidities and improves quality of life. Therefore, correct, early diagnosis and characterization of a pituitary adenoma is crucial for patients, to trigger timely, appropriate treatment and to optimize outcome. This article provides an overview of the epidemiology of hormonal syndromes associated with pituitary adenomas, discusses the difficulties of and considerations for their diagnosis, and reviews the comorbidities that may develop, but can be prevented, by accurate diagnosis and appropriate treatment. We hope this review will help general practitioners and non-endocrinology specialists to suspect secreting pituitary adenomas and refer patients to an endocrinologist for confirmation of the diagnosis and treatment.

Adrenal insufficiency

Adrenal insufficiency is a life-threatening condition that occurs secondary to impaired secretion of adrenal glucocorticoid and mineralocorticoid hormones. This condition can be caused by primary destruction or dysfunction of the adrenal glands or impairment of the hypothalamic-pituitary-adrenal axis. In children, the most common causes of primary adrenal insufficiency are impaired adrenal steroidogenesis (congenital adrenal hyperplasia) and adrenal destruction or dysfunction (autoimmune polyendocrine syndrome and adrenoleukodystrophy), whereas exogenous corticosteroid therapy withdrawal or poor adherence to scheduled corticosteroid dosing with long-standing treatment constitute the most common cause of acquired adrenal insufficiency. Although there are classic clinical signs (eg, fatigue, orthostatic hypotension, hyperpigmentation, hyponatremia, hyperkalemia, and hypoglycemia) of adrenal insufficiency, its early clinical presentation is most commonly vague and undefined, requiring a high index of suspicion. The relevance of early identification of adrenal insufficiency is to avoid the potential lethal outcome secondary to severe cardiovascular and hemodynamic insufficiency. The clinician must be aware of the need for increased corticosteroid dose supplementation during stress periods.

Safety and efficacy of calcipotriol plus betamethasone dipropionate gel in the treatment of scalp psoriasis in adolescents 12-17 years of age

Summary

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Managing Cushing's disease: the state of the art

Cushing's disease is a rare chronic disease caused by a pituitary adenoma, which leads to excess secretion of adrenocorticotropic hormone (ACTH). The over-production of ACTH leads to hyperstimulation of the adrenal glands and a chronic excess of cortisol, resulting in the signs and symptoms of a severe clinical state (Cushing's syndrome) that leads to significant morbidity, negative impacts on the patient's quality of life, and, if untreated, increased mortality. The management of patients with Cushing's disease is complicated by the heterogeneity of the condition, with signs and symptoms that overlap with those of other diseases, and high subclinical incidence rates. Controversies surrounding the tests used for screening and identifying patients with Cushing's disease add to the challenge of patient management. Surgical intervention to remove the adenoma is the first-line treatment for patients with Cushing's disease, but medical therapies are useful in patients who relapse or are unsuitable for surgery. The recent introduction of pasireotide, the first pituitary-directed medical therapy, expands the number of treatment options available for patients with Cushing's disease. This state-of-the-art review aims to provide an overview of the most recent scientific research and clinical information regarding Cushing's disease. Continuing research into improving the diagnosis and treatment of Cushing's disease will help to optimize patient management.

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.

Enhanced dermal delivery of diflucortolone valerate using lecithin/chitosan nanoparticles: in-vitro and in-vivo evaluations

The objective of this study was to prepare a suitable formulation for dermal delivery of diflucortolone valerate (DFV) that would maintain the localization in skin layers without any penetration and to optimize efficiency of DFV. Drug-loaded lecithin/chitosan nanoparticles with high entrapment efficiency (86.8%), were successfully prepared by ionic interaction technique. Sustained release of DFV was achieved without any initial burst release. Nanoparticles were also incorporated into chitosan gel at different ratios for preparing a more suitable formulation for topical drug delivery with adequate viscosity. In ex-vivo permeation studies, nanoparticles increased the accumulation of DFV especially in the stratum corneum + epidermis of rat skin without any significant permeation. Retention of DFV from nanoparticle in chitosan gel formulation (0.01%) was twofold higher than commercial cream, although it contained ten times less DFV. Nanoparticles in gel formulations produced significantly higher edema inhibition in rats compared with commercial cream in in-vivo studies. Skin blanching assay using a chromameter showed vasoconstriction similar to that of the commercial product. There were no barrier function changes upon application of nanoparticles. In-vitro and in-vivo results demonstrated that lecithin/chitosan nanoparticles in chitosan gel may be a promising carrier for dermal delivery of DFV in various skin disorders.

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.

[Iatrogenic adrenal insufficiency]

Adrenal insufficiency is a disease caused by the deficit in production and/or secretion of glucocorticoids. The aetiology of Adrenal Insufficiency (AI) can be classified into primary and secondary, and it should be taken that the incidence and prevalence of the secondary formare much higher than the primary form. One of the main causes of AI is due to prescription of exogenous steroids. It can be taken orally, which is more common, or topically. The latter is more uncommon but it should not be a a reason for ruling it out. We have to be aware when giving a topical treatment and to monitor the frequency our patients ask for the prescription.