A Florid Case of Iatrogenic Cushing's Syndrome Induced by Topical Steroid with Osteoporosis and Hypogonadism

Keratoconus: a potential risk factor for osteoarthritis

PURPOSE

This study was undertaken to compare the distal femoral cartilage thickness in patients with keratoconus (KC) with that of age- and sex-matched healthy controls, in order to identify a potential risk factor for early osteoarthritis in patients with KC and to allow initiation of early rehabilitation.

METHODS

Thirty-six KC patients between 18 and 35 years of age and 36 healthy controls were included in this study. Keratometry readings (K1, K2), central corneal thickness (CCT), anterior chamber depth (ACD), iridocorneal angle (ICA), and corneal volumes (CV) were measured using a Sirius imaging system (Costruzioni Strumenti Oftalmici, Italy). Also, the distal femoral cartilage thickness (DFCT) was assessed bilaterally using ultrasound by the same physiatrist. Lateral femoral condyle (LFC), intercondylar area (ICA), medial femoral condyle (MFC), and body mass index (BMI) values were recorded.

RESULTS

Patient and control groups were comparable in terms of age, gender, and BMI. On the other hand, patients with KC had a significant reduction in right LFC, MFC thickness and left ICA, MFC as compared to controls (p < 0.05). In the corneal topographic evaluation of the groups, it was observed that K₁, K₂, CCT, and ACD values differed significantly.

CONCLUSIONS

Detection of thinner DFCT in KC patients suggests that these patients may be future candidates of osteoarthritis.

Topical Corticosteroid Therapy for Psoriasis-A Review of Clobetasol Propionate 0.025% Cream and the Clinical Relevance of Penetration Modification

Topical corticosteroids (TCs) have played a central role, over the past several decades, as a treatment for many dermatologic disorders. A number of factors, including potency, anticipated efficacy, vehicle formulation, and patient preference, directly influence the success or failure of any TC. In this article, the author reviews and discusses the current literature on various aspects of TCs for the treatment of plaque psoriasis, including an overview of product selection tendencies of patients, conventional use and formulations of topical clobetasol propionate (CP) 0.05%, and the use of special additives (e.g., penetration enhancers) to increase CP potency. The author highlights data from recent studies that evaluated a new CP cream formulation that incorporates half the concentration of traditional CP (0.025%) without the loss of super-potency (Class I) status and without the use of traditional potency enhancement with propylene glycol.

Implication of Topical Steroids in the Onset of Osteoporosis

The systemic bioavailability of steroids has long been implicated as a cause for osteoporosis (OP); however, much less is known about the effect of topical steroids on bone homeostasis. This is a case of an 11-year-old male who is a known case of generalised pustular psoriasis for 8-year duration with frequent exacerbations controlled with topical betamethasone dipropionate. He presented with generalised progressive bone pain and positive history of bone fracture. The diagnosis of OP was established on the results of DEXA, which were -2.7 SD and -2.4 SD for the lumbar spine and whole body, respectively. Although the cutoff value is the same (<-2 SD) in children, the definition of OP is more reliant on the densitometry Z score, as opposed to adults, who are approached using the T score. The element of psoriasis poses a risk for the development of OP due to the presence of a chronic inflammatory disease state that increases bone turnover. Furthermore, the compromised skin barrier and associated vasodilation seen in psoriasis enhance the absorption of topically applied agents and increase their bioavailability. Children are a targeted risk group as they are more vulnerable to the manifestation of systemic adverse affects of topically applied steroids as a result of their increased ratio of total surface area relative to their body weight and slower drug metabolism. We recommend that children undergoing long-term topical steroid therapy be screened for OP with the consideration of instituting prophylactic treatment especially in those suffering from chronic inflammatory disease states.

Male fertility and skin diseases

Male fertility can be affected by a variety of organs diseases, including the skin. Several genodermatoses affect the skin and several other organs including the male reproductive system, commonly in the form of cryptorchidism and hypogonadism. The most relevant syndromes are associated with dyschromias, such as deSanctis-Cacchione, poikiloderma congenital, LEOPARD, and H syndrome; others with ichthyosis, such as Rud, and trichothiodystrophy; or a group of unrelated genodermatoses, such as ablepharon macrostomia, Coffin-Siris, Gorlin-Goltz, and Werner. Acquired skin diseases may also affect male fertility usually in the form of orchitis or epididymal obstruction or androgen antagonists. These include infections (leprosy and HIV), autoimmune (erythema nodosum leprosum), granulomatous (sarcoidosis, Langerhans cell histiocytosis), nutritional deficiency (zinc), and malignancy. Several therapeutics of skin diseases are notorious for their effects on male fertility, most notably are the cytotoxic drugs (methotrexate), irradiation, and antiandrogens (spironolactone, finasteride). Although the prevalence of these skin diseases is low, the associated male infertility represents a challenge due to the difficulty of its management. Clinical management of the skin diseases should include consideration of their effects not only on the diseases but also on the male reproductive system.