Adrenal and Pituitary Functions during Long-Term Topical Steroid Therapy

Abstract

The results of investigations in 6 psoriasis patients, who have been treated with corticosteroid ointments (15–50 g daily) under occlusive dressings over a long period (minimum of 2 till more than 5 years) on the consequences of this therapy for the pituitary-adrenocortical system are related. In accordance with the literature a systemic effect during therapy is evident by a lowering of the 17-ketogenic steroids in the 24-hour urine and the plasma cortisol levels, and in an insufficient reaction to metyrapone. Stimulation with exogenous ACTH was followed by a normal adrenocortical response in all patients. With the insulin-tolerance test a good reaction to stress during therapy is found in the 5 tested patients. It is plausible, therefore, that the feedback system will resume its responsiveness after discontinuing the local therapy and that the suppression does not indicate permanent damage to the pituitary adrenal functions.

Topical Steroid Depression of the Hypothalamic-Pituitary-Adrenal Axis in Psoriasis vulgaris

“…The data presented here support the results of others [5,8,11,13,14,21] which indicate that topically applied fluorinated steroids are responsible at least in part for this depression. A quantitative measure of the degree of suppression found in this study would have been easier to obtain if the tests could have been performed on the same patients some time before or after the psoriatic flare had occurred.…”

“…M unro and C lift [16] in a series of 40 similar outpatients on long-term topical steroid therapy found no evidence of resulting pituitary-adrenal insufficiency as determined by the insulin stress test. On the other hand, H endrickse and Moolenar [8] found adrenal suppression in 6 psoriasis outpatients on long-term topical therapy as measured by decreased urinary 17KS and plasma cortisol levels and a reduced response to metyrapone stimulation, although insulin stress response and ACTH response was normal.…”

Topical Corticosteroids: Clinical Examples of Abuses

“…11,12 In addition to the cushingoid features, the infant had hypertension which resulted in an intracerebral bleed and convulsions. Other systemic side effects that may result from the injudicious use of topical corticosteroids are growth retardation in children, 16 ischemic necrosis of the femoral head, 17 glaucoma and posterior subcapsular cataracts, particularly from the use of corticosteroids around the eye, 18 hyperglycemia and glycosuria 19 and Cushing syndrome with secondary renal insufficiency. 20 The amount of topical corticosteroid that can be used without causing harm is not well defined but as judged by the vasoconstrictor assays, 4 μg of drug per square centimeter of skin surface will give maximum response, indicating that a very thin layer is needed to apply to the skin.…”

A Case of Growth Retardation and Cushing’s Syndrome Due to Excessive Application of Betamethasone-17-Valerate Ointment

“…When large quantities of topical steroids are used on an erythematous skin surface or when occlusive dressings are applied, the amount of percutaneously absorbed steroid can be so great that suppres sion of the adrenal function occurs [1,6,7,12,13]. The stress responsiveness of the pituitary-adrenal axis in the adult generally remains intact, however, even when large amounts of topical corticosteroids are applied under occlu sive dressing for a long time [6], According to Feiwel el al.…”

“…When large quantities of topical steroids are used on an erythematous skin surface or when occlusive dressings are applied, the amount of percutaneously absorbed steroid can be so great that suppres sion of the adrenal function occurs [1,6,7,12,13]. The stress responsiveness of the pituitary-adrenal axis in the adult generally remains intact, however, even when large amounts of topical corticosteroids are applied under occlu sive dressing for a long time [6], According to Feiwel el al. [4,5] suppression of the adrenal function can be found in children with eczema who are treated with 5 mg betamethasone-17-valerate/day without occlusive dressings, and the authors conclude that the hazards of topical steroids must, therefore, be much greater in children than in adults.…”