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PRACTICE: D R Woods, C S Arun, P A Corris, and P Perros Cushing's syndrome without excess cortisol BMJ 2006; 332: 469-470 [Full text]

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Topical Corticosteroids and Cushing's syndrome

SACHA I GOOLAMALI, Richard C.D Staughton   (26 April 2006)

Topical Corticosteroids and Cushing's syndrome 26 April 2006
SACHA I GOOLAMALI, Dermatology Clinical Fellow Chelsea and Westminster Hospital, SW10 9NH, Richard C.D Staughton Send response to journal: Re: Topical Corticosteroids and Cushing's syndrome	Editor--D R Woods et al(1)highlighted the association between the use of inhaled corticosteroids, in their case fluticasone and iatrogenic Cushing’s syndrome, with subsequent adrenal insufficiency resulting from suppression of the hypothalamic-pituitary-adrenal (HPA) axis. Combination with itraconazole, a cytochrome P450 CYP3A4 enzyme system inhibitor had further potentiated this. The same week we admitted a 40 year old man with iatrogenic Cushing’s syndrome brought on by excessive use of topical corticosteroid creams for extensive psoriasis. He had been using 0.05% clobetasol propionate ointment (Dermovate Glaxo) in 100g tubes, obtaining them privately in addition to his NHS supply at a rate of approximately 100g/week for 10 years. On examination, he had widespread psoriasis with severe and excessive signs of skin atrophy (with epidermal pallor and thinning, telangiectasia and easy bruising.) On general examination, he was cushingoid but normotensive. Dermovate was withdrawn as an inpatient and his psoriasis became active and unstable. The skin gradually settled over a 2 week period with bed rest and hourly emollient therapy. No overt Addisonian symptoms followed with blood pressure and urea and electrolytes remaining normal. He was started on Methotrexate and 10 weeks later his psoriasis is quietening well. Two 9am serum cortisol levels were low at 30 and 36nmol/l (normal range 200-700nmol/l). A subsequent long synacthen test showed a depressed response indicative of adrenocortical insufficiency. Cushing’s disease per se was excluded by a midnight cortisol and three 24hr urinary cortisol measurements which were normal. A CT scan of the adrenal glands was normal. Investigation with insulin tolerance and tetracosactrin tests suggest that adrenocortical insufficiency particularly seen on topical steroid withdrawal is caused by suppression at a hypothalamic-pituitary rather than adrenal level(2) and that there appears to be a linear relationship between the quantity of steroid used and the degree of HPA axis suppression. Those patients using over 50g weekly develop features of Cushing’s syndrome in addition to profound suppression.(3) The use of Dermovate is frequently favoured by patients due to the often rapid and dramatic improvement it can have on stubborn dermatoses, however this may lead to over-usage. Clinicians should therefore consider the quantities their patients may be using and exercise caution when prescribing these as well as systemic corticosteroids. Sacha I.Goolamali Clinical Fellow, Dermatology sachagoolamali@yahoo.co.uk Richard C.D Staughton Consultant Dermatologist Chelsea and Westminster Hospital, London SW10 Competing interests: None declared 1.Woods DR, Arun CS, Corris PA. Cushing’s syndrome without excess cortisol. Br Med J.2006 Feb 25;332(7539):469-70. 2.Staughton R.C.D, August P.J. Cushing’s Syndrome and Pituitary-Adrenal Suppression due to Clobetasol Propionate. Br Med J.1975 May 24;2(5968):419 -421 3. Carruthers J.A, August P.J, Staughton R.C.D. Observations on the systemic effect of topical clobetasol propionate (Dermovate). Br Med J.1975 Oct 25;4(5990):203-204 Competing interests: None declared Editorial note The patient whose case is described has given his signed informed consent to publication.