Severe Adrenal Deficiency With Topical Steroid Application for Psoriasis

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The patient in the case study applied clobetasol propionate 0.05% topically every day for 18 years.
The patient in the case study applied clobetasol propionate 0.05% topically every day for 18 years.

At the the 26th American Association of Clinical Endocrinologists Annual Scientific Sessions & Clinical Congress, lead study author Kaitlyn Steffensmeier, MS III, of the Dayton Veterans Affairs (VA) Medical Center, Dayton, OH, presented a case study describing a patient “who developed secondary adrenal insufficiency secondary to long-term topical steroid use and who with decreased topical steroid use recovered.”

The patient was a 63-year-old white male with a 23-year history of psoriasis. For 18 years, the patient had been applying Clobetasol Propionate 0.05% topically on several areas of his body every day. Upon presentation to the endocrine clinic for evaluation of his low serum cortisol, the patient complained of a 24-pound weight gain over a 2-year period, feeling fatigued, as well as facial puffiness.

Laboratory analysis found that the patient's random serum cortisol and adrenocorticotropic hormone (ACTH) levels were low (0.2 µg/dL and <1.1 pg/mL, respectively). According to the study authors, “the labs were indicative of secondary adrenal insufficiency.” Additionally, a pituitary MRI “showed a 2 mm hypoenhancing lesion within the midline of the pituitary gland consistent with Rathke's cleft cyst versus pituitary microadenoma.”

The patient was initiated on 10 mg of hydrocortisone in the morning and 5 mg in the evening and was instructed to decrease the use of his topical steroid to 1 time per month. For the treatment of his psoriasis, the patient was started on apremilast, a phosphodiesterase-4 enzyme (PDE4) inhibitor, and phototherapy.

After 2.5 years, the patient had a subnormal response to the cosyntropin stimulation test. However, after 3 years, a normal response with an increase in serum cortisol to 18.7 µg/dL at 60 minutes was obtained; the patient was then discontinued on hydrocortisone. Additionally, a stable pituitary tumor was shown via a repeat pituitary MRI.

The study authors explained that although secondary adrenal insufficiency is not commonly reported, “one study showed 40% of patients with abnormal cortisol response to exogenous ACTH after two weeks of topical glucocorticoids usage.” Another meta-analysis of 15 studies (n=320) revealed 4.7% of patients developing adrenal insufficiency after using topical steroids. Because of this, “clinicians need to be aware of potential side effects of prolong topical steroid use,” added the study authors.


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Reference

Steffensmeier K, Cheema B, Gupta A. Topical steroid use leading to severe adrenal insufficiency in a patient with psoriasis. Abstract 123. Presented at: 26th American Association of Clinical Endocrinologists Annual Scientific Sessions & Clinical Congress; May 3-7, 2017; Austin, TX.

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