High Cortisol Levels Seen to Ease Psoriasis in Cyclic Cushing’s Patient

Symptoms of psoriasis vulgaris, an autoimmune disease that mainly affects the skin, eased in a man with cyclic Cushing’s disease during a short episode of hypercortisolemia, a period marked by cortisol levels rising above healthy limits, according to a case study.

Believed to be the first such case reported, it was described in the study, “Case of cyclic Cushing’s disease with improvement of psoriatic skin lesions during a period of hypercortisolemia,” published in the Journal of the Endocrine Society.

In people with cyclic Cushing’s syndrome, which includes Cushing’s disease, periods of normal cortisol production are interspersed with bouts of hypercortisolemia. Some reports indicate that patients can develop autoimmune diseases, including rheumatic disorders and psoriasis, after a period of hypercortisolism.

Physicians in Japan described what is thought to be a unique case of a patient whose symptoms of psoriasis eased, instead of emerging or worsening, while hospitalized with hypercortisolemia.

“To the best of our knowledge, there have been no reports of improvement in an autoimmune-related disease during a period of cortisol hypersecretion in cyclic [Cushing’s syndrome],” the researchers wrote.

The 45-year-old man had Cushing’s disease caused by a large pituitary tumor that produced adrenocorticotropic hormone (ACTH), which stimulates cortisol production.

He was taking topical glucocorticoids and methotrexate to treat psoriasis vulgaris and psoriatic arthritis.  

The patient had also been experiencing an intermittent sensation of “whole-body swelling” lasting for several weeks, in which his psoriatic skin lesions and joint pain would temporarily ease, even without medication. He reported that these episodes had been occurring in two-to-three month intervals for several years.

At admission, the man showed typical physical signs of Cushing’s, including central obesity, fat accumulation above the collarbone and at the back of the neck, and a round “moon face.” His blood and urine cortisol levels were both within a normal range.

During his two-week hospitalization, he experienced a bout of hypercortisolemia, in which his blood cortisol level reached 75.7 micrograms per deciliter (mcg/dL; normal range: 5–25 mcg/dL), and his urine cortisol levels reached 10,500 mcg/day (normal range: 11.2–80.3 mcg/day). His ACTH levels also reached a peak of 585 picograms per milliliter (pg/mL; normal range: 10–60 pg/mL). 

Blood analysis revealed a high white blood cell count, reduced levels of the inflammatory marker C-reactive protein, and low potassium levels, all consistent with hypercortisolemia. The patient also showed signs of sodium retention, likely caused by prolonged glucocorticoid use.

Notably, his hypercortisolemia coincided with an amelioration of his psoriatic skin lesions, consistent with what the patient had been experiencing during “whole-body swelling” episodes in prior months. 

He was discharged from the hospital after two weeks, with a blood cortisol level of 20.5 mcg/mL. He also underwent surgery to remove the pituitary tumor, after which his swelling sensations subsided. 

“We have encountered a very rare case of cyclic pituitary [Cushing’s syndrome] in which we observed dramatic improvement of psoriasis vulgaris due to transient hypersecretion [excessive release] of cortisol during a short hospital stay,” the researchers wrote.