Long-term topical steroid use linked to Cushing syndrome in adolescent

The case of a teenage girl who developed drug-induced Cushing’s syndrome after long-term use of a very potent corticosteroid ointment was described in a recent report.

The researchers noted that Cushing’s caused by topical corticosteroids has been reported before, but most pediatric cases have involved infants and young children. This case shows that serious side effects can also occur in adolescents.

“Clinicians should prescribe the lowest appropriate potency [of corticosteroid], provide clear application and review instructions, and assess for adrenal suppression when Cushingoid features develop,” the researchers wrote.

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The report, “Iatrogenic Cushing Syndrome With Glucocorticoid-Induced Adrenal Insufficiency Following Prolonged Topical Clobetasol Use in an Adolescent,” was published in Cureus.

Cushing’s syndrome is a broad term for disorders in which symptoms are driven by high cortisol levels. Cortisol is a hormone produced by the adrenal glands that helps the body respond to stress. Chronically high cortisol levels can cause Cushing’s symptoms such as weight gain, skin changes, and mental health complications.

Cushing’s disease is a specific form of Cushing’s syndrome caused by a tumor in the brain’s pituitary gland. Cushing’s syndrome can also develop as a side effect of corticosteroid treatment because these medications act like cortisol in the body. Long-term corticosteroid exposure can also suppress the body’s own cortisol production, causing adrenal insufficiency. This means a person can have Cushing’s features from the medication while producing too little natural cortisol.

Corticosteroids are powerful anti-inflammatory medicines used to treat many health problems. Some are used topically, meaning they are applied directly to the skin as creams or ointments, for problems such as rashes.

In this report, researchers in the U.K. described a 15-year-old girl who was prescribed a corticosteroid ointment for a rash. She was first given the moderately potent corticosteroid betamethasone. When the rash had not improved seven weeks later, treatment was switched to clobetasol, a very potent corticosteroid.

After six months of using clobetasol ointment, she developed dark stretch marks, called striae, on her thighs and lower legs, even though she reported that she had not applied the ointment to her thighs. Striae can be a sign of Cushing’s syndrome.

Further questioning found that the girl also had fatigue, low mood, and difficulty sleeping. Tests showed that her natural cortisol levels were extremely low and that her adrenal glands could not produce an adequate cortisol response. Together with her Cushingoid features and prolonged clobetasol exposure, the findings supported a diagnosis of corticosteroid-induced Cushing’s syndrome and adrenal insufficiency.

Adrenal function recovered after clobetasol was stopped

Following the diagnosis, clobetasol ointment was stopped, and the girl started treatment with hydrocortisone to replace the cortisol her body was not making adequately. She and her family were also taught how to manage the risk of adrenal crisis. Psychological and school-based support was arranged to help with her low mood and self-consciousness about the striae.

Repeat testing showed partial adrenal recovery after about 2.5 months. By seven months, her adrenal function had recovered enough for hydrocortisone to be discontinued. By 13 months, the girl’s striae had faded substantially to “mild pink-red discolouration,” the researchers reported. The possible benefits and risks of pulsed-dye laser therapy to improve the appearance of the striae were also discussed.

The girl’s mood also improved considerably: “Her mother described a marked improvement in mood and behaviour, stating that ‘it was like a cloud had lifted’ and that ‘she giggles again,'” the researchers reported.

Overall, the researchers said this teen’s experience highlights the need for doctors to consider Cushing’s syndrome and adrenal suppression as potential complications of prolonged use of potent or very potent topical corticosteroids.

“This case reinforces the importance of prescribing the lowest appropriate topical corticosteroid potency, clearly specifying the quantity, site, frequency and duration of application, arranging clinical review before repeat prescribing of potent or very potent corticosteroids and assessing for [glucocorticoid-induced adrenal insufficiency] when Cushingoid features develop, even when glucocorticoid exposure is topical,” the researchers wrote.