Toddler develops Cushing’s syndrome from topical steroid use
Case report: Potent cream used daily for 4 months to treat diaper rash
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An 18-month-old girl developed treatment-related Cushing’s syndrome after prolonged use of a high-potency topical steroid cream prescribed for diaper rash, according to a recent case report.
The parents had sought treatment after the toddler gained about 6 kg, or slightly more than 13 pounds, over three months. The child also showed other signs of Cushing’s, including a moon face and hair growth on her back, the clinician reported.
“Owing to ambiguous guidance regarding treatment duration [with this medication], the parents applied the cream three to four times daily to the diaper area over … four months,” the researcher wrote.
According to the doctor, the steroid was stopped under close monitoring, and the little girl’s symptoms gradually lessened as her natural hormone function began the process of recovery.
“This case highlights the potential for high-potency topical corticosteroids to induce iatrogenic [treatment-related] Cushing syndrome in infants and children, emphasizing the necessity for careful prescribing, clear caregiver instructions, and vigilant clinical monitoring,” the author wrote.
The report, “Topical Steroid-Induced Cushing Syndrome in an 18-Month-Old Child: A Case Report,” was published in the journal Cureus.
Cushing’s syndrome refers to the signs and symptoms that result from prolonged exposure to excess cortisol. It can be caused by long-term use of steroid medications, when it’s known as exogenous Cushing’s syndrome, or by conditions within the body. The most common endogenous cause is Cushing’s disease, in which a pituitary tumor produces too much ACTH, leading the adrenal glands to make excess cortisol.
18-month-old girl diagnosed after rapid weight gain
Topical corticosteroids are commonly used to treat inflammatory skin conditions in children. When used correctly and for short periods, they are generally considered safe. the clinician here noted.
However, when potent steroids are used for too long, too often, or without clear medical guidance, the medication can be absorbed through the skin and cause bodywide effects.
Infants and young children are especially vulnerable because their skin is thinner and their body surface area is larger relative to their weight. Absorption can be even higher in the diaper area, where moisture and occlusion, or a blockage, can increase the amount of medication absorbed.
This case report, by a pediatric endocrinologist at Qassim University in Saudi Arabia, described the case of a toddler who developed treatment-related Cushing’s syndrome after prolonged use of clobetasol, a steroid cream, for diaper dermatitis.
The child was referred to a pediatric clinic because of rapid weight gain. Her growth and development had previously been normal, and her diet was considered appropriate for her age, according to the report.
Her care team learned that the child had been prescribed clobetasol propionate, a potent topical corticosteroid, sold as Temovate among others, four months earlier for diaper dermatitis, or inflammation of the skin in the diaper area, more commonly called diaper rash. Because the parents had not received clear instructions about how long to use it, they applied the cream to the diaper area several times daily over the course of a few months.
On examination, the child weighed 16 kg, or about 35 pounds — above the 97th percentile for her age and sex. She had generalized obesity, moon face, facial redness, and increased hair growth on the back, all consistent with the symptoms of Cushing’s. Her blood pressure and other vital signs were normal, and she had no stretch marks, bruising, or skin darkening, the report noted.
Blood tests showed low afternoon cortisol and very low adrenocorticotropic hormone, or ACTH. ACTH is a hormone that normally signals the adrenal glands to produce cortisol. The low levels were consistent with suppression of the hypothalamic-pituitary-adrenal, or HPA, axis — the hormone system that controls the body’s cortisol production.
An abdominal ultrasound showed normal adrenal glands, helping rule out an adrenal tumor. Based on the child’s symptoms, lab results, and prolonged exposure to a potent topical steroid, she was diagnosed with iatrogenic, or treatment-related, Cushing’s syndrome.
Researcher calls for guidelines for steroid use in kids
The topical steroid was discontinued gradually to reduce the risk of adrenal crisis, a potentially serious condition that can occur when the body cannot make enough cortisol after steroid withdrawal.
The child was closely monitored, primarily through clinical follow-up, as repeat laboratory testing was limited by practical and financial constraints. She remained stable during the withdrawal period, with no signs of adrenal crisis or unstable blood pressure.
A telephone follow-up within one week showed an early lessening of her Cushing’s-like facial features. Later follow-up showed gradual improvement in clinical signs and partial recovery of the HPA axis function.
The clinician noted that steroids “constitute a cornerstone of dermatologic therapy” for patients of all ages with skin inflammation. However, the doctor wrote that “topical corticosteroids represent a double-edged sword in pediatric dermatology.”
Future efforts should focus on developing standardized guidelines for pediatric topical corticosteroid use, enhancing awareness of rare but significant systemic [bodywide] effects.
While “highly effective” as a short-term, targeted treatment, “their inappropriate or prolonged use may predispose to significant local and systemic adverse effects,” the researcher wrote.
According to the researcher, “future efforts should focus on developing standardized guidelines for pediatric topical corticosteroid use, enhancing awareness of rare but significant systemic [bodywide] effects.” Further, efforts should be made to “[encourage] reporting of similar cases to inform evidence-based dermatologic practice in the pediatric age group,” the report concluded.
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