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Correspondence

Indian Pediatr 2016;53: 76-77

Exogenous Cushing Syndrome due to Topical Clobetasone use for Diaper Rash

 

*Ganesh Jevalikar and Ojasvini Sharma

Division of Endocrinology and Diabetes, Medanta, The Medicity, Gurgaon, Haryana, India.
Email: [email protected]

  


Inadvertent use of topical corticosteroids can be associated with systemic side effects, more so in infants and children due to their higher total body surface area-to-weight ratio and thinner skin [1]. We report a case with exogenous Cushing syndrome due to application of topical steroids for diaper rash.

An 8-month-old girl presented with prominent cheeks and excessive facial hairs. Birth weight was 2.6 kg. Caloric intake was normal. Parents denied medications, except oral calcium. Her weight was 8.2 kg (just above 50th centile), length was 63.5 cm (<3rd centile), and blood pressure was 86/60 mm Hg. Cushingoid facies, hypertrichosis (Fig. 1a) and hypopigmentation in diaper area (Fig. 1b) were noted. Topical application of a cream (containing 0.05% clobetasol propionate, gentamicin and miconazole) in diaper area and buttocks for last 3 months was reported by parents. A low 8 AM serum cortisol (0.22 µg/dL, normal 4.5- 22.6) with low ACTH (5.9 pg/mL, normal <46 pg/mL) confirmed the diagnosis of exogenous Cushing syndrome. The use of the cream was discontinued and replacement hydrocortisone was given in the dose of 6 mg/m2/day. After 3 months, improved facial appearance, skin pigmentation, and recovery of serum cortisol (10.9 µg/dL) was documented.


(a)
 
 

(b)

Fig. 1 Cushingoid facies (a), and hypopigmentation in diaper area (b) due to topical clobetasol use.

Clobetasol, a superpotent topical corticosteroid, is the most frequently described topical agent to cause Cushing syndrome [2]. Application for even couple of weeks can cause systemic toxicity [3]. Most cases are related to its use in diaper dermatitis, as the occlusive effect of the diaper and underlying inflammation increase systemic absorption. Female preponderance of cases indicates additional absorption from vaginal mucosa [3].

Most cases of diaper dermatitis can be managed with frequent change of diapers, periods of "rest" from diaper use, and application of a protective barrier agent containing petroleum or zinc oxide. If deemed necessary, low potency topical steroids (e.g. 2.5% hydrocortisone) may be used for a short period of time (3-5 days) [4]. Use of finger-tip units (FTU) can guide the amount of topical medication [5]. Using high potency steroids (clobetasol, betamethasone) is inappropriate.

If adrenal suppression is noted following topical steroid use, replacement hydrocortisone should be given and dose enhancement during stress (fever, trauma, surgery) should be explained to parents.

References

1. Hengge UR, Ruzicka T, Schwartz RA, Cork MJ. Adverse effects of topical glucocorticosteroids. J Am Acad Dermatol. 2006;54:1-15.

2. Tempark T, Phatarakijnirund V, Chatproedprai S, Watcharasindhu S, Supornsilchai V, Wananukul S. Exogenous Cushing’s syndrome due to topical corticosteroid application: case report and review literature. Endocrine. 2010;38:328-34.

3. Sattar H, Manzoor J, Mirza L, Sheikh AM, Butt TA. Iatrogenic Cushing’s syndrome in children presenting at Children’s Hospital Lahore using nappy rash ointments. J Pak Med Assoc. 2015;65:463-6.

4. Humphrey SR, Drolet BA. Principles of Therapy. In: Kliegman RM, Stanton BF, St Jeme JW, Schor NF, editors. Nelson Textbook of Pediatrics. 20th ed. Philadelphia: Elsevier;2015. p.2608-10.

5. Long CC, Mills CM, Finlay AY. A practical guide to topical therapy in children. Br J Dermatol.1998;138:293-6.

 

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