Our objective was to assess the risk of adrenal insufficiency (AI) with short-term use of low- to moderate-potency topical corticosteroids (TCS) for treatment of atopic dermatitis. Our systematic literature search revealed 9 studies (n = 371) that evaluated AI using adrenocorticotropic hormone stimulation testing, with measures of serum cortisol levels at baseline and following at least 2 weeks of TCS application. Biochemical AI was defined by a stimulated cortisol level of ≤18.0 µg/dL (~500 nmol/L). The overall proportion of AI with low-to-moderate TCS use was 2.7% (95% confidence interval = 1.47% to 4.89%). None of the children showed any clinical evidence of AI or adrenal crisis. Short-term use of low- to moderate-potency TCS for the treatment of atopic dermatitis is associated with a low risk of adrenal suppression. General practitioners do not need to test these patients for adrenal suppression in the absence of concerning signs and symptoms of AI.
ShawTECurrieGPKoudelkaCWSimpsonEL.Eczema prevalence in the United States: data from the 2003 National Survey of Children’s Health. J Invest Dermatol. 2011;131:67-73.
2.
EichenfieldLFBoguniewiczMSimpsonELet al. Translating atopic dermatitis management guidelines into practice for primary care providers. Pediatrics. 2015;136:554-565.
3.
van ZuurenEJFedorowiczZChristensenRLavrijsenAArentsBWM.Emollients and moisturisers for eczema. Cochrane Database Syst Rev. 2017;(2):CD012119.
4.
EmersonRMWilliamsHCAllenBR.Severity distribution of atopic dermatitis in the community and its relationship to secondary referral. Br J Dermatol. 1998;139:73-76.
5.
GalliENeriIRicciGet al. Consensus conference on clinical management of pediatric atopic dermatitis. Ital J Pediatr. 2016;42:26.
6.
EichenfieldLFAhluwaliaJWaldmanABorokJUdkoffJBoguniewiczM.Current guidelines for the evaluation and management of atopic dermatitis: a comparison of the Joint Task Force Practice Parameter and American Academy of Dermatology guidelines. J Allergy Clin Immunol. 2017;139(4S):S49-S57.
7.
World Health Organization. WHO Model Prescribing Information: Drugs Used in Skin Diseases. Geneva, Switzerland: World Health Organization; 1997.
8.
StoughtonRB.Bioassay system for formulations of topically applied glucocorticosteroids. Arch Dermatol. 1972;106:825-827.
9.
EichenfieldLFTomWLBergerTGet al. Guidelines of care for the management of atopic dermatitis: section 2. Management and treatment of atopic dermatitis with topical therapies. J Am Acad Dermatol. 2014;71:116-132.
10.
SchneiderLTillesSLioPet al. Atopic dermatitis: a practice parameter update 2012. J Allergy Clin Immunol. 2013;131:295-299.e1-e27.
11.
HanifinJMCooperKDHoVCet al. Guidelines of care for atopic dermatitis, developed in accordance with the American Academy of Dermatology (AAD)/American Academy of Dermatology Association “Administrative Regulations for Evidence-Based Clinical Practice Guidelines.” J Am Acad Dermatol. 2004;50:391-404.
12.
Al-KhalafAHKhatriIA.Cerebral venous sinus thrombosis in a patient with Cushing’s syndrome due to topical steroid. Neurosciences (Riyadh). 2016;21:75-76.
13.
PazderskaAPearceSH.Adrenal insufficiency—recognition and management. Clin Med (Lond). 2017;17:258-262.
14.
GoldbloomEBMokashiACummingsEAet al. Symptomatic adrenal suppression among children in Canada. Arch Dis Child. 2016;102:338-339.
15.
KazlauskaiteREvansATVillabonaCVet al. Corticotropin tests for hypothalamic-pituitary-adrenal insufficiency: a metaanalysis. J Clin Endocrinol Metab. 2008;93:4245-4253.
16.
BornsteinSRAllolioBArltWet al. Diagnosis and treatment of primary adrenal insufficiency: an endocrine society clinical practice guideline. J Clin Endocrinol Metab. 2016;101:364-389.
HeickmanLKWGhajarLDConawayMRogolAD. Evaluation of hypothalamic-pituitary-adrenal axis suppression following cutaneous use of topical corticosteroids in children: a meta-analysis. Horm Res Paediatr. 2018;89:389-396.
19.
AgrestiACoullBA.Approximate is better than “exact” for interval estimation of binomial proportions. Am Stat. 1998;52:119-126.
20.
Van HouwelingenHCArendsLRStijnenT.Advanced methods in meta-analysis: multivariate approach and meta-regression. Stat Med. 2002;21:589-624.
21.
LuckyAWGroteGDWilliamsJLet al. Effect of desonide ointment, 0.05%, on the hypothalamic-pituitary-adrenal axis of children with atopic dermatitis. Cutis. 1997;59:151-153.
22.
HebertAA; Desonide Foam Phase III Clinical Study Group. Desonide foam 0.05%: safety in children as young as 3 months. J Am Acad Dermatol. 2008;59:334-340.
23.
BroersenLHPereiraAMJørgensenJODekkersOM.Adrenal insufficiency in corticosteroids use: systematic review and meta-analysis. J Clin Endocrinol Metab. 2015;100:2171-2180.
24.
SemizSBalcıYIErginSCandemirMPolatA.Two cases of Cushing’s syndrome due to overuse of topical steroid in the diaper area. Pediatr Dermatol. 2008;25:544-547.
25.
ŞiklarZBostanciİAtliÖDallarY.An infantile Cushing syndrome due to misuse of topical steroid. Pediatr Dermatol. 2004;21:561-563.
26.
TemparkTPhatarakijnirundVChatproedpraiSWatcharasindhuSSupornsilchaiVWananukulS.Exogenous Cushing’s syndrome due to topical corticosteroid application: case report and review literature. Endocrine. 2010;38:328-334.
27.
MatsudaKKatsunumaTIikuraYKatoHSaitoHAkasawaA.Adrenocortical function in patients with severe atopic dermatitis. Ann Allergy Asthma Immunol. 2000;85:35-39.
28.
FriedlanderSHebertAAllenD; Fluticasone Pediatrics Safety Study Group. Safety of fluticasone propionate cream 0.05% for the treatment of severe and extensive atopic dermatitis in children as young as 3 months. J Am Acad Dermatol. 2002;46:387-393.
29.
HebertAAFriedlanderSFAllenDB.Topical fluticasone propionate lotion does not cause HPA axis suppression. J Pediatr. 2006;149:378-382.
30.
ZuegerTJordiMLaimerMStettlerC.Utility of 30 and 60 minute cortisol samples after high-dose synthetic ACTH-1-24 injection in the diagnosis of adrenal insufficiency. Swiss Med Wkly. 2014;144:w13987.
31.
AghaATomlinsonJWClarkPMHolderGStewartPM.The long-term predictive accuracy of the short synacthen (corticotropin) stimulation test for assessment of the hypothalamic-pituitary-adrenal axis. J Clin Endocrinol Metab. 2006;91:43-47.
32.
DorinRIQuallsCRCrapoLM.Diagnosis of adrenal insufficiency. Ann Intern Med. 2003;139:194-204.
33.
RaverotVRichetCMorelYRaverotGBorson-ChazotF.Establishment of revised diagnostic cut-offs for adrenal laboratory investigation using the new Roche Diagnostics Elecsys® Cortisol II assay. Ann Endocrinol (Paris). 2016;77:620-622.
TollefsonMMBrucknerAL; Section on Dermatology. Atopic dermatitis: skin-directed management. Pediatrics. 2014;134:e1735-e1744.
36.
CharmanCRMorrisADWilliamsHC.Topical corticosteroid phobia in patients with atopic eczema. Br J Dermatol. 2000;142:931-936.
37.
UdkoffJWaldmanAAhluwaliaJBorokJEichenfieldLF.Current and emerging topical therapies for atopic dermatitis. Clin Dermatol. 2017;35:375-382.
38.
MortimerKJTataLJSmithCJet al. Oral and inhaled corticosteroids and adrenal insufficiency: a case-control study. Thorax. 2006;61:405-408.
39.
DohilMAAlvarez-ConnellyEEichenfieldLF : Fluocinolone acetonide 0.01% in peanut oil: safety and efficacy data in the treatment of childhood atopic dermatitis in infants as young as 3 months of age. Pediatr Dermatol. 2009;;26:262-268.
40.
EichenfieldLFBasuSCalvareseBTrancikRJ : Effect of desonide hydrogel 0.05% on the hypothalamic-pituitary-adrenal axis in pediatric subjects with moderate to severe atopic dermatitis. Pediatr Dermatol. 2007;24(3):289-295.
41.
MoshangT.Prednicarbate emollient cream 0.1% in pediatric patients with atopic dermatitis. Cutis. 2001;68(1):63-69.
42.
EichenfieldLEllisCNFivensonDHebertAADromgooleSPiacquadioD : Evaluation of adrenal suppression of a lipid enhanced, topical emollient cream formulation of hydrocortisone butyrate 0.1% in treating children with atopic dermatitis. Pediatr Dermatol. 2007;24(1):81-84.
43.
AbramovitsWOquendoM : Hydrocortisone butyrate 0.1% cream (proprietary lipid rich cream vehicle) does not significantly suppress hypothalamic-pituitary-adrenal axis and is effective in pediatric patients 3 months and older with extensive atopic dermatitis. Skinmed. 2010;8(3):150-154.
