Percutaneous Adrenal Suppression With Topically Applied Corticosteroids James C.

Gruenberg, MD, George

R.

Mikhail,

MD

\s=b\Synthetic fluorinated derivatives of cortisone, when topically applied, are absorbed readily and may suppress adrenal function. In the case presented here, large quantities of topically applied triamcinolone acetonide were used in the treatment of atopic dermatitis. This caused a noticeable decrease in the plasma cortisol level. That this was the result of adrenal suppression rather than insufficiency was indicated by a satisfactory response of the plasma cortisol level to a cosyntropin injection test. In patients with a history of recent and extensive use of topically applied corticosteroids, appropriate diagnostic and therapeutic measures are indicated to avoid postoperative adrenal insufficiency. (Arch Surg 111:1165, 1976)

corticosteroids adrenal has received attention in the widespread use in many dermatoses.

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REPORT OF A CASE admitted to Henry Ford Hospital on 38-year-old May 14, 1975, for a recrudescence of a long-standing, generalized atopic dermatitis with secondary erythroderma. As an outpatient she had been using approximately 15 gm/day of 0.025% triamcinolone acetonide cream (Aristocort, Kenalog). A

woman was

The dermatitis was treated with 0.025% triamcinolone acetonide under wet towels applied to the entire skin for one hour three times a day, followed by reapplication of the cream. A total of 1,362 gm of cream were used daily. On the seventh hospital day no plasma cortisol concentration was detected at 8 AM. Thereafter, the wet soaks were discontinued, and 30 gm of the cream were applied to the affected areas of skin after a daily bath. On the 21st day, the 8 am plasma cortisol level was 0.2|tig/100 ml (normal, 6.0 to 18.0); it was lO.Ofig/lOO ml at 45 minutes after intramuscular injection of 0.25 mg of cosyntropin (normal response, greater than 50% of control). Investigation of an iron-deficiency anemia led to resection on June 5 of an adenocarcinoma of the proximal transverse colon. Therapy with hydrocortisone sodium succinate (Solu-Cortef), 100 mg every six hours for 48 hours, was started the night before the

cream

Accepted

publication June 23, 1976. departments of surgery (Dr Gruenberg) and dermatology (Dr Mikhail), Henry Ford Hospital, Detroit. Reprint requests to Department of Surgery, Henry Ford Hospital, 2799 W Grand Blvd, Detroit, MI 48202 (Dr Gruenberg). From the

for

operation, and the incision was allowed to heal by secondary intention. Otherwise, the operative management was carried out in the usual way, and the postoperative course was satisfactory. There was no clinical evidence of adrenal insufficiency either during therapy or during withdrawal therapy. COMMENT

Systemic effects of topically applied corticosteroids depend on the condition of the skin, the area and method of steroid application, and the concentration and amount of the steroid.1 Synthetic fluorinated derivatives of cortisone are readily absorbed, and as little as 9 gm of 0.025% betamethasone-benzoate in a cream base applied under occlusion to 30%> of the body surface area of an adult with atopic dermatitis can produce adrenal suppression.2 Since there is no method for the direct assay of triamcinolone in the plasma, the degree of cortisol suppression serves as an indication of the amount of circulating exogenous steroid. In the patient presented here, the morning plasma cortisol level was decreased noticeably even after marked reduction of the amount of topically applied steroid, indi¬ cating continued absorption of the exogenous steroid. The satisfactory response to cosyntropin indicated adrenal suppression rather than adrenal insufficiency. The possibility of adrenal suppression should be consid¬ ered in any patient treated with topically applied steroids, particularly for an inflammatory dermatosis involving a large area of skin. Evaluation of the pituitary-adrenal axis should be undertaken whenever feasible, and steroid therapy in excess of the patient's physiologic needs should be given in order to obviate postoperative adrenal insuffi¬ ciency.

Nonproprietary

Names and Trademarks of

Drugs

Betamethasone benzoate—Benisone Gel, Flu róbate.

Cosyntropin—Cortrosyn. References 1. James VHT, Munro DD, Freiwel M: Pituitary-adrenal function after occlusive topical therapy with betamethasone-17-valerate. Lancet 2:1059\x=req-\ 1967. 2. Mikhail GR: Percutaneous absorption of betamethasone-17-benzoate. Henry Ford Hosp Med J 18:179-186, 1970.

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Percutaneous adrenal suppression with topically applied corticosteroids.

Percutaneous Adrenal Suppression With Topically Applied Corticosteroids James C. Gruenberg, MD, George R. Mikhail, MD \s=b\Synthetic fluorinated...
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