Published: 13 December 2017

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Adrenal Suppression Associated with the Use of Topical Corticosteroids

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Prescriber Update 38(4): 52-53
December 2017

The Centre for Adverse Reactions Monitoring (CARM) has received a case report concerning a patient who experienced adrenal insufficiency after regular use of topical corticosteroids to treat psoriasis. The corticosteroid preparation included clobetasol propionate (Dermol) ointment, betamethasone dipropionate (Daivobet) ointment and mometasone furoate lotion. The patient required treatment with oral steroid supplements for adrenal insufficiency.

Adrenal suppression from topical steroid use can occur in both adults and children, although children are at greater risk due to their high surface area to volume ratio¹.

Medsafe would like to remind healthcare professionals that diluting steroids in an emollient does not reduce the likelihood or severity of an adverse reaction, or alter the efficacy of the medicine^2,3. Moreover, it may lead to over use of these medicines and increase the risk of experiencing adverse reactions, including adrenal suppression.

The choice of topical corticosteroid should be determined by the severity of the skin condition and the part of the body to which the product will be applied^3,4. Topical corticosteroid products are available in a range of potencies (Table 1). It is best practice to use the lowest potency corticosteroid needed to control symptoms. A weaker topical corticosteroid should be prescribed if needed, rather than diluting a more potent product in an emollient as this does not actually weaken the effect.

Table 1: Potency of topical corticosteroid medicines available on prescription in New Zealand⁵

Potency	Topical corticosteroid preparation
Mild	hydrocortisone 1%
Moderate (2-25 times as potent as hydrocortisone)	clobetasone butyrate 0.05% triamcinolone acetonide 0.02%
Potent (100-150 times as potent as hydrocortisone)	betamethasone dipropionate 0.05% (Diprosone®, Daivobet®†) betamethasone valerate 0.1% diflucotolone valerate 0.1% hydrocortisone butyrate 0.1% methylprednisolone aceponate 0.1% mometasone furoate 0.1%
Very potent (up to 600 times as potent as hydrocortisone)	betamethasone dipropionate 0.05% in propylene glycol base (Diprosone OV®) clobetasol propionate 0.05%

^† Daivobet^® contains calcipotriol 0.005% and betamethasone dipropionate 0.05%

Serious adverse reactions are rarely seen with appropriate use of topical corticosteroids. The risk of adverse effects is increased by:

• use of higher potency corticosteroids
• application of the corticosteroid to a large area of skin and/or application of a large quantity over prolonged periods
• application of the corticosteroid under occlusion or to flexural and groin areas, which can increase absorption
• application to striae-prone areas (eg, axillae or groin)
• concomitant use of oral or high-dose inhaled corticosteroids³.

Healthcare professionals are also reminded to consider the risk of antimicrobial resistance associated with inappropriate use of topical antibiotic/corticosteroid preparations⁶.

New Zealand data sheets for topical corticosteroids include information on the risk of systemic effects, including adrenal suppression (www.medsafe.govt.nz/Medicines/infoSearch.asp).

References

1. Mylan New Zealand Ltd. 2017. Dermol Data Sheet 4 April 2017. URL: medsafe.govt.nz/profs/Datasheet/d/Dermolcrmoint.pdf (accessed 30 October 2017).
2. Hoare C, Li Wan Po A, Williams H. 2000. Systematic review of treatments for atopic eczema. Health Technology Assessment 4(37): 1–191.
3. Best Practice Advocacy Centre. 2016. Topical corticosteroids for childhood eczema: clearing up the confusion. Best Practice Journal December 2016. URL: bpac.org.nz/2016/docs/topical-corticosteroids.pdf (accessed 30 October 2017).
4. DermNet New Zealand. 2016. Topical steroids 4 January 2016. URL: dermnetnz.org/topics/topical-steroids/ (accessed 30 October 2017).
5. New Zealand Formulary. 2017. Topical corticosteroids. 1 November 2017. URL: http://nzf.org.nz/nzf_6272 (accessed 31 October 2017).
6. World Health Organization. 2017. Antibiotic Resistance October 2017. URL: who.int/mediacentre/factsheets/antibiotic-resistance/en/ (accessed 31 October 2017).