Endocrine Abstracts

Clinical practice suggests that low dose steroid treatment delivered locally to the site of action may rarely lead to disturbances of the hypothalamic-pituitary-adrenal axis. We present three clinical examples:

Case 1: A 72 yr old man with a history of severe sinusitis was referred because of three episodes of profound anorexia, vomiting and proximal muscle weakness which coincided with discontinuing his Betnesol (betamethasone sodium phosphate 0.1%) nose drops. He had been taking two drops daily for fifteen years. On examination his skin was thin and easily bruised. He had significant hypertension (210/110). A short synacthen test (off Betnesol) revealed a low basal cortisol level (94nanamol/l) and a delayed, inadequate response (172 and 247 at 30 and 60 minutes respectively). On low dose oral hydrocortisone therapy he remains asymptomatic having discontinued his Betnesol.

Case 2: A 59 yr old lady presented with recurrent severe hyponatraemia (117 milimol/l) requiring hospital admission. She admitted to inhaling two puffs of Becloforte (beclomethasone dipropionate 250 microgram/metered inhalation) eight times daily over many years for mild asthma. Subsequent investigations revealed absent 9am cortisol and failure to respond to a short synacthen test. ACTH levels were normal (30.9 nanogram/l) as were pituitary hormones, adrenal antibodies and adrenal imaging. Following oral hydrocortisone replacement she is well and has had no further hyponatraemic episodes.

Case 3: A 38 yr old man with chronic scalp psoriasis self-treated with a topical cosmetic agent Skincap for 2 years. He presented with typical cushingoid features and left hip pain. Radiographic examination revealed osteonecrosis of the femoral head. Random cortisol was low (138nanamol/l) but an overnight dexamethasone suppression five months after discontinuing Skincap was normal, suggesting an exogenous cause for his Cushing's. Subsequent analysis of Skincap led to a ban due to excessive levels of clobestol propionate.

Physicians need to be aware of adrenal suppression by locally delivered steroids.