Endocrine Abstracts

The use of topical corticosteroids in the treatment of dermatosis, which includes psoriasis, is a common approach. With local use of corticosteroids, an increase in the concentration of corticosteroids in the area of the inflammatory process is noted, therefore local corticosteroids are believed not to have a suppressive effect on the function of the adrenal glands.

Purpose: To demonstrate a side effect of hypercortisolism after uncontrolled long-term use of clobetasol propionate in the treatment of psoriasis.

Materials and Methods: The patient’s salivary cortisol levels, as well as repeated study of cortisol and ACTH in blood plasma were determined. The patient underwent a biochemical blood test and glucose level was determined. MRI of the pituitary gland with contrast and CT scan of the adrenal glands were performed.

Results and Discussion: A 42-year-old female patient, who has been suffering from a common form of psoriasis for more than 10 years, complained of weight gain of 15 kg over the past year and stretch marks on the skin. For the last 1.5 years, she has been using clobetasol propionate 0.5 mg/g (25 g) and applied to the skin daily (without doctor’s recommendations). Approximate equivalent doses of the drug in terms of prednisolone amounted from 36 mg to 72 mg per day. On examination matronism, "Cushingoid" body features, wide purple striae on the skin, psoriatic plaques on the entire surface of the body and skin of the forearms were revealed. Biochemical examination revealed hypoproteinemia and hypoalbuminemia and hyperglycemia. A hormonal study showed a suppressed level of plasma cortisol of 18.6 and 5.78 (normal value is 166-507 nmol/l), salivary cortisol (once) at 23:00 - 0.11 (normal value is 0.2-4.0 pg/ml) while maintaining a normal level of ACTH - 23.0 and 21.1 (normal value is 7.2-63.3 pg/l). Contrast-enhanced MRI of the pituitary gland (data on the adenoid pituitary gland were not obtained) and CT scan of the adrenal region (no structural sampling was identified) were performed. After the abolition of clobetasol propionate clinical signs of adrenal insufficiency were noted (hyperkalemia - 5.9 mmol/l., hypoglycemia - 2.9 mmol/l, a decrease in blood pressure to 85/70 mm Hg., the level of cortisol - 0.01 nmol/l). Thus, exogenous hypercortisolism was diagnosed. Secondary adrenal insufficiency due to long-term use of glucocorticoids was revealed. Replacement therapy with prednisolone 7.5 mg/day was prescribed; during the follow-up period (1 year), the daily dose of prednisolone decreased to 5 mg per day.

Conclusion: Clobetasol propionate has a marked inhibitory effect on the hypothalamic-pituitary-adrenal axis.