Iatrogenic Cushing Syndrome

Iatrogenic (exogenous) Cushing syndrome is glucocorticoid excess caused by medication rather than by the body’s own adrenal glands. The MHRA (Drug Safety Update, May 2024) lists its features as a red, puffy, rounded face, acne, excess facial and body hair, high blood pressure, weight gain, stretch marks, slow wound healing and frequent infections. In children, growth suppression is a key sign (PrescQIPP 2022). Enough steroid can be absorbed through the skin to cause it. It usually comes together with HPA Axis Suppression, so a child who stops suddenly, or falls ill, can go into adrenal crisis.

HPA Axis Suppression [precedes] Iatrogenic Cushing Syndrome Topical Corticosteroids [causes] Iatrogenic Cushing Syndrome

How much steroid it takes. DermNet says Cushing-type effects from Topical Corticosteroids are rare and reported only after long-term use of large amounts, such as more than about 50 g of Clobetasol Propionate or more than 500 g of Hydrocortisone per week (adult-scale figures). Most cases follow inappropriate prescribing or over-the-counter sale of potent steroids. The Australasian consensus (Mooney et al. 2015) found 25 paediatric case reports of adrenal suppression. These children had mostly used superpotent clobetasol for 1–17 months for nappy-area eczema, where the nappy acts as an occlusive dressing. Two very young infants died of sepsis linked to marked overuse. The same consensus states that pathological adrenal suppression has not been reported when TCS are used for routine eczema management in children.

Clobetasol Propionate [causes] Iatrogenic Cushing Syndrome Nappy Rash [relates] Iatrogenic Cushing Syndrome

Documented toddler cases. Razzaghy Azar et al. (J Compr Pediatr 2015) describe three young children and one adult who used clobetasol for months without supervision. An 11-month-old boy had clobetasol 0.05% applied 6–7 times a day for nappy rash. He developed a moon face, blood pressure of 170/100, height −4 SD and suppressed cortisol and ACTH. Hypertension persisted after stopping in two children, and one was left with permanent visual loss. This is also the hidden risk in Adulterated Herbal Creams, “natural” products that turn out to contain undeclared very potent steroids.

Adulterated Herbal Creams [causes] Iatrogenic Cushing Syndrome

Undeclared steroids in "natural" creams

A cream sold as herbal or steroid-free that clears eczema dramatically, then causes a severe flare when stopped, may contain a hidden potent steroid. Months of heavy use on a toddler, especially under a nappy, can cause Cushing features and adrenal suppression. Do not stop suddenly after long heavy use; see a doctor and bring the product.

Keeping it in proportion. For a 1–4-year-old using mild or moderate steroids as prescribed, in courses measured by Fingertip Unit, the risk of Cushing syndrome is extremely small. Fear of it is a large part of Steroid Phobia and leads to under-treatment, which has its own harms. The things that raise risk are recognisable: very potent products, use on large areas or under occlusion (nappy, Wet Wrap Therapy), months of continuous use without review, and products obtained without a prescription. The MHRA advises families using prolonged or very potent steroids to watch for the features above and seek prompt medical attention.

Steroid Phobia [relates] Iatrogenic Cushing Syndrome Fingertip Unit [prevents] Iatrogenic Cushing Syndrome

Connections

• Adulterated Herbal Creams — clinical consequence of hidden potent steroid, source: Razzaghy Azar J Compr Ped 2015
• HPA Axis Suppression — accompanies Cushing’s; adrenal insufficiency on stopping, source: Razzaghy Azar 2015
• Topical Corticosteroids — case reports mostly from superpotent TCS overuse, source: Mooney 2015
• Clobetasol Propionate — >50 g/week threshold; infant cases after unsupervised use, source: DermNet; Razzaghy Azar 2015
• MHRA — lists Cushing features; advises families to seek prompt attention, source: MHRA DSU May 2024
• Nappy Rash — nappy occlusion in most infant case reports, source: Mooney 2015
• Steroid Phobia — rare risk often overestimated by parents, source: Mooney 2015