Bilateral Femoral Avascular Necrosis in a Man with Psoriasis: Responsibility of Topical Corticosteroids and Role of Cyclosporine

Reichert-Pénétrat, S; Tréchot, P.; Barbaud, A.; Gillet, Pierre; Schmutz, J.‐L.

doi:10.1159/000051794

Cited by 18 publications

(11 citation statements)

References 5 publications

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“…This however is related to the fact that topical preparations may be applied, in extended courses, to diseased skin, thus facilitating systemic absorption of significant amounts of corticosteroid. 9 Our patient presented with avascular necrosis of both femur heads two years after cessation of a three month tapered course of corticosteroids. It is therefore very unlikely that the course of steroids given was the cause of the femur head necrosis.…”

Section: Discussionmentioning

confidence: 83%

Nodular regenerative hyperplasia, portal vein thrombosis, and avascular hip necrosis due to hyperhomocysteinaemia

Buchel¹

2005

Gut

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A male patient with portal hypertension, portal vein thrombosis, spontaneous splenorenal shunt formation, and encephalopathy, thought to have post-hepatitis B cirrhosis, is described. His condition deteriorated and necessitated liver transplantation. In the explant liver, nodular regenerative hyperplasia with pronounced vascular lesions both in portal venules and in arterioles was found instead of classical cirrhosis. Two years post-transplant he developed bilateral ischaemic femur head necrosis. The three disorders (portal vein thrombosis, nodular regenerative hyperplasia, and ischaemic hip necrosis) seemed to be due to a common vasculopathy induced by hyperhomocyteinaemia. Genetic studies showed that he carried a mutation in the gene encoding for formation of methylenetetrahydrofolate reductase. Treatment with folic acid combined with pyridoxine (vitamin B6) and cyanocobalamin (vitamin B12) normalised his serum homocysteine levels. N odular regenerative hyperplasia of the liver is characterised by the presence of diffuse rather small regenerative nodules in the absence of fibrosis. It is thought to result from occlusion of the terminal branches of hepatic arterioles and portal venules, secondary to endothelial cell damage. [1][2][3] It is associated with systemic and vascular disorders such as systemic lupus erythematodes, progressive systemic sclerosis, Sjögren's syndrome, polyarteritis nodosa, rheumatoid arthritis, 1 2 4 5 and with coagulopathies such as anticardiolipin and antiphospholipid antibodies or factor V Leiden mutation. 4 6 7 An association with myeloproliferative and lymphoproliferative disorders has also been described.We describe a patient with nodular regenerative hyperplasia of the liver and portal vein thrombosis, eventually requiring liver transplantation. This was followed by bilateral avascular necrosis of his femur heads. In looking for coagulopathies, it was demonstrated that this patient had hyperhomocysteinaemia of intermediate grade. Further study documented that he was a heterozygote for the methylenetetrahydrofolate reductase gene C677T mutation. To our knowledge this is the first report of nodular regenerative hyperplasia associated with hyperhomocysteinaemia. CASE REPORTA 51 year old male with mild psoriasis, for which he never received any medication that could induce portal hypertension, was evaluated for possible liver transplantation. He had initially been seen at the haematology clinic for suspected myelodysplasia because of a marked splenomegaly with leuco-and thrombocytopenia (table 1). Further investigations established the presence of an atrophic right liver lobe (atrophy of segments 4 and 5) and a hypertropic caudate and left liver lobe, with portal vein thrombosis and a spontaneous splenorenal shunt. He had pronounced oesophageal varices with a variceal pressure of 20.6 mm Hg and a hepatic portal vein pressure gradient of 25 mm Hg, mild encephalopathy (ammonia levels above 80 mM; normal values ,50 mM), and osteopenia. He was thought to have post-hepatitis B cirrhosis as...

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Section: Discussionmentioning

confidence: 83%

Nodular regenerative hyperplasia, portal vein thrombosis, and avascular hip necrosis due to hyperhomocysteinaemia

Buchel¹

2005

Gut

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“…Much more controversial is the relationship with topical GC use: three cases have been reported in adults after cutaneous administration, but the therapy was extremely long (3-4 years), or the patient assumed other potentially toxic drugs [9]. In children, two cases with osteonecrosis and cutaneous steroid exposure have been described, but both were human immunodeficiency virus infected, and this has been recognized as a risk factor [3].…”

Section: Discussionmentioning

confidence: 99%

Osteonecrosis of the hip after short courses of oral and inhaled steroids in a child with an increased number of glucocorticoid receptors

et al. 2006

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“…Except in children where growth retardation may also occur and in cases of abuse in the adult, systemic effects of topical steroids are rare. Avascular necrosis of the femur with use of topical steroids has been reported [26].…”

Section: Adverse Effects Of Topical Steroidsmentioning

confidence: 99%

Misuse and abuse of topical steroids: implications

Nnoruka¹,

Daramola²,

Ike³

2007

Expert Review of Dermatology

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Topical steroids, having revolutionized dermatotherapy over several decades, remain the mainstay of treatment for steroid-responsive inflammatory dermatoses worldwide. Challenges, nevertheless, abound on the usage of topical steroids, particularly with their inappropriate application. Several steps and improved formulations are constantly evolving in the scientific world, aimed at addressing most of the associated adverse events. However, until the dawn of the 'ideal topical steroid', the implications of application misuse will remain significant. This review discusses the concept of 'misuse and abuse' of topical steroids, gives an overview of topical steroids, differentiates 'misuse' as opposed to 'abuse' of application of topical steroids as they occur in different settings and provides a schematic algorithm for the appropriate and optimal application of topical steroids. Consequently, this separation will allow a more accurate estimation of the burdens of these two aspects that require different solutions. 31-40 (2007) Topical glucocorticoids are the foundation of dermatotherapeutics [1], particularly for the noninfected inflammatory dermatoses, such as the eczemas and dermatitis. Their availability since 1952 has marked the most important milestone in dermatology to date [2,3]. Although the 'ideal' topical steroids have not yet been synthesized, topical administration of steroids still remains the safest mode of administration for glucocorticoids.Topical steroids are derivatives of the prototype hydrocortisone, a natural glucocortico steriod of the adrenal cortex. Chemical substitutions at certain key positions of the cyclopentanophenathrene nucleus, altering both its glucocorticoid and mineralocorticoid properties, affects the potency of these drugs. For example, halogenation at the 9-α position enhances the potency by improving activity within the target cell and decreasing breakdown into inactive metabolites [4], while masking or removing the hydrophilic 17-dihydroxyacetone side chain or the 16 α-hydroxy group increases the lipophilicity of the molecule, thereby enhancing penetration through the stratum corneum [1,5].The existence of a reservoir within the stratum corneum for most topical xenobiotics, particularly topical steroids [6,7], affects the choice of application frequency and the dose, while percutaneous absorption is dependent on the intrinsic property of the steroid, the vehicle used, the anatomical site, age of patient and method of application (i.e., under occlusion or hydration). However, individual variation in percutaneous absorption can also be quite pronounced. All of these factors must be taken into account when considering the potential for undesirable effects of topical steroids.Abuse of steroids could be regarded as the use of steroids to achieve purposes other than a therapeutic one, while misuse of steroids can be regarded as the inappropriate use of steroids for therapeutic purposes. These terms are introduced in this article for the purpose of describing the inapt use of prescr...

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Bilateral Femoral Avascular Necrosis in a Man with Psoriasis: Responsibility of Topical Corticosteroids and Role of Cyclosporine

Cited by 18 publications

References 5 publications

Nodular regenerative hyperplasia, portal vein thrombosis, and avascular hip necrosis due to hyperhomocysteinaemia

Nodular regenerative hyperplasia, portal vein thrombosis, and avascular hip necrosis due to hyperhomocysteinaemia

Osteonecrosis of the hip after short courses of oral and inhaled steroids in a child with an increased number of glucocorticoid receptors

Misuse and abuse of topical steroids: implications

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