Topical corticosteroid treatment: systemic side-effects

Abstract

A 27-year-old man attending the dermatology clinic for the management of psoriasis complained of severe bilateral hip pain of recent onset. Psoriasis vulgaris affected 15% of his body surface for which he was applying a combination of topical corticosteroids obtained from two separate physicians (0AE05% betamethasone dipropionate 100 mL, mometasone furoate 0AE1% cream 30 g and betamethasone valerate 0AE1% cream 65 g every month). Plain radiography of the hips demonstrated minor flattening of the superior aspect of the left femoral head and a normal right hip. Magnetic resonance imaging (MRI), T1 weighted images, demonstrated areas of isointense necrotic bone surrounded by hypointense revascularization in the collapsed superior aspects of both femoral heads ( Fig. 1) consistent with a diagnosis of stage III osteonecrosis of both femoral heads. This association is extremely rare, but systemic effects of potent topical corticosteroids are increasingly recognized.Osteonecrosis should be considered as a cause of new-onset hip joint pain or limitation in patients using long-term potent topical corticosteroids, particularly in combination. Plain radiography is insensitive in the early stages of disease and MRI is the imaging modality of choice. Figure 1. Magnetic resonance imaging, T1 weighted image, coronal view of pelvis. The superior aspect of the left femoral head consists of an irregular isointense area of necrotic bone that has undergone moderate collapse. There is a hypointense band inferior to this which is a revascularization front consisting of resorption proximal to the necrotic bone and bone formation distally. There are bilateral ring lesions consisting of necrotic bone surrounded by reparative tissue. There is also a small degree of collapse of the superior aspect of the right femoral head.

Topical Corticosteroids and Topical Calcineurin Inhibitors in the Treatment of Atopic Dermatitis: Focus on Percutaneous Absorption

“…1,5 In 2003, there was a case report of femoral head osteonecrosis in a man who applied 3 TCSs. 55 These effects are rarely seen today but may be a concern among clinicians and patients/families. TCIs have been used to treat many patients and have not been associated with clinically significant adverse systemic effects.…”

Bilateral osteonecrosis of the femoral head associated with corticosteroid therapy for alopecia areata: a case report and review of the literature

“… 22 Few studies regarding topical corticosteroid-induced ONFH following the long-term use of corticosteroids in psoriasis have been reported. 23 , 24 In the present case, topical, systemic (intravenous), and oral corticosteroid therapies were administered. We could not verify when ONFH had occurred.…”

Corticosteroids: Options in the era of steroid-sparing therapy

“…[20][21][22] Bilateral femoral avascular necrosis rarely has been associated with patients receiving treatment with topical corticosteroids. 23,24 Systemic effects of most concern are suppression of the HPA axis, growth retardation in children, cataract formation, and glaucoma development. Although suppression of the HPA axis is generally minor and transient when it occurs, rare cases of Cushing's syndrome have been reported in patients using class 1 topical corticosteroids for as long as 1 year and with misuse of topical agents in infants.…”