Chinese herbal remedy found to contain steroids and antifungals

Abstract

A 14-year-old boy with early-onset guttate psoriasis vulgaris presented at our clinic with several reddish-purple, horizontal streaks on the distal part of his shins. Previously, he had been treated with narrow-band ultraviolet B, topical corticosteroids ranging from mild (hydrocortisone 17-butyrate cream 1 mg/g) to moderate (mometasone furoate cream 1 mg/g and betamethasone valerate ointment 1 mg/g), and tacrolimus ointment 1 mg/g—but the response to treatment was not long lasting. The family consulted a licensed practitioner of traditional Chinese medicine who prescribed a so-called herbal cream (figure). The patient applied the cream topically on the psoriatic lesions twice a day. After 9 months of doing this, he developed a new rash on his shins that was later confirmed to be striae distensae (figure). We suspected that the cause was exposure to a corticosteroid—but the patient had not been using a corticosteroid either topically or systemically during this time. The so-called herbal cream was suspected as a possible source; however, the content label only listed herbal ingredients including Chinese sumac, Sophora flavescens, Stemona tuberosa Lour. Nevertheless, the location of the striae was very unusual, and as a simple test, the herbal cream was applied on the upper arm of the senior physician; after 12 h, a strong vasoconstriction effect was seen (figure), which further raised our suspicion that the cream contained a corticosteroid. We therefore sent it for analysis at the Department of Official Medicines Control Laboratory, Swedish Medical Products Agency, Uppsala, Sweden. The laboratory used liquid chromatography-tandem mass spectrometry and nuclear magnetic resonance, and reported that the cream contained both a potent corticosteroid (0·065% clobetasol propionate) and the antifungals ketoconazole and miconazole. We then reported this herbal product to the Danish Medicines Agency to ensure that it was dealt with appropriately.