Topical steroid risk analysis: Differentiating between physiologic and pathologic adrenal suppression

Abstract

Background: Topical corticosteroids are a mainstay of therapy for inflammatory skin disorders. Hypothalamic–pituitary–adrenal (HPA) axis suppression is a potential systemic risk of topical steroid use. Our aim was to review available data on the risk of HPA axis suppression associated with long-term topical steroid use and to distinguish between pathologic and physiologic adrenal suppression.Methods: We performed a PubMed search for literature that evaluated the risk of HPA axis suppression associated with topical steroid use.Results: Fifteen of sixteen clinical trials reviewed did not report any pathologic adrenal suppression. In the single clinical trial that reported pathologic adrenal suppression, the patients used twice the maximum recommended amount of clobetasol propionate continuously for as long as 18 months. Physiologic adrenal suppression was seen as early as 1–2 weeks after treatment with class I–IV topical corticosteroids. In about half of these patients, cortisol levels spontaneously returned to normal within a few weeks, despite continuous therapy.Conclusion: Even when adrenal suppression occurs, topical corticosteroids are unlikely to be associated with clinical signs or symptoms of HPA axis suppression and are extremely safe as long as they are used within the current safety guidelines.