Which group of patients is at highest risk for adverse systemic reactions to prolonged topical corticosteroid (steroid) use: children, young adults, middle-aged adults, pregnant women, or breast-feeding women?

Children Are at Highest Risk for Adverse Systemic Reactions to Prolonged Topical Corticosteroid Use

Children are at the highest risk for adverse systemic reactions to prolonged topical corticosteroid use due to their higher skin surface area to body weight ratio, which increases percutaneous absorption and systemic exposure. 1, 2, 3

Why Children Are Most Vulnerable

Children have several physiological factors that increase their risk:

• Higher ratio of total body surface area to body weight compared to adults 3
• Thinner skin barrier that allows greater percutaneous absorption 1
• Developing hypothalamic-pituitary-adrenal (HPA) axis that is more susceptible to suppression 1
• Ongoing growth and development that can be affected by systemic corticosteroid exposure 1

Specific Systemic Adverse Effects in Children

Growth and Development Concerns

• Growth retardation and temporary growth deceleration 1
• Suppression of the HPA axis (reported in 1.7% to 87% of cases) 1
• Potential impact on bone mineral density with long-term use 1

Other Systemic Effects

• Increased risk of infections due to immunosuppressive effects 1
• Rare cases of Pneumocystis carinii pneumonia have been reported 1
• Behavioral changes including irritability, fussiness, and insomnia in up to 29% of infants 1

Comparison to Other Groups

Pregnant Women

• While pregnant women have concerns regarding fetal exposure, the systemic absorption in children poses a more direct risk due to their developing systems 1
• Pregnant women have mature physiological systems that can better metabolize absorbed corticosteroids

Breastfeeding Women

• Minimal amounts of topical corticosteroids enter breast milk 1
• The risk to the nursing infant is lower than the direct risk to children using topical corticosteroids

Young and Middle-aged Adults

• Have fully developed physiological systems and lower surface area to body weight ratios
• Better skin barrier function compared to children 1
• More efficient metabolism and clearance of absorbed medications

Clinical Recommendations to Minimize Risk

1. For children requiring topical corticosteroid therapy:

   • Use the lowest potency effective for the condition 4
   • Limit treatment duration (shorter courses when possible) 4
   • Avoid application to large body surface areas 1
   • Avoid occlusive dressings which increase absorption 3
   • Avoid application to thin-skinned areas (face, genitals, skin folds) 4

2. Monitoring recommendations:

   • Regular assessment of growth in children on long-term therapy 1
   • Consider monitoring morning cortisol levels for prolonged use 1
   • Regular skin examinations for signs of atrophy or other local adverse effects 1

3. Alternative considerations:

   • Consider non-steroidal alternatives when appropriate 1
   • Use intermittent therapy rather than continuous application 1
   • Consider topical calcineurin inhibitors for sensitive areas in children over 2 years 1

Conclusion

The evidence clearly demonstrates that children represent the highest risk group for adverse systemic reactions to prolonged topical corticosteroid use. Their unique physiological characteristics, including higher surface area to body weight ratio and thinner skin barrier, make them particularly vulnerable to systemic absorption and subsequent adverse effects. Careful selection of corticosteroid potency, limited duration of use, and appropriate monitoring are essential when treating pediatric patients.