Which patient group is at highest risk for adverse systemic reactions to prolonged topical corticosteroid use?

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

Children, especially infants and young children (0-6 years), are at highest risk for adverse systemic reactions to prolonged topical corticosteroid use due to their higher skin surface area to body weight ratio and thinner skin barrier. 1

Why Children Are Most Vulnerable

Physiological Factors

• Higher surface area to body weight ratio: Children have a significantly higher skin surface area relative to body weight compared to adults, leading to greater systemic absorption of topical medications 1
• Thinner skin barrier: Children's skin is thinner, allowing for increased percutaneous absorption 1
• Developing HPA axis: The hypothalamic-pituitary-adrenal axis is still developing in children, making it more susceptible to suppression 1
• Ongoing growth and development: Systemic corticosteroid exposure can affect normal growth patterns 2

Evidence of Increased Risk

• The American Academy of Dermatology guidelines specifically note that "younger patients ages 0 through 6 years, and especially infants given their high BSA-to-volume ratio compared with older children and adults, are vulnerable to HPA suppression" 2
• HPA axis suppression has been reported in 1.7% to 87% of cases in children using topical corticosteroids 1
• Growth retardation and temporary growth deceleration can occur in children using topical corticosteroids 1

Specific Adverse Effects in Children

Systemic Effects

• Growth suppression: Can lead to temporary or permanent growth deceleration 1
• HPA axis suppression: Can impair stress response and normal hormonal function 1
• Cushingoid features: As reported in case studies of infants developing cushingoid habitus after frequent topical steroid use 3
• Increased intraocular pressure: Can occur with prolonged use, especially around the eyes 2
• Behavioral changes: Irritability, fussiness, and insomnia can occur in up to 29% of infants 1

Risk Factors for Increased Absorption

• Occlusion: Covering treated areas increases absorption 2
• Application to large surface areas: Increases total systemic exposure 2
• Use of high-potency formulations: Class I steroids pose greater risk 2
• Application to thin-skinned areas: Face, genitalia, and intertriginous areas absorb more medication 2

Clinical Implications and Recommendations

Monitoring

• Regular assessment of growth in children on long-term topical corticosteroid therapy 2, 1
• Consider monitoring morning cortisol levels for prolonged use 1
• Regular skin examinations for signs of atrophy or other local adverse effects 2

Prescribing Guidelines

• Use lower potency formulations in children when possible 4
• Limit treatment duration, especially with high-potency products 2
• For clobetasol and halobetasol (Class I steroids), maximal weekly use should be 50g or less 2
• Consider non-steroidal alternatives when appropriate, such as topical calcineurin inhibitors for sensitive areas 2, 1
• Avoid application to large body surface areas in children 1

Comparison to Other Patient Groups

While all patients can experience adverse effects from topical corticosteroids, other groups have physiological advantages that make them less vulnerable than children:

• Adults: Have fully developed physiological systems, thicker skin, and lower surface area to body weight ratios 1
• Pregnant women: Have mature physiological systems that can better metabolize absorbed corticosteroids 1
• Elderly: May have increased skin fragility but don't have the same surface area to body mass concerns as children 1

The evidence clearly demonstrates that children, particularly infants and young children under 6 years of age, represent the patient group at highest risk for adverse systemic reactions to prolonged topical corticosteroid use.