Which patient groups are at highest risk for adverse systemic reactions to prolonged topical corticosteroid (steroid) use?

Patient Groups at Highest Risk for Adverse Systemic Reactions to Prolonged Topical Steroids 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

High-Risk Patient Groups

Children

• Higher vulnerability due to:
  • Greater body surface area-to-volume ratio 1
  • Thinner skin barrier allowing greater percutaneous absorption 1
  • Developing hypothalamic-pituitary-adrenal (HPA) axis more susceptible to suppression 1
  • Ongoing growth and development can be affected by systemic corticosteroid exposure 1
  • HPA axis suppression reported in 1.7% to 87% of cases 1
  • Risk of growth retardation and temporary growth deceleration 1
  • Behavioral changes including irritability, fussiness, and insomnia (reported in up to 29% of infants) 1

Patients with Compromised Skin Barrier

• Individuals with atopic dermatitis or other conditions with impaired skin barrier function 2
• Patients with thin skin areas (face, genitalia, intertriginous areas) 1
• Those using occlusive dressings which significantly increase absorption 3

Elderly Patients

• Thinner skin due to aging process
• Often have comorbidities that may increase risk of adverse effects 2
• Higher risk of skin atrophy, purpura, and telangiectasia 3

Risk Factors That Increase Systemic Absorption

1. Application Area Factors:

   • Large surface area application 1
   • Application to thin-skinned areas (face, genitals, flexures) 1
   • Use of occlusive dressings 3

2. Medication Factors:

   • Higher potency formulations (Class I steroids like clobetasol) 1
   • Prolonged duration of use 3
   • Formulation type (ointments generally have higher absorption than creams) 4

3. Patient-Specific Factors:

   • Liver failure patients (reduced metabolism of absorbed steroids) 4
   • Pre-existing conditions like diabetes or hypertension 2

Potential Adverse Systemic Effects

• HPA axis suppression 2, 1
• Growth retardation in children 1
• Cushing's syndrome (reported in infants and adults) 3
• Metabolic disturbances (glucose intolerance) 2
• Hypertension 2
• Decreased bone mineral density 1
• Increased risk of infections due to immunosuppressive effects 1
• Rare cases of Pneumocystis carinii pneumonia 1

Monitoring Recommendations for High-Risk Groups

• Regular assessment of growth in children on long-term therapy 1
• Monitoring morning cortisol levels for prolonged use in children 1
• Regular skin examinations for signs of atrophy or other local adverse effects 1
• Blood pressure monitoring in susceptible individuals 2

Prevention Strategies

• Limit treatment duration, especially with high-potency products 1
• For Class I steroids like clobetasol, maximal weekly use should be 50g or less 1
• Consider non-steroidal alternatives such as topical calcineurin inhibitors for sensitive areas 1
• Use intermittent therapy rather than continuous application in children 1
• Select lower potency formulations for high-risk areas and patients 5

Common Pitfalls to Avoid

• Applying high-potency steroids to large surface areas in children
• Prolonged use without monitoring for systemic effects
• Failure to recognize early signs of systemic absorption
• Neglecting to educate patients/caregivers about proper application amounts
• Using occlusive dressings in high-risk patients without close monitoring

By understanding these risk factors and implementing appropriate monitoring strategies, clinicians can minimize the risk of adverse systemic effects while still providing effective treatment with topical corticosteroids.