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 high body surface area-to-volume ratio compared to older age groups. 1, 2
Why Children Are Most Vulnerable
- Children have a higher body surface area-to-volume ratio, which increases percutaneous absorption of topical corticosteroids and risk of systemic effects 1, 2
- Infants and young children have thinner skin, allowing for greater penetration and absorption of topical medications 1, 3
- The developing hypothalamic-pituitary-adrenal (HPA) axis in children is more susceptible to suppression from exogenous corticosteroids 1
- Growth suppression is a unique concern in the pediatric population that doesn't affect other groups 1
- Children may be less able to metabolize and eliminate corticosteroids compared to adults 4, 5
Documented Adverse Systemic Effects in Children
- HPA axis suppression with abnormal morning cortisol levels 1, 3
- Growth deceleration, though most children experience "catch-up" growth after completion of therapy 1
- Cushing's syndrome with cushingoid features (moon face, central obesity, striae) 3, 6
- Increased susceptibility to infections due to immunosuppressive effects 1
- Weight gain and increased appetite 1
- Rare cases of severe disseminated infections have been reported in infants using potent topical corticosteroids 3
Comparison to Other Patient Groups
- Young adults, middle-aged adults, and elderly have lower body surface area-to-volume ratios, reducing risk of systemic absorption 1, 2
- Pregnant women have concerns about potential fetal effects, but their personal risk of systemic effects is lower than children's 7
- Breastfeeding women have minimal systemic absorption when using topical corticosteroids appropriately 7
Clinical Recommendations for Pediatric Patients
- Use the lowest potency topical corticosteroid effective for the shortest duration possible 1, 2
- High-potency or ultra-high-potency topical corticosteroids should be avoided or used with extreme caution in infants and young children 1, 2
- Careful monitoring of growth is recommended in children using topical corticosteroids long-term 1
- Regular skin checks for signs of atrophy and other local adverse effects 1, 2
- Consider alternative treatments such as topical calcineurin inhibitors for sensitive areas like the face and genital regions 1, 2
- Provide detailed application instructions to caregivers to prevent overuse 1, 2
Special Considerations
- For clobetasol and other high-potency agents, maximal weekly use should be limited in children 1
- Recovery period for HPA axis suppression in children averages 3-4 months after discontinuation of topical corticosteroids 3
- Occlusive dressings significantly increase absorption and should be avoided in pediatric patients 1, 2
- Application to large surface areas increases risk of systemic effects 1, 7
While all patient groups can experience adverse systemic effects from prolonged topical corticosteroid use, children represent the highest risk population due to their unique physiological characteristics and developmental vulnerabilities.