Are steroid creams recommended for patients with diabetes mellitus (DM)?

Steroid Creams in Diabetic Patients

Steroid creams can be used in diabetic patients for appropriate dermatologic indications, but require careful monitoring for systemic absorption and hyperglycemia, particularly with potent formulations, large surface area application, prolonged use, or occlusive dressings. 1, 2

Key Safety Considerations

Risk of Systemic Absorption and Hyperglycemia

• Topical corticosteroids can cause systemic absorption leading to hyperglycemia and glucosuria, particularly when potent steroids are applied over large surface areas or used for prolonged periods 1, 2
• The FDA specifically warns that systemic absorption of topical corticosteroids has produced reversible HPA axis suppression, manifestations of Cushing's syndrome, hyperglycemia, and glucosuria in some patients 1, 2
• A meta-analysis demonstrated a significant association between topical corticosteroid use and development of type 2 diabetes (OR 1.24,95% CI 1.15-1.34), with risk increasing with cumulative dose and duration rather than potency alone 3
• Long-term use (>180 days) increases diabetes risk 1.32-fold, and cumulative loads of 731-1460 mg increase risk 1.44-fold 4

Conditions That Augment Systemic Absorption

• Application of more potent steroids (such as clobetasol propionate or betamethasone) significantly increases systemic absorption risk 1, 2
• Use over large surface areas, prolonged use beyond 2 weeks, and addition of occlusive dressings all enhance systemic absorption 1, 2
• Patients receiving large doses of potent topical steroids applied to large surface areas should be evaluated periodically for evidence of HPA axis suppression 1, 2

Practical Management Algorithm

When Topical Steroids Are Indicated

• For localized disease: Use the lowest potency steroid effective for the condition, applied to lesional skin only 5
• For moderate to severe dermatologic conditions: Very potent topical steroids (5-15 g twice daily) may be necessary, but require close glucose monitoring 5
• Limit treatment duration to 2-week periods when possible, as clobetasol propionate topical solution is generally well tolerated for this timeframe 2

Monitoring Requirements

• Monitor blood glucose levels more frequently during topical steroid therapy, particularly with potent formulations or large surface area application 6, 7
• Check glucose 2-4 hours after application when hyperglycemic effect is maximal, not just fasting levels 6, 8
• Target blood glucose range should be 80-180 mg/dL (5.6-10.0 mmol/L) during steroid therapy 6, 8

Adjusting Diabetes Management

• For patients on oral diabetes medications, continue baseline medications and monitor blood glucose 4 times daily during steroid therapy 7
• For patients already on insulin, consider increasing total daily insulin dose by 30-50% during topical steroid treatment if systemic absorption is suspected 7
• If significant hyperglycemia develops (consistently >180 mg/dL), consider temporary insulin therapy with NPH insulin 0.1-0.2 units/kg/day administered in the morning 6, 8

Common Pitfalls to Avoid

• Do not ignore the cumulative effect: Risk of diabetes increases with cumulative dose and duration, not just potency 3
• Do not rely solely on fasting glucose: This will miss the peak hyperglycemic effect of steroids, which occurs during the day 6, 8
• Do not use occlusive dressings without careful consideration: These dramatically increase systemic absorption and hyperglycemia risk 1, 2
• Do not continue potent topical steroids indefinitely: Limit to shortest effective duration and consider switching to less potent alternatives 1, 2

Special Populations

• Pediatric patients may absorb proportionally larger amounts of topical corticosteroids and are more susceptible to systemic toxicity, requiring even closer monitoring 1, 2
• Elderly patients or those with renal impairment should start with lower insulin doses (0.2-0.3 units/kg/day) if insulin becomes necessary 6

When to Discontinue or Modify Treatment

• If HPA axis suppression is noted, attempt to withdraw the drug, reduce frequency of application, or substitute a less potent steroid 1, 2
• If irritation develops or infection occurs, discontinue topical corticosteroids and institute appropriate therapy 1, 2
• Recovery of HPA axis function is generally prompt and complete upon discontinuation 1, 2