Can steroid creams cause systemic symptoms?

Can Steroid Creams Cause Systemic Symptoms?

Yes, topical corticosteroids can cause systemic symptoms, particularly hypothalamic-pituitary-adrenal (HPA) axis suppression, Cushing's syndrome, and related metabolic complications, especially with medium- to high-potency formulations, prolonged use, large surface area application, or occlusive dressing use. 1, 2

Mechanism and Risk Factors

Topical corticosteroids are absorbed percutaneously and can produce systemic effects through this route. 2 The risk of systemic absorption increases with:

• Potency class: Medium- and high-potency topical steroids (especially Class I superpotent agents like clobetasol) carry the highest risk 1, 2
• Application area: Large surface areas, occlusive dressings, and application to steroid-sensitive sites (face, intertriginous areas) increase absorption 1
• Duration and frequency: Excessive frequency or prolonged duration of use significantly increases risk 1
• Patient age: Pediatric patients are at substantially higher risk due to increased skin surface-to-body mass ratio 1, 2

Specific Systemic Complications

HPA Axis Suppression and Adrenal Insufficiency

• Clobetasol propionate has been shown to suppress the HPA axis at doses as low as 2 g per day 2
• Manifestations include glucocorticosteroid insufficiency after withdrawal, requiring supplemental systemic corticosteroids 2
• Recovery of HPA axis function is generally prompt upon discontinuation, though monitoring may be needed 2
• In documented cases, recovery periods averaged 3.49 ± 2.92 months in children and 3.84 ± 2.51 months in adults 3

Cushing's Syndrome

• Manifestations include hyperglycemia, glucosuria, weight gain, and cushingoid habitus 2, 4
• At least 43 cases of iatrogenic Cushing syndrome from superpotent topical steroids have been published over 35 years 3
• In adults, the most common indication leading to Cushing's syndrome was psoriasis treatment 3
• In children, most cases involved infants with diaper dermatitis 3

Other Systemic Effects

• Rare but serious: Unilateral or bilateral avascular necrosis of the femoral head 1
• Ocular complications: Increased intraocular pressure, glaucoma, and cataracts with periocular use 1
• Metabolic effects: Glucose intolerance, hypertension, weight gain 1
• Musculoskeletal: Decreased bone density, osteoporosis 1
• Other: Emotional lability, gastritis 1

Pediatric Considerations

Children face disproportionately higher risk of systemic toxicity. 1, 2

• Increased skin surface-to-body mass ratio leads to enhanced absorption 1
• Growth retardation is a specific pediatric concern 1
• Linear growth retardation and delayed weight gain have been reported 2
• HPA axis suppression, Cushing's syndrome, and intracranial hypertension can occur 2
• Two fatal cases in children involved severe disseminated CMV infection following early topical steroid use 3

Safe Use Guidelines

Dosing Limitations

• For superpotent steroids (Class I like clobetasol and halobetasol): Maximum 50 g per week for no more than 2 weeks at a time 1
• Only small areas should be treated at any one time 2
• Intermittent or localized use lessens systemic risk 1

Monitoring Requirements

When long-term use is necessary:

• ACTH stimulation test, morning plasma cortisol test, and urinary free cortisol test to evaluate HPA axis suppression 2
• Assessment of growth velocity in children 1
• Regular skin checks to assess for local atrophy 1
• Blood pressure monitoring 1
• Ophthalmologic examination 1
• Bone density evaluation in adults 1

Risk Mitigation Strategies

• Gradual reduction in usage following clinical response rather than abrupt discontinuation 1
• Avoid occlusive dressings unless specifically directed 2
• Consider substituting less potent corticosteroids when possible 2
• Combination with other topicals and variations in dosing schedules may lessen long-term side effect risk 1

Clinical Context

While systemic effects are possible, they remain relatively uncommon when FDA guidelines are followed. 5 A literature review found only 14 cases of Cushing's syndrome and 5 cases of pathologic adrenal suppression in adults using Class I superpotent topical steroids, suggesting that when amounts are kept within 50g per week, consecutive use for months may be safe without causing systemic effects. 5 However, all documented cases of Cushing's syndrome and adrenal suppression were reversible. 5

The key distinction is that local cutaneous side effects occur more frequently than systemic side effects, but systemic complications remain a real concern requiring vigilance, particularly in high-risk populations. 1