Iatrogenic Cushing Syndrome from Topical Corticosteroid Use in Infants: A Review of Published Cases
DOI:
https://doi.org/10.5281/zenodo.22279609Keywords:
Iatrogenic Cushing syndrome, Topical corticosteroids, Infants, Adrenal suppression, Clobetasol propionateAbstract
Background: Topical corticosteroids are widely used in infants, but thin, highly permeable skin and a high
surface-area-to-weight ratio permit systemic absorption sufficient to cause iatrogenic Cushing syndrome. Objective: To review published cases and case series of iatrogenic Cushing syndrome and hypothalamic-pituitary-adrenal (HPA) axis suppression from topical corticosteroid use in infants. Methods: Narrative review of case reports, case series, cohort and meta-analytic data, and management literature. Findings: Most reported infant cases followed unsupervised use of superpotent agents, chiefly clobetasol propionate, applied to the diaper area for 1-7 months; biochemistry uniformly showed secondary adrenal insufficiency (low cortisol with low or inappropriately normal ACTH). A meta-analysis of 522 children found suppression rising from 2.0% with low-potency to 6.6% with high-potency agents. Recovery after physiological hydrocortisone replacement and gradual withdrawal took a median of 2-6
months across series. Conclusions: Clinicians should recognise cushingoid infants promptly, avoid abrupt cessation of potent topical steroids, and taper under hydrocortisone cover to prevent adrenal crisis.
References
Hengge, U.R., Ruzicka, T., Schwartz, R.A., Cork, M.J. (2006) Adverse effects of topical glucocorticosteroids. Journal of the American Academy of Dermatology, 54(1): 1-15.
Coondoo, A., Phiske, M., Verma, S., Lahiri, K. (2014) Side-effects of topical steroids: A long overdue revisit. Indian Dermatology Online Journal, 5(4): 416.
Turpeinen, M., Salo, O.P., Leisti, S. (1986) Effect of percutaneous absorption of hydrocortisone on adrenocortical responsiveness in infants with severe skin disease. British Journal of Dermatology, 115(4): 475-484.
Turpeinen, M. (1988) Influence of age and severity of dermatitis on the percutaneous absorption of hydrocortisone in children. British Journal of Dermatology, 118(4): 517-522.
Ahmed, S.M., Ahmed, S.F., Othman, S., Abdullah, H.O., Mohammed, S.H., Salih, A.M., et al. (2021) Topical corticosteroid-induced iatrogenic cushing syndrome in an infant; a case report with literature review. Annals of Medicine and Surgery, 71: 102978.
Tempark, T., Phatarakijnirund, V., Chatproedprai, S., Watcharasindhu, S., Supornsilchai, V., Wananukul, S. (2010) Exogenous Cushing's syndrome due to topical corticosteroid application: case report and review literature. Endocrine, 38(3): 328-334.
Wood Heickman, L.K., Davallow Ghajar, L., Conaway, M., Rogol, A.D. (2018) Evaluation of Hypothalamic-Pituitary-Adrenal Axis Suppression following Cutaneous Use of Topical Corticosteroids in Children: A Meta-Analysis. Hormone Research in Paediatrics, 89(6): 389-396.
Ho, C.W.L., Loke, K.Y., Lim, Y.Y.J., Lee, Y.S. (2014) Exogenous Cushing Syndrome: A Lesson of Diaper Rash Cream. Hormone Research in Paediatrics, 82(6): 415-418.
Alkhuder, L., Mawlawi, H. (2019) Infantile Iatrogenic Cushing Syndrome due to Topical Steroids. Case Reports in Pediatrics, 2019: 2652961.
Jevalikar, G., Sharma, O. (2016) Exogenous Cushing Syndrome due to Topical Clobetasone use for Diaper Rash. Indian Pediatrics, 53: 76-77.
Kuikel, S., Aryal, S., Basnyat, R.S., Rimal, S. (2022) Cushing Syndrome in a Pediatric Patient with Topical Steroid Overuse. Case Reports in Endocrinology, 2022: 8487737.
Razavi, Z., Sanginabadi, M. (2014) Linear Growth Arrest Without Weight Gain Due to Overuse of Topical Clobetasol. Oman Medical Journal, 29(6): 454-457.
Almansour, S. (2026) Topical Steroid-Induced Cushing Syndrome in an 18-Month-Old Child: A Case Report. Cureus, 18(5): e109303.
Estrada-Chávez, G., Estrada, R., Engelman, D., Molina, J., Chávez-López, G. (2018) Cushing Syndrome due to Inappropriate Corticosteroid Topical Treatment of Undiagnosed Scabies. Tropical Medicine and Infectious Disease, 3(3): 82.
Matejek, N., Hoos, J., Holterhus, P.M., Bettendorf, M., Choukair, D. (2022) Topical glucocorticoid application causing iatrogenic Cushing's syndrome followed by secondary adrenal insufficiency in infants: two case reports. Journal of Medical Case Reports, 16(1): 455.
Kilci, F., Sarıkaya, E. (2025) Pediatric iatrogenic Cushing's syndrome: a series of seven cases induced by topical corticosteroid use. Journal of Pediatric Endocrinology and Metabolism, 38(8): 863-867.
Güven, A. (2020) Different Potent Glucocorticoids, Different Routes of Exposure but the Same Result: Iatrogenic Cushing's Syndrome and Adrenal Insufficiency. Journal of Clinical Research in Pediatric Endocrinology, 12(4): 383-392.
Bhusal, M., Aryal, E., Bhattarai, S., Shrestha, S.B., Rajouria, A. (2019) Iatrogenic Cushing Syndrome due to Application of Potent Topical Corticosteroid: A Case Report. Nepal Journal of Dermatology, Venereology and Leprology, 17(1): 73-75.
Tiwari, A., Goel, M., Pal, P., Gohiya, P. (2013) Topical-steroid-induced iatrogenic Cushing syndrome in the pediatric age group: A rare case report. Indian Journal of Endocrinology and Metabolism, 17(7): 257-258.
Broersen, L.H.A., Pereira, A.M., Jørgensen, J.O.L., Dekkers, O.M. (2015) Adrenal Insufficiency in Corticosteroids Use: Systematic Review and Meta-Analysis. The Journal of Clinical Endocrinology and Metabolism, 100(6): 2171-2180.
Feiwel, M., James, V.H.T., Barnett, E.S. (1969) Effect of potent topical steroids on plasma-cortisol levels of infants and children with eczema. The Lancet, 293(7593): 485-487.
Ellison, J.A., Patel, L., Ray, D.W., David, T.J., Clayton, P.E. (2000) Hypothalamic-Pituitary-Adrenal Function and Glucocorticoid Sensitivity in Atopic Dermatitis. Pediatrics, 105(4): 794-799.
Nieman, L.K., Biller, B.M.K., Findling, J.W., Newell-Price, J., Savage, M.O., Stewart, P.M., et al. (2008) The Diagnosis of Cushing's Syndrome: An Endocrine Society Clinical Practice Guideline. The Journal of Clinical Endocrinology and Metabolism, 93(5): 1526-1540.
Santos-Oliveira, J., Torrão, L., Torres-Costa, S., Silva, M., Pedrosa, A.C., Araújo, J., et al. (2025) Iatrogenic Cushing Syndrome and Secondary Adrenal Insufficiency in a Child due to Topical Ocular Corticosteroids: A Case Report. Case Reports in Ophthalmology, 16(1): 194-201.
Semiz, S., Balcı, Y.I., Ergin, Ş., Candemir, M., Polat, A. (2008) Two Cases of Cushing's Syndrome Due to Overuse of Topical Steroid in the Diaper Area. Pediatric Dermatology, 25(5): 544-547.
Ali, T., Habib, A., Zohair, M., Aman, L. (2023) Betamethasone cream to treat diapers rash causing Cushing syndrome. Journal of Pediatric Endocrinology and Metabolism, 36: 414-417.
Siegfried, E.C., Jaworski, J.C., Kaiser, J.D., Hebert, A.A. (2016) Systematic review of published trials: long-term safety of topical corticosteroids and topical calcineurin inhibitors in pediatric patients with atopic dermatitis. BMC Pediatrics, 16(1).
Chung, J.G., Cheng, H., Croxson, M., Agnew, K., Alsweiler, J., Lamb, S. (2021) Topical corticosteroid wet wrap treatment and adrenal suppression: An Auckland perspective. JAAD International, 5: 66-68.
