Iatrogenic adrenal gland suppression from use of a potent topical steroid

We report the case of a 5‐year‐old boy with long‐standing severe atopic eczema since 6 months of age. He had been applying potent topical steroids such as betamethasone valerate 0.1% (Betnovate®, Glaxo Wellcome, Uxbridge, UK) continuously at up to 30 g per week and clobetasol propionate 0.05% (Dermovate®, Glaxo Wellcome) intermittently over the last year to control his eczema. As far as we are aware, he had not used any other topical steroid. He also had asthma from the age of 12 months with moderate severity requiring hospitalization about twice yearly. He was on regular beclomethasone dipropionate (Becotide®, Allen & Hanburys, Uxbridge, UK) inhaler twice daily for asthma control. He first presented to us when he was 5 years old, and we noted that he was small for his age (height and weight at the 9th percentile on the growth chart). It was uncertain whether he had fallen off the growth centile or whether he was growing along the 9th centile, which could be normal for him (mid‐parental height was 165 cm and he was 103 cm). However, in view of the chronic use of potent topical steroid, we decided to investigate him. He had no other medical problems. Full blood count, renal and liver biochemistry, and thyroid function test were normal. Serum immunoglobulin E (IgE) was raised at 3850 kU/l (range 0–70). His early‐morning serum cortisol was low at 277 nmol/l (range 300–700). A short adrenocorticotrophic hormone stimulation (Synacthen®) test was performed, showing cortisol levels of 8 nmol/l at baseline (normal > 120), 112 nmol/l at 30 min (normal > 570) and 150 nmol/l at 60 min (normal > 570). An increase in serum cortisol of more than 200 nmol/l from baseline was expected but was not observed in his case, indicating adrenal gland suppression. Interestingly, no steroid skin side‐effects such as striae or atrophy were noted.