Adverse Systemic Reactions to Prolonged Topical Corticosteroid Use in Children

Introduction to Risk Factors

Children, especially infants and young children, have a higher body surface area-to-volume ratio, increasing percutaneous absorption of topical corticosteroids and risk of systemic effects, according to the American Academy of Dermatology 1, 2, 3
Infants and young children have thinner skin, allowing for greater penetration and absorption of topical medications, as noted by the American Academy of Dermatology 2
The developing hypothalamic-pituitary-adrenal (HPA) axis in children is more susceptible to suppression from exogenous corticosteroids, as reported in Pediatrics 4, 5
Growth suppression is a unique concern in the pediatric population, as stated by the American Academy of Dermatology and Pediatrics 1, 4, 5

HPA axis suppression with abnormal morning cortisol levels can occur in children using topical corticosteroids, according to Pediatrics 4, 5
Growth deceleration is a potential adverse effect, though most children experience "catch-up" growth after completion of therapy, as reported in Pediatrics 4, 5
Increased susceptibility to infections due to immunosuppressive effects is a concern in children using topical corticosteroids, as noted in Pediatrics 4, 5
Weight gain and increased appetite are potential adverse effects of topical corticosteroid use in children, according to Pediatrics 4, 5

The American Academy of Dermatology recommends using the lowest potency topical corticosteroid effective for the shortest duration possible in pediatric patients 1, 2, 3
High-potency or ultra-high-potency topical corticosteroids should be avoided or used with extreme caution in infants and young children, as advised by the American Academy of Dermatology 2, 3
Careful monitoring of growth is recommended in children using topical corticosteroids long-term, according to the American Academy of Dermatology 1, 2
Regular skin checks for signs of atrophy and other local adverse effects are recommended for children using topical corticosteroids, as noted by the American Academy of Dermatology 1, 3
Consider alternative treatments such as topical calcineurin inhibitors for sensitive areas, as suggested by the American Academy of Dermatology 2, 6, 3

For clobetasol and other high-potency agents, maximal weekly use should be limited in children, as recommended by the American Academy of Dermatology 7, 1
Occlusive dressings significantly increase absorption and should be avoided in pediatric patients, according to the American Academy of Dermatology 1, 3
Application to large surface areas increases risk of systemic effects, as noted by the American Academy of Dermatology 1

Infants have a higher body surface area-to-volume ratio compared to older children and adults, which dramatically increases systemic exposure relative to body weight, according to the American Academy of Dermatology 8
Facial skin is naturally thinner and more permeable than trunk skin, further enhancing absorption, as noted by the American Academy of Dermatology 8

Skin atrophy develops with prolonged use, particularly on thin-skinned areas like the face, as reported by the Journal of Allergy and Clinical Immunology and the American Academy of Dermatology 8, 9
Telangiectasia (visible blood vessels) can occur with prolonged use, as reported by the Journal of Allergy and Clinical Immunology and the American Academy of Dermatology 8, 9
Striae (stretch marks) can develop, especially in occluded areas like the diaper region, according to the American Academy of Dermatology 8

The American Academy of Dermatology recommends limiting hydrocortisone 1-2.5% cream use to the shortest duration necessary, typically 3-7 days for acute flares, and applying a thin film once or twice daily maximum 8

Growth parameters (height, weight) should be assessed in infants requiring long-term therapy, as recommended by the American Academy of Dermatology 8
Regular skin checks should be performed for signs of atrophy, striae, or telangiectasia, according to the American Academy of Dermatology 8

The American Academy of Pediatrics recommends monitoring for growth deceleration, HPA axis suppression, and Cushingoid features in infants using prolonged hydrocortisone cream, with an incidence of HPA axis suppression ranging from 1.7% to 87% 10, 11
Infants using hydrocortisone cream are at risk of developing weight gain, increased appetite, and hypertension, with the incidence of hypertension being dose-dependent 10, 11
Behavioral changes, including irritability, fussiness, and insomnia, occur in up to 29% of infants receiving systemic corticosteroid exposure 10, 11
The American Academy of Pediatrics also recommends monitoring for increased infection risk, reduced B- and T-lymphocyte counts, and rare cases of Pneumocystis carinii pneumonia in infants using hydrocortisone cream 10, 11

Fatal cardiomyopathy and interventricular septal hypertrophy have been described in infants using hydrocortisone cream 12, 13

Glaucoma and cataracts are potential adverse effects requiring monitoring in infants using hydrocortisone cream 10, 11, 14, 15

The American Academy of Pediatrics recommends monitoring blood pressure periodically during treatment, and considering morning cortisol levels if prolonged use is necessary 10, 11, 14, 15