Case-reports have made it evident that both inhaled, percutaneous, intranasal, intraarticular and ophthalmic administered
glucocorticoids have the potential to cause life threatening
adrenal insufficiency. With few and sometimes conflicting data and study methodology the prevalence of
adrenal insufficiency secondary to locally applied
glucocorticoids is not clear.
Adrenal insufficiency can only be correctly evaluated by a stimulation test, and has by this procedure been reported in up to 40-50% of patients treated with high-dose inhaled
glucocorticoids. Medium- to low-dose inhaled
glucocorticoids have been shown to cause adrenal suppression in 0-16% of patients.
Glucocorticoid creams and nasal
glucocorticoids can cause
adrenal insufficiency, also when used within prescribed doses, but the frequency seems to be less than with inhaled
glucocorticoids. Intraarticularly administered
glucocorticoids can cause adrenal suppression after a single injection. The systemic effect of locally applied
glucocorticoids depends on pharmacokinetic and -dynamic properties of the particular
glucocorticoid as well as individual factors. Many of the symptoms in iatrogen
adrenal insufficiency are unspecific and often difficult to differentiate from symptoms of underlying disease activity. The condition might therefore be more common than widely believed and underdiagnosed in clinical practice. Potential
adrenal insufficiency must therefore always be kept in mind in patients treated with all forms of
glucocorticoids. Clinically important points and patient management are discussed on the basis of a case report and review of the literature. More work assessing the prevalence of
adrenal insufficiency secondary to locally applied
glucocorticoids is urgently needed.