Corticosteroids—glucocorticoids, topical, skin

Sensory systems

Two patients developed central serous chorioretinopathy after prolonged treatment with glucocorticoids applied locally to the skin [ ].

• A 32-year-old man complained of reduced vision and metamorphopsia in the right eye. Best-corrected visual acuity was 20/25 in right eye and 20/20 in left eye. The left fundus was normal but in the right eye there was a well-circumscribed, shallow, serous detachment of the sensory retina. The clinical appearance was consistent with central serous chorioretinopathy, and the diagnosis was confirmed by fluorescein angiography, which showed a leakage point at the superior macula, spreading slowly in an inkblot configuration into the subretinal space. He had seborrheic dermatitis involving the central face, eyebrows, eyelids, and scalp for 2 years treated with topical hydrocortisone acetate cream 1%. After the initial prescription, he used the cream without further medical consultation when his symptoms got worse and used it for 4 weeks, 3–4 times a day before developing central serous chorioretinopathy.

• A 37-year-old man developed blurred vision in the left eye. He had central serous chorioretinopathy in the contralateral eye 5 years before, for which he had been treated with laser photocoagulation. Best-corrected visual acuity was 20/20 in each eye. There were scars from previous laser photocoagulation at the superior macula in the right eye. In the left eye there was a well-delineated area of serous detachment temporal to the fovea and small yellowish precipitates at the posterior aspect of the detached retina. Fluorescein angiography showed a leakage point at the upper pole of the detachment. He had pityriasis versicolor, for which he had used local diflucortolone valerate cream 0.1% in combination with isoconazole nitrate 1%. He had used the cream occasionally but had used it for 3 weeks before the onset of symptoms. He also used diflucortolone valerate cream 0.1% during the first episode of central serous chorioretinopathy.

Three patients developed advanced glaucoma while using topical facial glucocorticoids. Two other patients developed ocular hypertension secondary to topical facial glucocorticoids [ ]. Glaucoma and ocular hypertension have been reported after dermal application of glucocorticoids for facial atopic eczema [ ]. Glaucoma has also been reported after the use of a glucocorticoid ointment in a young boy [ ].

• A 6-year-old boy underwent a resection of levator palpebrae superioris for congenital blepharoptosis. Postoperatively, an ointment containing 0.1% dexamethasone and neomycin (Maxitrol) was applied to the operated eyelid three times a day to reduce lid edema. Four days later the surgical correction was satisfactory and there were no symptoms, but the intraocular pressure was raised to 44 mmHg in the operated eye, although normal in the other eye. The glucocorticoid was withdrawn and topical ocular hypotensive agents were prescribed. The intraocular pressure returned to normal the next day, and the antiglaucoma treatments were maintained for 1 week and tapered over the next 2 weeks. Subsequent follow-up confirmed normal intraocular pressure and no glaucomatous damage.

The ocular hypertensive response in this case could have been due to systemic absorption of glucocorticoid through the skin of the eyelid, especially when there was a surgical wound. Alternatively, a sufficient amount of ointment could have seeped over the eyelid margins, causing the rise in intraocular pressure, similar to the application of eye-drops.

Skin

Although glucocorticoids are used to treat eczema, they can sometimes cause or exacerbate it.

• A 74-year-old man developed worsening eczema 24 hours after he applied clobetasol (Decloban) to treat chronic eczema of his external ear [ ]. Twelve years earlier he had noted exacerbation of a cutaneous lesion after he had applied a topical glucocorticoid. He had also had generalized erythema after an intra-articular injection of paramethasone. Patch tests to a series of glucocorticoids were positive for all drugs except flupametasone, fluocortine, and tixocortol. In addition, intradermal tests were positive to hydrocortisone and prednisolone, despite negative patch tests.

The authors commented that most glucocorticoid-sensitized patients react to several of the same group and less frequently of different groups. No case of hypersensitivity to glucocorticoids of all four classes has previously been reported.

• Chronic lichenified eczema has been attributed to prolonged use of topical methylprednisolone aceponate and budesonide (strength and duration of therapy not stated) in a 26-year-old woman [ ]. Patch tests were positive for methylprednisolone aceponate and budesonide cream, but negative for all other topical glucocorticoids.

• An 18-year-old woman presented with a pruritic eczematous eruption that developed after topically applying an ointment containing hydrocortisone acetate, neomycin sulfate, and Centella asiatica [ ]. She was positive to all three ingredients of the ointment.