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General: Systemic absorption of topical corticosteroids can produce reversible hypothalamic-pituitary-adrenal (HPA) axis suppression with the potential for glucocorticosteroid insufficiency after withdrawal of treatment.Manifestations of Cushing's syndrome, hyperglycemia, and glucosuria can also be produced in some patients by systemic absorption of topical cor-ticosteroids while on treatment.
Patients applying a topical steroid to a large surface area or to areas under occlusion should be evaluated periodically for evidence of HPA-axis suppression. This may be done by using the ACTH stimulation, A.M.plasma cortisol or urinary free cortisol tests.
If HPA axis suppression is noted, an attempt should be made to withdraw the drug, to reduce the frequency of application, or to substitute a less potent steroid. Recovery of HPA axis function is generally prompt and complete upon discontinuation of the drug. Infrequently, signs and symptoms of steroid withdrawal may occur, requiring supplemental systemic corti-costeroids. For information on systemic supplementation, see prescribing information for those products.
Pediatric patients may be more susceptible to systemic toxicity from equivalent doses due to their larger skin surface to body mass ratios. (See PRECAUTIONS-Pediatric Use). If irritation develops, Pandel (hydrocortisone probutate cream) Cream, 0.1% should be discontinued and appropriate therapy instituted. Allergic contact dermatitis with corticosteroids is usually diagnosed by observing a failure to heal rather than noting a clinical exacerbation, as observed with most topical products not containing corticosteroids.
If concomitant skin infections are present or develop, an appropriate antifungal or antibacterial agent should be used. If a favorable response does not occur promptly, use of Pandel (hydrocortisone probutate cream) Cream, 0.1% should be discontinued until the infection has been adequately controlled.
The following tests may be helpful in evaluating if HPA axis suppression does occur:
ACTH stimulation test
A.M.plasma cortisol test
Urinary free cortisol test
Carcinogenesis, Mutagenesis and Impairment of Fertility
Long-term animal studies have not been performed to evaluate the carcinogenic potential or the effect on fertility of topical corticosteroids.
In two mutagenicity experiments using hydrocortisone probutate, negative responses were observed in the occurrence of micronuclei in the bone marrow of mice and in the Ames reverse mutation test bacterial assay - with and without metabolic activation.
Teratogenic Effects - Pregnancy Category C. Corticosteroids have been shown to be teratogenic in laboratory animals when administered systemically at relatively low dosage levels. Some corticosteroids have been shown to be teratogenic after dermal application to laboratory animals.
Hydrocortisone probutate has not been tested for teratogenicity when applied topically; however, it is absorbed percutaneously, and studies in Wistar rats using the subcutaneous route resulted in teratogenicity at dose levels equal to or greater than 1 mg/kg. This dose is approximately 12 times the human average topical dose of Pandel (hydrocortisone probutate cream) Cream, 0.1% assuming 3% absorption and an application of 30 g/day on a 70 kg individual. Abnormalities seen included delayed ossification of the caudal vertebrae and other skeletal variations, cleft palate, umbilical hernia, edema, and exencephalia.
In rabbits, hydrocortisone probutate given by the subcutaneous route was teratogenic at doses equal to or greater than 0.1 mg/kg. This dose is approximately 2 times the human average topical dose of Pandel (hydrocortisone probutate cream) Cream, 0.1% assuming 3% absorption and an application of 30 g/day on a 70 kg individual. Abnormalities seen included delayed ossification of the cau-dal vertebrae and other skeletal abnormalities, cleft palate and increased fetal mortality.
The differences between the doses used in animal studies and the proposed human dose may not fully predict the human outcome. The animals received a bolus subcutaneous dose, whereas humans receive a dermal application, where absorption is lower and highly dependent on various factors (e.g., vehicle, integrity of epidermal barrier, occlusion).
There are no adequate and well-controlled studies of the teratogenic potential of hydrocortisone probutate in pregnant women. Although human epidemiological studies do not indicate an increased incidence of teratogenicity with the use of topical corticosteroids, Pandel (hydrocortisone probutate cream) Cream should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus.
Systemically administered corticosteroids appear in human milk and could suppress growth, interfere with endogenous corticosteroid production, or cause other untoward effects. It is not known whether topical administration of corticosteroids could result in sufficient systemic absorption to produce detectable quantities in human milk. Because many drugs are excreted in human milk, caution should be exercised when Pandel (hydrocortisone probutate cream) Cream, 0.1% is administered to a nursing woman.
Safety and effectiveness in pediatric patients have not been established. Because of a higher ratio of skin surface area to body mass, pediatric patients are at a greater risk than adults of HPA axis suppression and Cushing's syndrome when they are treated with topical corticosteroids. They are therefore also at a greater risk of adrenal insufficiency during and/or after withdrawal of treatment. Adverse effects including striae have been reported with inappropriate use of topical corticosteroids in infants and children.
Hypothalamic-pituitary-adrenal (HPA) axis suppression, Cushing's syndrome, linear growth retardation, delayed weight gain, and intracranial hypertension have been reported in children receiving topical corticosteroids. Manifestations of adrenal suppression in children include low plasma cortisol levels and an absence of response to ACTH stimulation. Manifestations of intracranial hypertension include bulging fontanelles, headaches, and bilateral papilledema.This monograph has been modified to include the generic and brand name in many instances.
Last reviewed on RxList: 6/24/2008
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