FRI210 Rare Clobetasol Induced Adrenal Insufficiency In A Patient With Chronic Psoriasis
Authors: Rivera Hiram Maldonado , Subtain Ali , Pastori Santiago , Gonzalez Javier A , Vallepu Shirisha R , Shahid Novera , Angueira Eugenio , Shaaban Noreen 
Published: October 2023

Abstract
Disclosure: H. Maldonado Rivera: None. A. Subtain: None. S. Pastori: None. J.A. Gonzalez: None. S.R. Vallepu: None. N. Shahid: None. E. Angueira: None. N. Shaaban: None.
A 38-year man with PMH of severe plaque psoriasis presented to the ED with complaints of right leg weakness. Patient denied nausea, vomiting, headache, chest pain, shortness of breath, and tremors. His skin psoriasis has been affecting him since childhood but got worse at age 24. The patient has been using clobetasol creams to reduce the itchiness and scaly skin that is formed throughout his body. Patient had morning cortisol level of 2.0 mcg/dL (n &gt;15 mcg/dL). Patient’s cortisol level increased to 13.6 mcg/dL in the first 30 minutes and 17.0 mcg/dL at 60 minutes of corticotropin stimulation test. Based on the result, patient is diagnosed with adrenal insufficiency due to values of cortisol being &lt;18.0mcg/dL. ACTH levels measured at the start were 22.1 pg/mL (n 6-76 pg/mL). This patient’s adrenal insufficiency is potentially multifactorial. The patient may have secondary adrenal insufficiency due to chronic use of clobetasol, a medium-potency topical steroid which has been associated with adrenal insufficiency with prolonged use. This is the most probable diagnosis in the presence of stable blood pressure and in the absence of nausea, vomiting, hyponatremia, hyperkalemia, hypercalcemia, and eosinophilia. However, the patient’s lack of gaining weight and hyperpigmentation seen in the lips and tongue as well as psoriasis, autoimmune skin disease condition may predispose the patient to develop primary adrenal insufficiency. In that case, the patient would need lifelong treatment with PO steroids, especially needing stress dosing if he becomes severely ill. This patient may be developing a primary adrenal insufficiency due to a potential autoimmune adrenalitis. Currently, patient has adequate blood pressure and electrolytes, which suggest he may develop disease later and is currently not in need of fludrocortisone. Patient’s anti-adrenal antibodies, anti-21-hydroxylase antibodies were negative. Patient was started on a medium stress dose of prednisone 20 mg PO in AM and 10 mg in PM. Patient was discharged with prednisone 10 mg PO in AM and 5 mg in PM (this is the equivalent of 40mg of hydrocortisone in AM and 20mg of Hydrocortisone in PM due to moderate illness). Eventually, patient’s prednisone dose was tapered to 5 mg in AM and 2.5mg in PM. Conclusion: This is a very rare case of clobetasol, a medium potency topical steroid used to treat severe plaque psoriasis causing secondary adrenal insufficiency due to negative feedback inhibition of hypothalamus-pituitary-adrenal axis. Reference: Ohman EM, Rogers S, Meenan FO, McKenna TJ. Adrenal Suppression following Low-Dose Topical Clobetasol Propionate. Journal of the Royal Society of Medicine. 1987;80(7):422-424.doi:10.1177/014107688708000709
Presentation: Friday, June 16, 2023