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Adrenal Insufficiency After Systemic Steroid Therapy for Hemangiomas

Only one infant developed insufficiency in this (small) study.

Although most hemangiomas of infancy do not require intervention, treatment is needed for those that are problematic or endanger health. The mainstay of therapy remains systemic corticosteroids, usually given for at least several months. Suppression of the hypothalamic-pituitary-adrenal (HPA) axis is a well-known effect of prolonged systemic corticosteroid therapy. However, the development of adrenal insufficiency can be idiosyncratic and unpredictable. Little data are available on HPA-axis suppression resulting from corticosteroid treatment of infant hemangiomas. Findings in two prior studies suggested a high prevalence of adrenal suppression (71% and 87%), but the results were based on first-morning serum cortisol levels, which may lack specificity. Furthermore, many of the subjects were still receiving glucocorticoids at the time of study.

These authors performed a prospective study of 16 infants with hemangiomas treated with systemic corticosteroids to determine the prevalence of HPA-axis suppression following treatment. Infants received 2 to 3 mg/kg/day of oral prednisolone for 4 weeks, followed by tapering over 5 to 7 months (duration of therapy, 5–12 months). Thirteen infants were tested between 1 and 16 days after completing treatment, and 3 were tested between 26 and 40 days after completing treatment. Ten healthy control infants were also evaluated.

Only one infant with hemangioma had adrenal insufficiency; this patient had no predictive or unique clinical or treatment findings. The infant recovered adrenal function 3 months later. All control infants had normal adrenal function.

Comment: Although this study is limited by its small size, the methods were rigorous and the data are reassuring. Nevertheless, until we know more, parents should still be counseled about the risk for adrenal insufficiency after corticosteroid treatment. Until adrenal function recovers, infants who become significantly ill may need stress dosing of glucocorticoids. Adrenal recovery is unpredictable, occurring several months to a year after corticosteroids are discontinued. Adrenal function testing helps in assessing risk.

— Mary Wu Chang, MD

Published in Journal Watch Dermatology April 17, 2009

Citation(s):

Lomenick JP et al. Prevalence of adrenal insufficiency following systemic glucocorticoid therapy in infants with hemangiomas. Arch Dermatol 2009 Mar; 145:262.

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• addendum
  Mary W. Chang, Associate Editor, Journal Watch Dermatology, 6 May 2009 5:17 PM EST
  The method used in this study was a combination low-dose/high-dose corticotropin stimulation test.