Therefore, patients receiving a large dose of any potent topical steroid applied to a large surface area or under an occlusive dressing should be evaluated periodically for evidence of HPA axis suppression by using the urinary free cortisol and ACTH stimulation tests, and for impairment of thermal homeostasis. If HPA axis suppression or elevation of the body temperature occurs, an attempt should be made to withdraw the drug, to reduce the frequency of application, substitute a less potent steroid, or use a sequential approach when utilizing the occlusive technique.
Pediatric patients may demonstrate greater susceptibility to topical corticosteroid-induced hypothalmic-pituitary-adrenal (HPA) axis suppression and Cushing's syndrome than mature patients because of a larger skin surface area to body weight ratio . HPA axis suppression, Cushing's syndrome, and intracranial hypertension have been reported in children receiving topical corticosteroids. Manifestations of adrenal suppression in children include linear growth retardation, delayed weight gain, low plasma cortisol levels, and absence of response to ACTH stimulation. Manifestations of intracranial hypertension include bulging fontanelles, headaches, and bilateral papilledema.
So CD4 counts appear to be a useful tool in assessing risk, but other factors also contribute such as lung architecture. In a retrospective study of 74 patients with interstitial lung disease on corticosteroids, 7 patients developed PCP. The mean dose at time of diagnosis was prednisone 37mg with mean duration of 10 weeks. CD4 counts ranged from 59 to 836, with a mean of 370 . The authors argued that due to their underlying lung disease, the patients were at higher risk for PCP and became infected at higher CD4 counts than patients with other underlying diseases.