There is little evidence as to what percentage of a topical corticosteroid dose is absorbed systemically. Studies investigating systemic effects do not measure how much of the corticosteroid is in the blood, but instead focus on measuring cortisol as a marker of hypothalamic-pituitary-adrenal (HPA) axis suppression. After a few weeks’ treatment with potent or very potent topical corticosteroids temporary HPA axis suppression does occur. However, this resolves upon cessation of the topical corticosteroid, without the need for dose tapering. 5, 19 HPA axis suppression is more marked when topical corticosteroids are applied under occlusion, . with wet wraps.
An example of an acute hepatitis-like syndrome arising after pulse methylprednisolone therapy. These episodes arise typically 2 to 4 weeks after a third or fourth cycle of pulse therapy, and range in severity from an asymptomatic and transient rise in serum aminotransferase levels to an acute hepatitis and even fulminant hepatic failure. In this instance, the marked and persistent rise in serum enzymes coupled with liver histology suggesting chronic hepatitis led to a diagnosis of new-onset autoimmune hepatitis, despite the absence of serum autoantibodies or hypergammaglobulinemia. Autoimmune hepatitis may initially present in this fashion, without the typical pattern of serum autoantibodies during the early, anicteric phase. The diagnosis was further supported by the prompt improvements in serum enzymes with prednisone therapy. The acute hepatitis-like syndrome that can occur after pulses of methylprednisolone is best explained as a triggering of an underlying chronic autoimmune hepatitis caused by the sudden and profound immunosuppression followed by rapid withdrawal. This syndrome can be severe, and fatal instances have been reported. Whether reinitiation of corticosteroid therapy with gradual tapering and withdrawal is effective in ameliorating the course of illness is unclear, but anecdotal reports such as this one suggest that they are beneficial and should be initiated promptly on appearance of this syndrome. Long term follow up of such cases is also necessary to document that the autoimmune hepatitis does not relapse once corticosteroids are withdrawn again.
Thyroid storm is a life-threatening condition of the hyperthyroid state. 26 It most commonly occurs in patients with Graves' disease but may also occur in those with multinodular goiter or toxic adenoma. 27 It is treated by correcting the hyperthyroidism and treating the precipitating events. 26 Correction of the hyperthyroid state involves using drugs such as propylthiouracil or methimazole (Tapazole), beta blockers or corticosteroids, which decrease the peripheral effects of thyroid hormone and the conversion of thyroxine (T 4 ) to the more potent triiodothyronine (T 3 ). 22 , 26 Dexamethasone can be used for that purpose, at a dosage of 2 mg intravenously every six hours, and can eventually can be switched to an oral dosage of 2 mg every six hours. 28