Cushingoid Features and Addisonian Crisis Following Abrupt Withdrawal of Potent Topical Corticosteroids: A Case Report

Abstract

We report the case of a 58-year-old man with psoriasis who developed Addisonian crisis and septic shock following abrupt cessation of long-term, unsupervised use of potent topical corticosteroids, obtained without a prescription. He presented with hypotensive septic shock due to community-acquired pneumonia, compounded by adrenal suppression from chronic clobetasol and betamethasone dipropionate use. A short Synacthen test confirmed adrenal insufficiency (basal cortisol 25 nmol/L, 30-minute value 40 nmol/L). Management included aggressive intravenous fluids, vasopressor support, broad-spectrum antibiotics, and intravenous hydrocortisone, resulting in progressive recovery. This case highlights the systemic risks associated with unsupervised use of high-potency topical corticosteroids. Chronic misuse can lead to Cushingoid features, proximal muscle weakness, features of metabolic syndrome, and life-threatening adrenal insufficiency following abrupt withdrawal. Clinicians should maintain a high index of suspicion for adrenal crisis in any patient presenting with unexplained hypotension, particularly if they have a Cushingoid appearance, recent steroid cessation, or an intercurrent illness. Improving patient education, ensuring supervised tapering, and tightening the regulation of potent topical corticosteroids are essential to prevent such outcomes.

Keywords: addisonian crisis; adrenal insufficiency; iatrogenic cushing’s syndrome; psoriasis; septic shock; steroid withdrawal; topical corticosteroids.