Topical corticosteroid treatment: systemic side-effects

Abstract

A 27‐year‐old man attending the dermatology clinic for the management of psoriasis complained of severe bilateral hip pain of recent onset. Psoriasis vulgaris affected 15% of his body surface for which he was applying a combination of topical corticosteroids obtained from two separate physicians (0·05% betamethasone dipropionate 100 mL, mometasone furoate 0·1% cream 30 g and betamethasone valerate 0·1% cream 65 g every month). Plain radiography of the hips demonstrated minor flattening of the superior aspect of the left femoral head and a normal right hip. Magnetic resonance imaging (MRI), T1 weighted images, demonstrated areas of isointense necrotic bone surrounded by hypointense revascularization in the collapsed superior aspects of both femoral heads (Fig. 1) consistent with a diagnosis of stage III osteonecrosis of both femoral heads. This association is extremely rare, but systemic effects of potent topical corticosteroids are increasingly recognized. Osteonecrosis should be considered as a cause of new‐onset hip joint pain or limitation in patients using long‐term potent topical corticosteroids, particularly in combination. Plain radiography is insensitive in the early stages of disease and MRI is the imaging modality of choice.