Patient Presentation
An 18-month-old male came to clinic after a bad night where he had sudden onset of a harsh, seal-like cough and difficulty breathing. The mother had taken him into the bathroom and made a steam bath which helped to calm him. He was able to drink and eventually go back to sleep but did awaken several times and needed the mother’s help to go back to sleep. “I’ve done this before, but he was up all night. We got a medicine for his brother once and that’s why I came in – to see if we can get some,” she said. He had a runny nose for the 24 hours before but was eating/drinking well and had no fever or other symptoms. He went to a group childcare and there was one child with similar symptoms. There were no known COVID-19 contacts. The past medical history was non-contributory.

The pertinent physical exam showed a slightly tired male with growth parameters in the 50-90%. His respiratory rate was 24 with an oxygen saturation of 97-99%. His voice and cry were hoarse sounding. He had moderate rhinorrhea. The rest of his examination was normal. The diagnosis of croup was made. The toddler was given one dose of dexamethasone in the clinic to help prevent worsening symptoms. Symptoms to monitor for were reviewed with the mother.

Discussion
Corticosteroids are a group of drugs which can be naturally or synthetically produced. Naturally occurring substances are produced in the adrenal gland, and are protein-bound (primarily corticosteroid-binding globulin and albumin). In the target tissues, they may need to be converted to an active substance. They are then reduced, oxidized, hydroxylated or conjugated as measures to inactivate them. Synthetic steroids have less protein binding and depending on their structure are more or less resistant to inactivation. Prednisone is the glucocorticoid most often used for treatment, especially as it has a short half-life. Prednisone must be converted to prednisolone to create any glucocorticoid effect. Asthma, acute severe dermatitis (e.g. poison ivy), chronic dermatitis (e.g. atopic dermatitis) are common uses of it for the primary care provider.

Systemic corticosteroids comparison:

• Short acting
  • Cortisol or hydrocortisone, cortisone acetate
  • Lasts 8-12 hours
  • Anti-inflammatory activity = hydrocortisone is considered the standard
• Intermediate
  • Prednisone, prednisolone, methylprednisolone, triamcinolone
  • Lasts 12-36 hours
  • Anti-inflammatory activity is increased 4-5 times, therefore an equivalent dose is less than hydrocortisone dosing (specific dosing must be checked)
• Long acting
  • Betamethasone, dexamethasone
  • Lasts 36-72 hours
  • Anti-inflammatory activity is increased ~30 times, therefore an equivalent dose is substantially less than hydrocortisone dosing (specific dosing must be checked)

Topical steroids are also commonly used by primary care providers.
Their percutaneous absorption and therefore the overall potential efficacy depends on several factors:

• Specific corticosteroid and its bioavailability
• Vehicle – ointments generally are more potent than creams, lotions, gels, solutions or foam. A review of these vehicles can be found here.
• Skin barrier integrity and/or inflammation – irritated, inflamed or broken skin has increased absorption
• Surface area – more surface area increases absorption
• Occlusive dressings – use under occlusal dressings increases absorption
• Anatomic area – areas with thin epidermis have increased absorption (e.g. eyelids, face, genitalia)
• Frequency and duration of use – more frequent or longer use increases absorption
• Age – infants and young children’s skin has increased absorption

A fingertip unit (FTU) is the “amount of ointment or cream expressed from a tube with a 5 mm diameter nozzle, applied from the distal skin crease to the tip of the index finger of an adult” is about 0.5 grams. FTU is a convenient way to measure the amount of topical medication being applied.
The general topical dosing in FTUs for an adult is:

One hand – 0.5
One arm – 3
One leg – 6
One foot – 2
Trunk (front or back) – 7
Face and neck – 2.5

A review of croup can be found here.

Learning Point
Dexamethasoneis a synthetic, fluoridated, potent glucocorticoid which has little mineralocorticoid effect. It is metabolized by the liver, excreted mainly in the urine and has a half-life of ~ 3 hours. Onset of action is rapid if given intravenously. It is available in tablets, oral solution or injectable suspension. Dexamethasone decreases white blood cell proliferation and migration and causes capillaries become less permeable. Various inflammatory proteins are inhibited and it also increases pulmonary circulation and surfactant production.

Some uses for dexamethasone include:

• Acute hypersensitivity/allergies
• Altitude sickness
• Cancer treatment
• Cerebral edema
• Croup
• Extubation
• Inflammation, other
• Multiple sclerosis
• Prenatal maternal use before delivery of premature infants
• Shock
• Testing for Cushing syndrome
• Spinal cord compression due to cancer metastasis

Side effects include:

• Insomnia – most frequently reported
• Immune suppression
• Cardiac – arrhythmias, increased blood pressure
• Central nervous system – increased intracranial pressure, pseudotumor cerebri, anxiety, depression
• Dermatologic – acne
• Endocrine/metabolic – adrenal suppression, hypothalmic-adrenal axis suppression, hyperglycemia, hypokalemia
• Gastrointestinal problems – weight gain, anorexia, indigestion, nausea, emesis
• Genitourinary – spermatogenic changes
• Ophthalmologic – glaucoma
• Orthopaedic – bone marrow suppression
• Pulmonary – pulmonary edema

Contraindications include cerebral malaria, systemic fungal infections, or hypersensitivity. Dexamethasone should be used with caution with many underlying renal, gastrointestinal or myasthenia gravis diseases. Latent infectious diseases can be activated due to immune suppression. Use during pregnancy has an associated risk of increased oral clefts in the fetus. Use of live-virus vaccine administration is often delayed if dexamethasone or systemic corticosteroids are being used.

Questions for Further Discussion
1. Why are systemic corticosteroids usually tapered when discontinuing the medication?
2. What are indications for consultation with a pharmacist?
3. What are some mineralocorticoid effects?

Related Cases

Disease: Croup | Steroids | Throat Disorders

Symptom/Presentation: Respiratory Distress

Specialty:General Pediatrics | Pharmacology / Toxicology

Age: Toddler

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Steroids and Croup.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

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Sarinho ESC, Melo VMPP. Glucocorticoid-induced Bone Disease: Mechanisms and Importance in Pediatric Practice. Rev Paul Pediatr. 2017;35(2):207-215. doi:10.1590/1984-0462;2017/;35;2;00007.

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Nieman LK. Pharmacologic Use of Glucocorticoids. UpToDate. Updated 3/2/2019, Accessed 2/25/21.

Goldstein BG, Goldstein AO. Topical Corticosteroids. Use and Adverse Effects. UpToDate. Updated 2/10/20, Accessed 2/25/21.

Johnson DB, Lopez MJ, Kelley B. Dexamethasone. In: StatPearls. StatPearls Publishing; 2021. Accessed March 2, 2021. http://www.ncbi.nlm.nih.gov/books/NBK482130/.

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa