Skin bruising in asthmatic subjects treated with high doses of inhaled steroids: Frequency and association with adrenal function

Abstract

High doses of inhaled corticosteroids (ICS) (budesonide and beclomethasone ≥800 μg·day-1) are commonly used in the treatment of asthma. Some investigators have presented evidence for cutaneus effects (bruising), which suggests systemic absorption. This study aimed to assess the prevalence of skin bruising, relate the occurrence of skin bruising to adrenocortical function, and determine the risk factors for skin bruising. One hundred adult asthmatic subjects taking high doses (800-2,000 μg·day-1) of ICS for 3 months or more were recruited in an asthma clinic, and 100 control subjects paired for sex and age were recruited from an ophthalmology out-patient clinic. A detailed questionnaire on asthma, general habits and cutaneous lesions was administered. A cutaneous examination was performed. Urine cortisol levels were assessed on two consecutive days. Blood cortisol level and the response to Cortrosyn injection (60 min test) were evaluated. One hundred adult asthmatics (66 females and 34 males), 73 on beclomethasone and 27 on budesonide, were included. The prevalence of skin bruising was 71% based on the questionnaire (32% in controls) and 48% (39 out of 81 subjects) based on direct examination of the skin. We found a satisfactory association between the response to questionnaire and examination of the skin. Adrenocortical function testing showed that a minority of subjects (14 with at least one abnormal test) had lower urinary or blood cortisol levels. These low cortisol levels occurred in subjects who reported skin bruising. By multiple logistic regression, being a female (odds ratio (OR)=20; 95% confidence interval (95% CI)=13-33) and taking ICS for asthma (OR=12; 95% CI=8-18) were significantly (t=5.4) related to the likelihood of developing skin bruising. In addition, among the asthmatic subjects, being older (OR=1.6; 95% CI=1.1-2.4/10 yrs interval) (t=23) and being a female (OR=22; 95% CI=7-75) (t=5.0) influenced the occurrence of skin bruising as documented by questionnaire. In asthmatic subjects, taking high doses of ICS is associated with: 1) increased occurrence of skin bruising by comparison with controls, particularly in older subjects; and 2) a generally normal adrenocortical function, although this function is significantly lower in subjects reporting skin bruising.