Penetration of Topical Steroid Preparations

To the Editor.— We read with interest the comments of Drs Lee and Rapp in your columns ( Arch Dermatol 112:261, 1976). We agree with them that increased percutaneous penetration and increased potency of topical corticosteroids will not solve all the problems of inflammatory skin disease. It has long been recognized that increased percutaneous penetration leads to adverse systemic effects such as suppression of the hypothalamicpituitary-adrenal (HPA) axis, although this has so far been observed mainly in children, adults with extensive inflammed skin, or adults treated with occlusion. Recently, a new topical corticosteroid, clobetasol propionate (Dermovate cream and ointment [Britain]) has been marketed in this country. It was found to be extremely effective and is now widely used. However, after a period, cases of pustular psoriasis began to appear, generally following cessation of treatment with this preparation. Some patients were clinically Cushingoid and showed evidence of adrenocortical insufficiency on withdrawal