A 24-year-old Sudanese woman presented with one month of fatigue, dizziness, abdominal distension and facial oedema. Hypocortisolaemia was present: morning cortisol 13 nmol/L (RR 240-620nmol/L), afternoon cortisol 9 nmol/L (RR 100 -280nmol/L). 

She appeared Cushingoid (moon facies, central obesity, skin fragility, striae) with skin depigmentation on face, back and hands. Blood pressure was 130/80 mmHg, fasting glucose 7.3 mmol/L (RR 4-6 mmol/L) and HbA1c 7.0% (RR<6.0%). ACTH was < 2pmol/L (RR 0–10pmol/L), with inadequate cortisol response to ACTH (169nmol/L at 60 minutes). Screening for exogenous glucocorticoid exposure revealed prolonged use of three skin lightening creams containing hydroquinone, 0.05% clobetasol proprionate and 0.05% betamethasone respectively. She was advised to cease the creams, and weaning treatment with short-term glucocorticoid replacement and hypoglycaemic therapy was initiated.

Skin lightening product use in African women is common (~25%)¹. These may contain potent corticosteroids, eg. clobetasol propionate and betamethasone dipropionate (super potent; class 1), and fluticasone propionate (potent; class 3)².  Corticosteroids decrease propriocortin (precursor for melanocyte signalling hormone) and cause epidermal cytostasis; prolonged use may reduce epidermal turnover, with fewer and less pigmented melanocytes³.

Severity of complications depends on potency, quantity, duration and extent of application.  Cutaneous complications include atrophy, telangiectasia, dermatitis, acne, striae, purpura, hypopigmentation and skin addiction syndrome². Endocrine complications include Cushing syndrome, diabetes mellitus, hypertension, oedema, menstrual irregularities and osteoporosis. Prolonged inhibition of HPA-axis may result in hypoadrenal crisis if the product is withdrawn abruptly. Application of 50g/week of clobetasol proprionate (3.5g applied twice daily) may cause secondary adrenal failure⁴: this equates to 500g/wk of 1% hydrocortisone⁵.

Lightening creams are exported to, and manufactured locally within, African countries (eg Nigeria) with high usage³. In Australia, prescription of highly potent topical steroids is limited to specialist prescribers however internet availability bypasses these regulations; ingredients may not be disclosed and counterfeit versions are available.