ArticlePDF Available

Psoriasis and vegetarian diets: A role for cortisol and potassium?



Vegetarian diets improved psoriasis symptoms in some studies. Beneficial effects of these diets are believed by others to be a result of better eicosanoid profile. However, the relation of a potassium deficiency to psoriasis is much less well documented; specially considering the fact that increased potassium is a key consequence of vegan and vegetarian diets. The conventional approach to psoriasis consists of utilizing corticosteroids including glucocorticoids. Higher potassium intake leads to higher cortisol secretion and biosynthesis. There are no qualitative differences between the effects of endogenous cortisol and exogenously applied synthetic glucocorticoids, all effects are transmitted via the same receptor. Recently, in a pilot study of patients with rheumatoid arthritis, potassium supplementation resulted in higher serum cortisol levels. I hypothesize that the improvement in psoriasis following vegetarian diets may be in part related to concomitant increases in dietary potassium intake which consequently increases cortisol biosynthesis and/or secretion.
Psoriasis and vegetarian diets: A role for cortisol and potassium?
Psoriasis is considered as a T-cell-mediated inflammatory skin
disease which is characterized by hyperproliferation and poor dif-
ferentiation of epidermal keratinocytes. The conventional ap-
proach to psoriasis consists of utilizing topical and/or oral
corticosteroids including synthetic glucocorticoids [1]. Glucocorti-
coids are potent anti-inflammatory and immunosuppressive
agents that are known to affect T-cell-mediated inflammation
by the inhibition of cellular proliferation and cytokine production
Vegetarian diets improved psoriasis symptoms in some studies
[3]. Beneficial effects of these diets are believed by others to be a
result of better eicosanoid profile [4], so that inflammatory pro-
cesses are suppressed. However, the relation of a potassium defi-
ciency to psoriasis is much less well documented; specially
considering the fact that increased potassium is a key consequence
of vegetarian diets [5].
Higher potassium intake leads to higher cortisol biosynthesis
[6]. There are no qualitative differences between the effects of
endogenous cortisol and exogenously applied synthetic glucocorti-
coids, which are used to treat psoriasis. The beauty of this is that all
effects are transmitted via the same receptor [7].
Results of a recent clinical trial showed that the elevated serum
cortisol followed potassium supplementation [8]. Briefly, thirty
two hypokalaemic patients (48.6 ± 6 y) with active rheumatoid
arthritis were investigated in a parallel randomized design for 28
days. In addition to their usual medication, the control group re-
ceived placebo, and the intervention group received 6000 mg chlo-
ride potassium dissolved in grape juice on 28 consecutive days. The
total potassium intakes, including dietary potassium and taking
compliance into account, were 1540 ± 260 (95% CI: 1397–1679)
and 6495 ± 285 (95% CI: 6342–6648) mg/day in placebo and inter-
vention group, respectively (P< 0.001). In the intervention group,
mean serum potassium and serum cortisol were significantly
raised by 1.51–1.75 mmol/L (P< 0.001) (95% CI) and 81.00–
115.20 nmoles/L (P< 0.001) (95% CI), respectively, at the end of
supplementation [8].
I would like to suggest a ‘‘Cortisol–Potassium” theory as a novel
mechanism for beneficial effects of vegetarian diets while not pre-
cluding the possibility of previously proposed mechanism of better
eicosanoid profile. I hypothesize that the improvement in psoriasis
following vegetarian diets may be in part related to concomitant
increases in dietary potassium intake which consequently in-
creases cortisol biosynthesis and/or secretion.
Disclosure statement
The author has nothing to disclose. No outside funding/support
was received for this study.
The author extends his sincere gratitude to Charles Edward We-
ber for review of the current letter and invaluable comments.
[1] Traub M, Marshall K. Psoriasis – pathophysiology, conventional, and alternative
approaches to treatment. Altern Med Rev 2007;12:319–30.
[2] Willis B, Benghuzzi H, White N, Tucci M, Cameron J. HEp-2 cells exposed to
glucocorticoids and LPS undergo organelle damage and apoptosis. Biomed Sci
Instrum 2003;39:383–8.
[3] Lithell H, Bruce A, Gustafsson IB, Hoglund NJ, Karlstrom B, Ljunghall K, et al. A
fasting and vegetarian diet treatment trial on chronic inflammatory disorders.
Acta Derm Venereol 1983;63:397–403.
[4] Wolters M. Diet and psoriasis: experimental data and clinical evidence. Br J
Dermatol 2005;153:706–14.
[5] Larsson CL, Johansson GK. Dietary intake and nutritional status of young vegans
and omnivores in Sweden. Am J Clin Nutr 2002;76:100–6.
[6] Li LA, Lin TC. Interacting influence of potassium and polychlorinated biphenyl
on cortisol and aldosterone biosynthesis. Toxicol Appl Pharmacol 2007;220:
[7] Buckbinder L, Robinson RP. The glucocorticoid receptor: molecular mechanism
and new therapeutic opportunities. Curr Drug Targets Inflamm Allergy
[8] Rastmanesh R, Abargouei AS, Shadman Z, Ebrahimi AA, Weber CE. A pilot study
of potassium supplementation in the treatment of hypokalemic patients with
rheumatoid arthritis: a randomized, double-blinded, placebo-controlled trial. J
Pain 2008;9:722–31.
Reza Rastmanesh
Shaheed Beheshti University of Medical Sciences,
Department of Human Nutrition,
Faculty of Nutrition and Food Sciences,
Arghavene Gharbi, Farahzadi Blvd,
Shahrake Gharb, P.O. Box 19395-4741,
Tehran, Iran
Tel.: +98 21 22357484; fax: +98 21 22360660
E-mail addresses:,
Gentamicin-induced deafness may be reversed by restarting cell cycle
So far, the acoustic hair cells of mammalian cochlea are consid-
ered as terminal cells, without the ability of regeneration after dam-
aged. Gentamicin-induced deafness is believed to be irreversible
due to damaged acoustic hair cells [1]. Artificial cochlea and gene
therapy are considered as valuable ways of treating gentamicin-in-
duced deafness, and both of them are aiming at replacing the func-
tions of damaged acoustic hair cells. However, more and more
clinical data show that the theory is becoming doubtful.
Recent reports showed that there are hair cell progenitors exist-
ing in the cochlea. The characteristic of hair cell progenitors is keep-
ing in resting state of cell cycle because lacking some special factors,
which will promote the regeneration of cell cycle and cell prolifer-
ation [2,3]. Clinical data showed that cyclin A2 may promote the
regeneration of cardiac muscle cells, which are considered as termi-
nal cells, by cell cycle regulation. It is interesting that the morphous
and function of regenerated cardiac muscle cells are similar to the
primary ones [4,5].
These studies lead to the hypothesis that gentamicin-induced
deafness may be reversed by restarting cell cycle. Actually, hair cell
progenitors may differentiate to hair cells with the stimulation of
368 Correspondence / Medical Hypotheses 72 (2009) 359–371
... Therefore, low-calorie diets can be considered an important aid factor in the prevention and treatment of psoriasis, as well as in weight management, reduction of inflammatory markers, improvement in the lipid and glucidic profiles, and reduction of the risk of associated diseases. 43,44 A vegetarian diet, provided it is well planned and structured, can be nutritionally adequate and have potential health benefits, including for individuals with psoriasis. 32,43 A new line of research, on plant-based diets, prioritizes the consumption of foods of plant origin as natural and as close to their original form as possible, advocating the consumption of food in its most complete form, free from refinement, processing, and artificial additives. ...
... 43,44 A vegetarian diet, provided it is well planned and structured, can be nutritionally adequate and have potential health benefits, including for individuals with psoriasis. 32,43 A new line of research, on plant-based diets, prioritizes the consumption of foods of plant origin as natural and as close to their original form as possible, advocating the consumption of food in its most complete form, free from refinement, processing, and artificial additives. It seems possible that a plant-based diet is able to influence the immune and metabolic response from changes mainly in the intestinal microbial state. ...
Full-text available
Background Psoriasis is a chronic inflammatory disease with systemic repercussions and an association with comorbidities such as metabolic syndrome, cardiovascular diseases, and obesity. Psoriasis patients have a higher prevalence of obesity compared to the general population. Diet is a relevant environmental factor, as malnutrition, inadequate body weight, and metabolic diseases, in addition to the direct health risk, affect the treatment of psoriasis. Objectives To evaluate food intake patterns, anthropometric, and metabolic syndrome-related aspects in psoriasis patients. Methods Cross-sectional study through anthropometric assessment and food frequency questionnaire. Food frequency questionnaire items were evaluated by exploratory factor analysis and identified dietary patterns were analyzed by multivariate methods. Results This study evaluated 94 patients, 57% female, with a mean age 54.9 years; the prevalence of obesity was 48% and of metabolic syndrome, 50%. Factor analysis of the food frequency questionnaire identified two dietary patterns: Pattern 1 – predominance of processed foods; Pattern 2 – predominance of fresh foods. Multivariate analysis revealed that Patterns 1 and 2 showed inverse behaviors, and greater adherence to Pattern 2 was associated with females, eutrophic individuals, absence of lipid and blood pressure alterations, and lower waist-to-hip ratio and skin disease activity. Study limitations Monocentric study conducted in a public institution, dependent on dietary memory. Conclusion Two dietary patterns were identified in a Brazilian sample of psoriasis patients. The prevalence of obesity and metabolic syndrome were greater than in the adult Brazilian population. The fresh diet was associated with lower indicators of metabolic syndrome in this sample.
... Ponadto u osób z przewlekłymi schorzeniami zapalnymi stosujących dietę wegetariańską obserwuje się zmniejszone stężenie laktoferyny, markera aktywności leukocytów obojętnochłonnych [36]. Dieta wegetariańska przyczynia się także do wyrównywania niedoborów potasu: wyższe spożycie potasu powoduje wzrost biosyntezy kortyzolu, który ma działanie przeciwzapalne [37]. Modyfikacją diety wegetariańskiej jest dieta przeciwzapalna proponowana przez doktora Johna Pagano, lekarza medycyny alternatywnej, bardzo popularnego w Stanach Zjednoczonych. ...
Full-text available
Psoriasis is a systemic disease, associated with the occurrence of metabolic disorders (obesity, diabetes, hyperuricemia, lipid disorders) and rapid development of atherosclerosis; therefore diet can be an important adjuvant therapy. A low-calorie diet is an important complement treatment of patients with psoriasis, particularly those with concomitant obesity. There are a lot of studies indicating that obesity is a risk factor for psoriasis and vice versa. Visceral adipose tissue produces numerous proinflammatory cytokines (TNF-α, IL-6, Il-8, Il-17, Il-18), the same ones that participate in development of psoriatic lesions. Important factors in the diet are the essential polyunsaturated omega-3 fatty acids. They have an anti-inflammatory effect because they inhibit the production of proinflammatory cytokines (I-1b, IL-6, IL-8, TNF-α) and adhesion molecules (ICAM-1, VCAM-1). In addition, supplementation of ome- ga-3 and natural antioxidants in the diet may help to reduce "oxidative stress" and systemic inflammation. The use of a gluten-free diet is controversial, but in patients with positive anti gliadin antibodies it seems justified. An essential element of the procedure is to avoid alcohol and all its forms and stimulants that have pro-inflammatory effects. We should advise our patients to avoid grapefruit juice during treatment with cyclosporine and limit the supply of simple sugars, animal fats and alcohol during treatment with retinoids. Dietary recommendations for patients with psoriasis are an important part of a holistic approach to patients who expect comprehensive care, not just the prescription.
Full-text available
Background: Extrinsic environmental factors, including patient lifestyle (alcohol intake, smoking, stress, sleep disturbances, and sedentary habit), diet and single nutrients intake may affect psoriasis clinical presentation, severity, and course. Methods: All English language articles dealing with psoriasis and lifestyle factors or diet gathered by an extensive PubMed search were carefully examined in order to explore their impact on the disease. Results: Current authoritative knowledge confirms that low-calories, Mediterranean, and protein restricted/vegetarian diets may be beneficial. Psoriatic patients are also recommended to engage regular physical activity, to avoid alcohol intake and to consume fish rich in omega-3 polyunsaturated fatty acids, as well as fruit and vegetables. Prebiotics and probiotics may also provide potential benefit, whereas vitamin D supplementation and gluten-free diet are useful in selected cases only. Conclusions: Changing of dietary and lifestyle habits alone does not replace conventional treatment, but must be considered as an adjuvant. Physicians may play a crucial role, by adequately acknowledging psoriatic patients on the advantages of proper lifestyle and diet habits as well as providing clues to reliable sources of dietary advice. This article is protected by copyright. All rights reserved.
Full-text available
Although changes in the expression of key steroidogenic enzymes such as cytochrome P450 cholesterol side-chain cleavage, 17 alpha-hydroxylase (P450c17), aldosterone synthase, and 3 beta-hydroxysteroid dehydrogenase (3 beta HSD) in the human adrenal cortex are known to be controlled by factors activating the protein kinase A or protein kinase C signaling pathways, little is known concerning the effects of increased intracellular Ca2+. In this study we describe the effects of K+, an agent known to increase intracellular Ca2+ through the opening of voltage-sensitive Ca2+ channels, on steroidogenesis in H295R human adrenocortical cells and corresponding changes in expression of these vital steroidogenic enzymes. Treatment of cells for 48 h with K+ (14 mM) resulted in an increase in aldosterone (3.5-fold) as well as the 17 alpha-hydroxylated steroids cortisol (2.9-fold) and dehydroepiandrosterone (DHEA; 3.7-fold). This action of K+ was accompanied by a dose-dependent (P < 0.05 at 6 mM K+ or above) and time-dependent (P < 0.05 at 24 h and beyond) increase in expression of P450c17 and, to a lesser extent, cytochrome P450 cholesterol side-chain cleavage messenger RNA (mRNA). Treatment with K+ also caused a time-dependent increase in aldosterone synthase mRNA levels, which were detectable by 12 h. Treatment with K+, however, was without effect on 3 beta HSD expression. These effects contrast with those of (Bu)2cAMP, which stimulated a greater increase in cortisol and DHEA secretion as well as P450c17 expression. The effects of K+ treatment also differ from those of AII, which promoted a greater aldosterone secretory response (5.7-fold), but a lesser effect on DHEA secretion (2.2-fold) and P450c17 expression. Although AII and TPA (known activators of protein kinase C) as well as forskolin and (Bu)2cAMP (known activators of protein kinase A) increased the expression of 3 beta HSD mRNA, K+ treatment was without effect, suggesting that elevation of [Ca2+]i in response to K+ did not activate the protein kinase C or protein kinase A signaling pathways. Furthermore, the effects of K+ on steroid secretion and 17 alpha-hydroxylase activity were reproduced by the voltage-sensitive Ca2+ channel activator BAYK 8644, and increases in P450c17 mRNA in response to K+ were reversed by the Ca2+ channel antagonist, nifedipine. We conclude that K+ can modulate the expression of key steroidogenic enzymes in H295R cells through the Ca2+ signaling pathway without involvement of the protein kinase A or protein kinase C pathways.(ABSTRACT TRUNCATED AT 250 WORDS)
Full-text available
EDITOR,—Alan Steuer and colleagues describe the unusual occurrence of a medical condition (sarcoidosis) that was suppressible by steroids and presented shortly after surgical treatment of Cushing's syndrome.1 The corollary of this—namely, that a pre-existing medical condition may be suppressed by the onset of Cushing's syndrome, reflecting the increased output of corticosteroids—is also true and may help diagnosis. The case of a 66 year old man who presented with diarrhoea and …
Background: Adolescents sometimes become vegetarian for ethical rather than health reasons. This may result in health problems caused by lack of interest in and knowledge of nutrition. Objective: We compared the dietary intake and nutritional status of young Swedish vegans and omnivores. Design: The dietary intakes of 30 vegans (15 males and 15 females; mean age: 17.5 ± 1.0 y) and 30 sex-, age-, and height-matched omnivores were assessed with the use of a diet-history interview and validated by the doubly labeled water method and by measuring nitrogen, sodium, and potassium excretion in urine. Iron status and serum vitamin B-12 and folate concentrations were measured in blood samples. Results: The diet-history method underestimated energy intake by 13% and potassium intake by 7% compared with the doubly labeled water method and 24-h urine excretion, respectively. Reported dietary nitrogen and sodium intakes agreed with the 24-h urinary excretion measure. Vegans had higher intakes of vegetables, legumes, and dietary supplements and lower intakes of cake and cookies and candy and chocolate than did omnivores. Vegans had dietary intakes lower than the average requirements of riboflavin, vitamin B-12, vitamin D, calcium, and selenium. Intakes of calcium and selenium remained low even with the inclusion of dietary supplements. There was no significant difference in the prevalence of low iron status among vegans (20%) and omnivores (23%). Two vegans with low intakes of vitamin B-12 had low serum concentrations. Conclusion: The dietary habits of the vegans varied considerably and did not comply with the average requirements for some essential nutrients.
Synopsis Mometasone, a synthetic 16α-methyl analogue of beclomethasone, is classified as a ‘potent’ glucocorticoid for dermatological use. It is available as 0.1% cream, ointment and lotion formulations for the treatment of patients with inflammatory glucocorticoid-responsive dermatoses. In patients with atopic dermatitis, the effects of mometasone 0.1% applied once daily over 2 to 3 weeks were similar to those of other glucocorticoids of similar potency, such as betamethasone dipropionate 0.05% twice daily and methylprednisolone aceponate 0.1% once daily. Mometasone 0.1% was significantly superior to twice-daily application of less potent glucocorticoids such as clobetasone 0.05%, hydrocortisone 1.0%, hydrocortisone butyrate and hydrocortisone valerate 0.2%. In patients with seborrhoeic dermatitis, mometasone 0.1% was more effective than ketoconazole 2.0% and hydrocortisone 1.0% in trials lasting 4 or 6 weeks. In the management of scalp psoriasis and psoriasis vulgaris, mometasone 0.1% applied once daily for 2 to 8 weeks was generally more effective than other glucocorticoids of similar or weaker potency such as betamethasone valerate 0.1%, fluocinolone acetonide 0.025%, fluticasone propionate 0.005%, triamcinolone acetonide 0.1% and hydrocortisone 1.0% and as effective as diflucortolone valerate 0.1%. Alternate day application of mometasone 0.1% for 2 weeks was as effective as once-daily application in maintaining symptom control in a small number of patients with psoriasis vulgaris. Although mometasone demonstrates greater anti-inflammatory activity and a longer duration of action than betamethasone, it has low potential to cause adverse systemic effects such as suppression of the hypothalamic-pituitary-adrenal (HPA) axis. Moreover, its atrophogenic potential is low and no greater than that of other glucocorticoids in its class, such as betamethasone valerate. Transient, mild to moderate, local adverse effects such as burning, stinging, folliculitis, dryness, acneiform eruptions and signs of skin atrophy have been reported with mometasone. Mometasone has shown a low risk of primary sensitisation and cross-reactions in preliminary patch test studies. Mometasone is a well tolerated topical glucocorticoid effective in the management of patients with atopic dermatitis, seborrhoeic dermatitis, scalp psoriasis and psoriasis vulgaris. In addition to its low potential for causing primary sensitisation and cross-reactions with other topical glucocorticoids, mometasone offers the convenience of once-daily administration. Pharmacological Properties Mometasone has high lipophilicity and displays greater in vitro affinity for glucocorticoid receptors in rat epidermis than betamethasone dipropionate. In suppressing erythema induced by ultraviolet (UV)-B light, mometasone showed greater activity and a longer duration of action than betamethasone dipropionate and betamethasone valerate. However, it showed little potential to suppress the hypothalamic-pituitary-adrenal axis in patients and healthy volunteers. An in vitro study on human fibroblasts and keratinocytes reported the anti-proliferative effects of mometasone to be negligible or small compared with those of betamethasone valerate. No clinical or histological signs of skin atrophy were observed in 6 volunteers after 12 months of once-daily application of mometasone 0.1% cream. Some clinical trials have found the atrophogenic potential of mometasone to be low and similar to that of hydrocortisone, prednicarbate, betamethasone valerate and methylprednisolone aceponate. However, in one trial, mometasone 0.1% ointment was associated with a significantly greater incidence and severity of skin atrophy and telangiectasia than methylprednisolone aceponate 0.1% ointment. Little topically applied mometasone reaches the systemic circulation. In human volunteers, only 0.7% of mometasone 0.1% ointment was systemically absorbed after a contact time of 8 hours without occlusive dressing. After application of 10g 0.1% ointment under occlusion, the plasma concentration of mometasone peaked at about 130 ng/L in 12 hours and then declined rapidly. Therapeutic Use Atopic dermatitis. In short term studies (≤6 weeks) once-daily mometasone 0.1% cream or ointment was significantly more effective in reducing total sign and symptom severity scores than twice-daily clobetasone 0.05% ointment, clobetasone 0.05% cream, hydrocortisone butyrate cream, hydrocortisone valerate 0.2% cream and hydrocortisone 1.0% cream and as effective as once-daily methylprednisolone aceponate 0.1% cream or twice-daily betamethasone dipropionate 0.05% ointment in the treatment of moderate to severe atopic dermatitis. Seborrhoeic dermatitis. Once-daily application of mometasone 0.1% solution was more effective and showed a faster onset of action than ketoconazole 2.0% shampoo applied twice weekly over 4 weeks in the treatment of patients with moderate to severe seborrhoeic dermatitis. Significantly greater improvement was observed after 6 weeks with mometasone 0.1% cream applied once daily than with hydrocortisone 1.0% cream applied twice daily. Psoriasis. Mometasone 0.1% lotion or ointment applied once daily was significantly more effective than twice-daily betamethasone valerate 0.1% lotion or ointment over 2 to 8 weeks in 3 trials in patients with scalp psoriasis or psoriasis vulgaris. The once-daily application of mometasone 0.1% cream, lotion or ointment formulations produced significantly greater reductions in total psoriatic symptom scores than once-daily hydrocortisone 1% ointment, twice-daily fluticasone propionate 0.005% ointment, triamcinolone acetonide 0.1% lotion or ointment or 3-times-daily fluocinolone acetonide 0.025% cream or ointment. In patients with psoriasis vulgaris, mometasone applied once daily was as effective as twice-daily diflucortolone valerate 0.1% ointment and triamcinolone acetonide 0.1% cream. Results of a preliminary short term study suggest that application of mometasone 0.1% ointment on alternate days may be as effective as once-daily application in maintenance therapy in patients with psoriasis vulgaris. Tolerability Topical mometasone 0.1% cream was associated with local cutaneous adverse effects in 1.6 and 7.0% of 319 adult and 74 paediatric patients, respectively. The most commonly encountered adverse effects included stinging, burning, pruritus, folliculitis, dryness, acneiform/erythematous eruptions, tenderness and signs of skin atrophy. These adverse effects were transient and of mild or mild to moderate intensity. Preliminary patch test studies have reported that the risk of primary sensitisation or cross-reaction with mometasone is low, even in patients known to be hypersensitive to glucocorticoids. Dosage and Administration Mometasone 0.1% cream, ointment or lotion is indicated for the symptomatic relief of inflammation and pruritus in patients with glucocorticoid-responsive dermatoses. It should be applied without occlusion to the affected areas once daily. Like other topical glucocorticoids, mometasone should not be used in patients with primary cutaneous viral, bacterial or fungal infections, rosacea, acne, perioral dermatitis, or perianal or genital pruritus. It may be used with caution in children aged ≥2 years.
We have presented a review of the interrelationship between the kidney and the adrenocortical steroids, aldosterone and cortisol primarily in the regulation of water and electrolyte metabolism. The presentation is divided into three parts: (1) the influence of cortisol and aldosterone on renal structure and function; (2) the effect of kidney disease on secretion and metabolism of these steroids, and (3) the role of the kidneys in the plasma clearance of these steroids and their metabolites. There is no evidence that an excess or deficit of these steroids have a direct effect on renal structure, but both are necessary to maintain normal GFR and RPF. Glucocorticoids augment renal hemodynamics in pharmacologic doses. The phenomenon of 'escape' by the kidney from the sodium-retaining effect of adrenocortical steroids is discussed in detail, as well as the ability of glucocorticoid to antagonize the sodium retaining activity of any adrenal steroid of analogue with lesser glucocorticoid noperties. It is included that the impaired water dunesis of glycocorticoid deficiency is due to the absence of the permissive action of these steroids on the kidney, augmented at times by enhanced ADH secretion in response to sustained nonosmotic stimuli. The effect of gluco and mineralocorticoids on the renal excretion of divalentions and uric acid is also discussed. While progressive chronic renal failure (CRF) does not seem to significantly after the secretion or metabolism of cortisol it is possible that CRF causes a state of chronic hyperaldosteronism that is essential to maintain normal excretion (secretion) of potassium per nephron as renal mass progressively decreases. A direct or an indirect effect of potassium ion may be responsible for the hypersecretion or aldosterone rather than the renin-angiotensin system.
Five patients received intramuscular injections of triamcinolone acetonide for periods ranging from five months to three years. Metyrapone tartrate testing was used to assess the function of the hypothalamic-pituitary-adrenal (HPA) axis during, after, and, in one case, before the drug therapy. The HPA axis function was found to be suppressed during the period of treatment and up to ten months after cessation of therapy. Lens opacities appeared in two of the five patients while they were receiving triamcinolone acetonide. Results of this study indicate that patients to whom triamcinolone acetonide has been administered should be given supportive doses of corticosteroids during stressful situations (eg, major surgery). They should also receive ophthalmologic examinations every three to six months while they are receiving the medication.
Increased function of the adrenal cortex is a normal response in times of physiologic and psychologic stress. Adrenal cortical secretions (e.g., glucocorticoids, aldosterone) orchestrate a multitude of internal processes aimed at maintaining homeostasis and psychologic integrity. Many patients admitted to a critical care unit will manifest some increase, even minor, in adrenal function. However, excessive secretions of these hormones can have a lethal effect of fluid and electrolyte balance, energy metabolism, and immune function. Cushing's syndrome denotes a disorder characterized by increased circulating levels of glucocorticoids (primarily cortisol). An easily recognizable disorder, it may arise from pathology of the adrenal cortex or the anterior pituitary glands, ectopic secretions from a nonendocrine tumor, or from excessive doses of exogenously administered glucocorticoids. Cushing's syndrome is rarely an admitting diagnosis to critical care but is a disorder that can seriously affect recovery from coexisting illnesses if not treated. Aldosteronism, although rare, will often be diagnosed after admission to a critical care unit for management of troublesome hypertension, hypokalemia, congestive heart failure, and various dysrhythmias. Suspicion of the diagnosis should always arise when these manifestations occur, particularly when hypokalemia is refractory to potassium supplementation. Without timely diagnosis and treatment, these patients will succumb to lethal dysrhythmias.
Twenty patients with arthritis and various skin diseases were studied on a metabolic ward during a 2-week period of modified fast followed by a 3-week period of vegetarian diet. During fasting, arthralgia was less intense in many subjects. In some types of skin diseases (pustulosis palmaris et plantaris and atopic eczema) an improvement could be demonstrated during the fast. During the vegan diet, both signs and symptoms returned in most patients, with the exception of some patients with psoriasis who experienced an improvement. The concentrations of lactoferrin in serum reflect the turnover and activity of neutrophil leukocytes. When this protein was initially increased it fell to normal values in most cases. The improvement or impairment of signs and symptoms was related to the lactoferrin levels in serum.
Two clinical trials were carried out in order to study adrenal suppression in 6 patients with psoriatic erythroderma and in 28 patients with psoriasis treated with topical glucocorticosteroids. Betamethasone-17-valerate (0.1%), betamethasone-17,21-dipropionate (0.05%) and budesonide (0.025%) ointments were studied in erythroderma; betamethasone-17,21-dipropionate and budesonide in psoriasis. The erythroderma study was an open, crossover experiment; the psoriasis study was a double-blind, group-comparative study. Adrenal suppression was measured as plasma cortisol concentrations with and without ACTH stimulation. The depressive activity on the HPA-axis in increasing order was budesonide, betamethasone-17-valerate and betamethasone-17,21-dipropionate. The differences, however, did not reach statistically significant levels.
CYP11B1 (11 beta-hydroxylase) and CYP11B2 (aldosterone synthase) are steroidogenic enzymes which mediate the final step (11 beta-hydroxylation) in cortisol synthesis and the final three steps (11 beta-hydroxylation, 18-hydroxylation, and 18-oxidation) in aldosterone synthesis, respectively. The enzymes share 93% identity in amino acid sequence and are encoded by two structurally similar genes which are located in tandem on chromosome 8q22, approximately 40 kb apart. Expression of the aldosterone synthase gene (CYP11B2) is limited to the zona glomerulosa of the adrenal cortex, thereby limiting the synthesis of aldosterone to that zone, where it is principally regulated by plasma levels of angiotensin II and potassium. The 11 beta-hydroxylase gene (CYP11B1) is expressed in the zona fasciculata, the zone which also expresses a 17-hydroxylase activity, where it mediates cortisol synthesis under the control of ACTH. Genetic recombination involving a mispairing of the two CYP11B genes can lead to duplications and deletions of the genes, creation of hybrid genes of several forms, or transfer of coding and regulatory sequences from one gene to the other. Since the two genes have related but different activities, are normally expressed in different zones, and respond to different physiological signals, such recombination has the potential to generate a variety of inherited disorders of steroid production. In this paper we review the range of mutations which can occur and the resulting disorders of steroid biosynthesis, and suggest some novel mutations which might be sought in variants of these endocrinological syndromes.