of cushing’s syndrome, hyperglycemia, and glucosuria. studies conducted in pediatric subjects demonstrated reversible hpa axis suppression after use of hydrocortisone butyrate lotion. pediatric patients may be more susceptible than adults to systemic toxicity from equivalent doses of hydrocortisone butyrate lotion due to their larger skin-surface-to-body-mass ratios [see use in specific populations (8.4) ] . patients applying a topical corticosteroid to a large surface area or to areas under occlusion should be considered for periodic evaluation of the hpa axis. this may be done by using cosyntropin (acth 1-24 ) stimulation testing (cst). minimize systemic corticosteroid effects by mitigating the risk factors for increased systemic absorption and using hydrocortisone butyrate lotion as recommended [see dosage and administration (2) ]. if hpa axis suppression is noted, the frequency of application should be reduced or the drug should be withdrawn, or a less potent corticosteroid should be substituted. signs and symptoms of glucocorticosteroid insufficiency may occur, requiring supplemental systemic corticosteroids [see adverse reactions (6) ] . 5.2 concomitant skin infections if skin infections are present or develop, an appropriate antifungal, antibacterial or antiviral agent should be used. if a favorable response does not occur promptly, use of hydrocortisone butyrate lotion should be discontinued until the infection has been adequately controlled [see adverse reactions (6) ] . 5.3 allergic contact dermatitis allergic contact dermatitis with corticosteroids is usually diagnosed by observing a failure to heal rather than noticing a clinical exacerbation. such an observation should be corroborated with appropriate patch testing. discontinue hydrocortisone butyrate lotion if the diagnosis is established [see adverse reactions (6) ] .

daily. ( 2 ) • rub in gently. ( 2 ) • discontinue hydrocortisone butyrate lotion when control is achieved. ( 2 ) • reassess diagnosis if no improvement is seen within 2 weeks. before prescribing for more than 2 weeks, any additional benefits of extending treatment to 4 weeks should be weighed against the risk of hpa axis suppression and local adverse events. safety and efficacy of hydrocortisone butyrate lotion has not been established beyond 4 weeks of use. ( 2 ) • avoid use under occlusion or in the diaper area. ( 2 ) • hydrocortisone butyrate lotion is not for oral, ophthalmic, or intravaginal use. ( 2 )

ical trials reflect exposure to hydrocortisone butyrate lotion twice daily for up to 4 weeks in separate clinical trials involving pediatric subjects 3 months to 18 years of age and adult subjects 18 years of age and older with mild to moderate atopic dermatitis. adverse reactions shown in the tables below include those for which there is some basis to believe there is a causal relationship to hydrocortisone butyrate lotion. although the rates of application site reactions in the vehicle group were greater than those in the hydrocortisone butyrate group in both studies, these rates are included in the tables (table 1 and table 2) because skin irritation is a known adverse reaction of topical corticosteroids. table 1. frequency of adverse reactions in pediatric subjects with mild to moderate atopic dermatitis hydrocortisone butyrate lotion (n=139) n (%) vehicle (n=145) n (%) application site reactions, including application site burning, pruritus, dermatitis, erythema, eczema, inflammation, or irritation 2 (1) 20 (14) infantile acne 1 (1) 0 (0) skin depigmentation 1 (1) 0 (0) table 2. frequency of adverse reactions in adult subjects with mild to moderate atopic dermatitis hydrocortisone butyrate lotion (n=151) n (%) vehicle (n=150) n (%) application site reactions, including application site burning, dermatitis, eczema, erythema, or pruritus 5 (3) 7 (5) 6.2 postmarketing experience because adverse reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure. the following additional local adverse reactions have been reported infrequently with topical corticosteroids, and they may occur more frequently with the use of occlusive dressings and higher potency corticosteroids. these reactions included: irritation, folliculitis, acneiform eruptions, hypopigmentation, perioral dermatitis, allergic contact dermatitis, secondary infection, skin atrophy, striae, miliaria, and telangiectasia.

female rats during gestation days 6 – 17. in the presence of maternal toxicity, fetal effects noted at 5.4 mg/kg/day (2x mthd) included an increased incidence of ossification variations and unossified sternebra. no treatment-related effects on embryofetal toxicity or teratogenicity were noted at doses of 5.4 mg/kg/day and 1.8 mg/kg/day, respectively (2x mthd and 0.7x mthd, respectively). subcutaneous doses of 0.1, 0.2 and 0.3 mg/kg/day hydrocortisone butyrate were administered to pregnant female rabbits during gestation days 7 – 20. an increased incidence of abortion was noted at 0.3 mg/kg/day (0.2x mthd). in the absence of maternal toxicity, a dose-dependent decrease in fetal body weight was noted at doses ≥0.1 mg/kg/day (0.1x mthd). additional indicators of embryofetal toxicity (reduction in litter size, decreased number of viable fetuses, increased post-implantation loss) were noted at doses ≥0.2 mg/kg/day (0.2x mthd). additional fetal effects noted in this study included delayed ossification noted at doses ≥0.1 mg/kg/day and an increased incidence of fetal malformations (primarily skeletal malformations) noted at doses ≥0.2 mg/kg/day. a dose at which no treatment-related effects on embryofetal toxicity or teratogenicity were observed was not established in this study. additional systemic embryofetal development studies were conducted in rats and mice. subcutaneous doses of 0.1 and 9 mg/kg/day hydrocortisone butyrate were administered to pregnant female rats during gestation days 9 – 15. in the presence of maternal toxicity, an increase in fetal deaths and fetal resorptions and an increase in the number of ossifications in caudal vertebrae were noted at a dose of 9 mg/kg/day (3x mthd). no treatment-related effects on embryofetal toxicity or teratogenicity were noted at 0.1 mg/kg/day (0.1x mthd). subcutaneous doses of 0.2 and 1 mg/kg/day hydrocortisone butyrate were administered to pregnant female mice during gestation days 7 – 13. in the absence of maternal toxicity, an increased number of cervical ribs and one fetus with clubbed legs were noted at a dose of 1 mg/kg/day (0.2x mthd). no treatment-related effects on embryofetal toxicity or teratogenicity were noted at doses of 1 and 0.2 mg/kg/day, respectively (0.2x mthd and 0.1x mthd, respectively). no topical embryofetal development studies were conducted with hydrocortisone butyrate lotion. however, topical embryofetal development studies were conducted in rats and rabbits with a hydrocortisone butyrate ointment formulation. topical doses of 1% and 10% hydrocortisone butyrate ointment were administered to pregnant female rats during gestation days 6 – 15 or pregnant female rabbits during gestation days 6 – 18. a dose-dependent increase in fetal resorptions was noted in rabbits (0.2 – 2x mthd) and fetal resorptions were noted in rats at the 10% hydrocortisone butyrate ointment dose (80x mthd). no treatment-related effects on embryofetal toxicity were noted at the 1% hydrocortisone butyrate ointment dose in rats (8x mthd). a dose at which no treatment-related effects on embryofetal toxicity were observed in rabbits after topical administration of hydrocortisone butyrate ointment was not established in this study. no treatment-related effects on teratogenicity were noted at a dose of 10% hydrocortisone butyrate ointment in rats or rabbits (80x mthd and 2x mthd, respectively). a peri- and postnatal development study was conducted in rats. subcutaneous doses of 0.6, 1.8 and 5.4 mg/kg/day hydrocortisone butyrate were administered to pregnant female rats from gestation day 6 to lactation day 20. in the presence of maternal toxicity, a dose-dependent decrease in fetal weight was noted at doses ≥1.8 mg/kg/day (0.7x mthd). no treatment-related effects on fetal toxicity were noted at 0.6 mg/kg/day (0.2x mthd). a delay in sexual maturation was noted at 5.4 mg/kg/day (2x mthd). no treatment-related effects on sexual maturation were noted at 1.8 mg/kg/day. no treatment-related effects on behavioral development or subsequent reproductive performance were noted at 5.4 mg/kg/day. 8.3 nursing mothers systemically administered corticosteroids appear in human milk and could suppress growth, interfere with endogenous corticosteroid production, or cause other untoward effects. it is not known whether topical administration of corticosteroids could result in sufficient systemic absorption to produce detectable quantities in human milk. because many drugs are excreted in human milk, caution should be exercised when hydrocortisone butyrate lotion is administered to a nursing woman. 8.4 pediatric use safety and efficacy in pediatric patients below 3 months of age have not been established. because of higher skin-surface-to-body-mass ratios, pediatric patients are at a greater risk than adults of hpa axis suppression when they are treated with topical corticosteroids [see warnings and precautions (5.1) ] . they are therefore also at a greater risk of glucocorticosteroid insufficiency after withdrawal of treatment and of cushing’s syndrome while on treatment. eighty-four (84) pediatric subjects (3 months to less than 18 years of age) with moderate to severe atopic dermatitis affecting at least 25% of body surface area (bsa) treated with hydrocortisone butyrate lotion three times daily for up to 4 weeks were assessed for hpa axis suppression. the disease severity (moderate to severe atopic dermatitis) and the dosing regimen (three times daily) in this hpa axis study were different from the subject population (mild to moderate atopic dermatitis) and the dosing regimen (twice daily) for which hydrocortisone butyrate lotion is indicated. seven of the 82 evaluable subjects (8.5%) demonstrated laboratory evidence of suppression, where the sole criterion for defining hpa axis suppression was a serum cortisol level of less than or equal to 18 mcg/dl after cosyntropin stimulation. suppressed subjects ranged in age from 1 to 12 years and, at the time of enrollment, had 35% to 90% bsa involvement. these subjects did not develop any other signs or symptoms of hpa axis suppression. at the first follow-up visit, approximately 1 month after the conclusion of treatment, cosyntropin stimulation results of all subjects had returned to normal, with the exception of one subject. this last subject recovered adrenal function by the second post-treatment visit, 55 days post-treatment. cushing’s syndrome, linear growth retardation, delayed weight gain, and intracranial hypertension have also been reported in pediatric patients receiving topical corticosteroids. manifestations of adrenal suppression in pediatric patients include low plasma cortisol levels to an absence of response to acth stimulation. manifestations of intracranial hypertension include bulging fontanelles, headaches, and bilateral papilledema. 8.5 geriatric use clinical studies of hydrocortisone butyrate lotion did not include sufficient numbers of subjects aged 65 and over to determine whether they respond differently from younger subjects.

days 6 – 17. in the presence of maternal toxicity, fetal effects noted at 5.4 mg/kg/day (2x mthd) included an increased incidence of ossification variations and unossified sternebra. no treatment-related effects on embryofetal toxicity or teratogenicity were noted at doses of 5.4 mg/kg/day and 1.8 mg/kg/day, respectively (2x mthd and 0.7x mthd, respectively). subcutaneous doses of 0.1, 0.2 and 0.3 mg/kg/day hydrocortisone butyrate were administered to pregnant female rabbits during gestation days 7 – 20. an increased incidence of abortion was noted at 0.3 mg/kg/day (0.2x mthd). in the absence of maternal toxicity, a dose-dependent decrease in fetal body weight was noted at doses ≥0.1 mg/kg/day (0.1x mthd). additional indicators of embryofetal toxicity (reduction in litter size, decreased number of viable fetuses, increased post-implantation loss) were noted at doses ≥0.2 mg/kg/day (0.2x mthd). additional fetal effects noted in this study included delayed ossification noted at doses ≥0.1 mg/kg/day and an increased incidence of fetal malformations (primarily skeletal malformations) noted at doses ≥0.2 mg/kg/day. a dose at which no treatment-related effects on embryofetal toxicity or teratogenicity were observed was not established in this study. additional systemic embryofetal development studies were conducted in rats and mice. subcutaneous doses of 0.1 and 9 mg/kg/day hydrocortisone butyrate were administered to pregnant female rats during gestation days 9 – 15. in the presence of maternal toxicity, an increase in fetal deaths and fetal resorptions and an increase in the number of ossifications in caudal vertebrae were noted at a dose of 9 mg/kg/day (3x mthd). no treatment-related effects on embryofetal toxicity or teratogenicity were noted at 0.1 mg/kg/day (0.1x mthd). subcutaneous doses of 0.2 and 1 mg/kg/day hydrocortisone butyrate were administered to pregnant female mice during gestation days 7 – 13. in the absence of maternal toxicity, an increased number of cervical ribs and one fetus with clubbed legs were noted at a dose of 1 mg/kg/day (0.2x mthd). no treatment-related effects on embryofetal toxicity or teratogenicity were noted at doses of 1 and 0.2 mg/kg/day, respectively (0.2x mthd and 0.1x mthd, respectively). no topical embryofetal development studies were conducted with hydrocortisone butyrate lotion. however, topical embryofetal development studies were conducted in rats and rabbits with a hydrocortisone butyrate ointment formulation. topical doses of 1% and 10% hydrocortisone butyrate ointment were administered to pregnant female rats during gestation days 6 – 15 or pregnant female rabbits during gestation days 6 – 18. a dose-dependent increase in fetal resorptions was noted in rabbits (0.2 – 2x mthd) and fetal resorptions were noted in rats at the 10% hydrocortisone butyrate ointment dose (80x mthd). no treatment-related effects on embryofetal toxicity were noted at the 1% hydrocortisone butyrate ointment dose in rats (8x mthd). a dose at which no treatment-related effects on embryofetal toxicity were observed in rabbits after topical administration of hydrocortisone butyrate ointment was not established in this study. no treatment-related effects on teratogenicity were noted at a dose of 10% hydrocortisone butyrate ointment in rats or rabbits (80x mthd and 2x mthd, respectively). a peri- and postnatal development study was conducted in rats. subcutaneous doses of 0.6, 1.8 and 5.4 mg/kg/day hydrocortisone butyrate were administered to pregnant female rats from gestation day 6 to lactation day 20. in the presence of maternal toxicity, a dose-dependent decrease in fetal weight was noted at doses ≥1.8 mg/kg/day (0.7x mthd). no treatment-related effects on fetal toxicity were noted at 0.6 mg/kg/day (0.2x mthd). a delay in sexual maturation was noted at 5.4 mg/kg/day (2x mthd). no treatment-related effects on sexual maturation were noted at 1.8 mg/kg/day. no treatment-related effects on behavioral development or subsequent reproductive performance were noted at 5.4 mg/kg/day.

gimen (twice daily) for which hydrocortisone butyrate lotion is indicated. seven of the 82 evaluable subjects (8.5%) demonstrated laboratory evidence of suppression, where the sole criterion for defining hpa axis suppression was a serum cortisol level of less than or equal to 18 mcg/dl after cosyntropin stimulation. suppressed subjects ranged in age from 1 to 12 years and, at the time of enrollment, had 35% to 90% bsa involvement. these subjects did not develop any other signs or symptoms of hpa axis suppression. at the first follow-up visit, approximately 1 month after the conclusion of treatment, cosyntropin stimulation results of all subjects had returned to normal, with the exception of one subject. this last subject recovered adrenal function by the second post-treatment visit, 55 days post-treatment. cushing’s syndrome, linear growth retardation, delayed weight gain, and intracranial hypertension have also been reported in pediatric patients receiving topical corticosteroids. manifestations of adrenal suppression in pediatric patients include low plasma cortisol levels to an absence of response to acth stimulation. manifestations of intracranial hypertension include bulging fontanelles, headaches, and bilateral papilledema.

n be absorbed through normal intact skin. inflammation and/or other disease processes in the skin, occlusive dressings, or widespread application may increase percutaneous absorption. once absorbed through the skin, topical corticosteroids are handled through pharmacokinetic pathways similar to systemically administered corticosteroids.

/kg/day (0.7x mthd). mild effects on maternal animals, such as reduced food consumption and a subsequent reduction in body weight gain, were seen at doses ≥0.6 mg/kg/day (0.2x mthd).

effects on maternal animals, such as reduced food consumption and a subsequent reduction in body weight gain, were seen at doses ≥0.6 mg/kg/day (0.2x mthd).

te severity. results favored hydrocortisone butyrate lotion over vehicle.

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