The Journal of the Arkansas Medical Society Issue 3 Vol 115 | Page 14

CASE STUDY
Inadvertent Exposure to Topical Testosterone:
an Overlooked Phenomenon
Chrystal Lau 1 ; Yu-Chi Annie Wang, MD 2 ; Emir Tas, MD 2
1
College of Medicine, UAMS, Little Rock
2
Arkansas Children’s Hospital, Division of Endocrinology and Diabetes, UAMS, Little Rock
Abstract
opical testosterone products are
effective and popular treatment
options for patients with andro-
gen deficiency. While testosterone transfer to
T
immediate contacts is a known potential hazard,
there continue to be cases of unintentional expo-
sure. This report describes a pair of siblings with
signs and symptoms of hyperandrogenism due to
secondary contact with their father’s topical tes-
tosterone product.
Introduction
Testosterone therapy, primarily administered
via long-acting injections and topical gels, is the
standard of care in the treatment of patients with
testosterone deficiency. 1 Topical gel administra-
tion is effective and convenient, making it a popu-
lar choice among patients and providers.
In recent years, there has been mounting
concern surrounding the potential for interper-
sonal testosterone transfer between a patient
and his immediate contacts. Several cases have
reported isosexual or contrasexual precocity in
the children of patients who utilize topical tes-
tosterone products. 2, 3, 4 As the number of cases of
unintentional testosterone transfer began to grow,
the FDA called for black box warnings on two of
the popular topical gels in 2009. This warning was
then expanded to include all topical testosterone
products and includes caution against the risk of
secondary exposure, advising that children avoid
contact with unwashed or unclothed application
sites. Despite these warnings, testosterone trans-
fer among family members still occurs and if left
untreated can precipitate detrimental somatic (i.e.
rapid bone maturation and compromised adult
height) and emotional (i.e., anxiety, depression,
disruptive behavior) consequences in a growing
child. Signs of early puberty always warrant a
thorough investigation to identify its etiology and
to individualize treatment plans. We describe a
3-year-old boy and his 6-year-old sister with signs
and symptoms of hyperandrogenism due to sec-
ondary exposure to their father’s topical testoster-
one product.
Patient Report
A 3-year-and-2-month-old previously healthy
male was referred to the Endocrinology Clinic at
Arkansas Children’s Hospital for initial evaluation
of precocious puberty. Patient history was nega-
tive for recent growth spurt, presence of acne, and
deepening voice. Physical examination revealed a
well-developed toddler who was tall for his age
(height at the 97th percentile, figure 1). He had
pubic hair (Tanner stage II), descended and pre-
pubertal testes (~2 mL each, Tanner stage I), and a
generous penile size for age (7 cm non-stretched
length, 2.5 cm width, consistent with Tanner stage
III-IV). There were no suspicious skin lesions, birth-
marks, or other abnormal findings.
His bone age was interpreted to be eight
years using standard images of the Greulich-Pyle
skeletal atlas (figure 2). His chronological age
was 3-years-2-months, which was greater than
5 standard deviations (SD) above the mean (Pre-
dicted adult height 151 cm; Mid-parental target
height 178 cm).
Laboratory assessment was notable for sig-
nificantly elevated total testosterone (223 ng/dl;
RR<10) and only mildly elevated Androstenedione
> Continued on page 64.
Figure 2.
A. Bone age X-ray image of a healthy three-year-old male child.
B. Patient’s X-ray examination of the left wrist. Note the presence of three
(trapezium, trapezoid and scaphoid) extra ossified carpal bones (arrows), and wider
epiphyses of the phalanages (chevron).
62 • THE JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
VOLUME 115