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Moon face

Moon face, also known as moon facies, is a medical sign characterized by a rounded, puffy, and full appearance of the face resulting from excessive fat deposits or fluid retention in the facial tissues.^[1]^[2] This condition is not a standalone diagnosis but a visible symptom often linked to underlying hormonal imbalances, particularly elevated levels of cortisol, the body's primary stress hormone.^[3] It typically develops gradually and can affect self-esteem due to its distinctive, moon-like facial contour, though it is generally not painful.^[2] The most common cause of moon face is long-term use of corticosteroid medications, such as prednisone, which mimic cortisol and lead to fat redistribution, particularly in the face, neck, and abdomen.^[2]^[3] Another primary etiology is Cushing's syndrome, a disorder resulting from prolonged exposure to high cortisol levels, either due to overproduction by the adrenal glands (endogenous causes like pituitary adenomas or adrenal tumors) or external sources like steroid therapy (exogenous causes).^[1]^[3] Less frequently, moon face may arise from hypothyroidism, where insufficient thyroid hormone production causes fluid retention and weight gain, or in rare cases, from obesity-related fat accumulation.^[2] Associated symptoms often include a fatty hump on the upper back (buffalo hump), stretch marks, muscle weakness, high blood pressure, and increased risk of type 2 diabetes, highlighting the systemic nature of the underlying conditions.^[1]^[3] Treatment for moon face focuses on addressing the root cause to reduce cortisol excess or steroid dependency, with improvements in facial appearance typically occurring over several months.^[2] For steroid-induced cases, physicians may gradually taper the dosage or switch to alternative therapies while monitoring for withdrawal symptoms.^[3] In Cushing's syndrome, options include surgical removal of tumors, radiation therapy, or medications to block cortisol production, depending on whether the issue stems from the pituitary, adrenal glands, or ectopic sources.^[1] For hypothyroidism-related moon face, synthetic thyroid hormone replacement like levothyroxine is standard.^[2] Supportive measures, such as a low-sodium diet, weight management, and avoiding alcohol, can help minimize swelling, but self-treatment is discouraged due to potential risks.^[2] Early diagnosis through blood tests, imaging, or specialist consultation is crucial to prevent complications like osteoporosis or cardiovascular disease.^[1]

Overview

Definition and Characteristics

Moon face, also known as moon facies, is a medical term describing a distinctive rounded and puffy swelling of the face caused by fat redistribution and fluid retention, which imparts a full, moon-like appearance. This condition primarily affects the sides of the face, creating a broadened, circular contour that contrasts with the individual's typical facial structure.^[4]^[5] The key physical characteristics include prominent fullness in the cheeks and temples due to localized fat deposits in the temporal fossae and buccal areas, often resulting in a double chin and a face so rounded that the ears may not be visible when viewed from the front. The skin over these areas frequently appears flushed or reddish, a phenomenon termed facial plethora, and may be thin and fragile, predisposing it to easy bruising.^[4]^[6] Unlike general facial edema, which stems mainly from fluid accumulation and can affect various body parts diffusely, moon face emphasizes fat deposition over pure water retention, yielding a more defined, non-sagging rounded profile often likened to "chipmunk cheeks." It is commonly associated with prolonged corticosteroid use or hypercortisolism.^[4]^[1]

Pathophysiology

Moon face, or moon facies, arises primarily from the effects of excess glucocorticoids, such as cortisol or synthetic equivalents, which disrupt normal adipose tissue distribution and metabolism. These hormones bind to glucocorticoid receptors in adipocytes, upregulating the expression and activity of lipoprotein lipase, an enzyme that hydrolyzes triglycerides into free fatty acids for uptake and storage. This process preferentially occurs in visceral adipose depots, including the facial region, leading to central adiposity and the characteristic rounding of the face.^[7]^[8]^[9] In addition to fat redistribution, glucocorticoids contribute to facial fullness through their partial mineralocorticoid activity. By binding to mineralocorticoid receptors in the kidney, they promote sodium reabsorption and subsequent water retention via activation of the renin-angiotensin-aldosterone system pathways, resulting in edema that exacerbates the puffy appearance. This fluid retention is particularly pronounced in conditions of prolonged glucocorticoid exposure, such as extended steroid therapy.^[10]^[11]^[12] Glucocorticoids also induce dermal changes that accentuate moon face by thinning the skin and underlying tissues. Their catabolic effects stimulate protein breakdown through upregulation of ubiquitin-proteasome pathways and inhibition of collagen synthesis, reducing dermal extracellular matrix integrity and leading to skin atrophy. This results in a smoother, more taut facial appearance over the accumulated fat.^[13]^[14] The prominence of facial features in moon face stems from a combination of central fat accumulation and peripheral muscle wasting. Excess glucocorticoids promote proteolysis in skeletal muscle via increased expression of myostatin and FOXO transcription factors, causing atrophy in the limbs and face's peripheral structures, which contrasts with the centralized fat gain and relatively enhances the rounded facial contour.^[8]^[15]^[10]

Causes

Exogenous Causes

The primary exogenous cause of moon face is prolonged systemic administration of corticosteroids, such as prednisone or prednisolone, typically at daily doses exceeding 7.5 mg for more than 3 months.^[10] This iatrogenic form of Cushing syndrome arises from the therapeutic use of these synthetic glucocorticoids, which are among the most commonly prescribed medications worldwide for immunosuppressive and anti-inflammatory purposes. These medications induce moon face through a dose- and duration-dependent mechanism involving fat redistribution, where synthetic glucocorticoids mimic the physiological actions of cortisol, promoting central adiposity including facial fat accumulation.^[10] Common indications necessitating such long-term therapy include autoimmune disorders like rheumatoid arthritis, immunosuppression following organ transplantation, chronic severe asthma, and various inflammatory conditions such as inflammatory bowel disease or vasculitis.^[16] Although systemic corticosteroids are the predominant exogenous trigger, moon face can rarely result from overuse of topical or inhaled formulations, which may lead to sufficient systemic absorption to produce cushingoid features.^[17] For instance, potent topical steroids applied extensively over large skin areas or high-dose inhaled steroids in patients with impaired barriers can contribute to this effect, though the risk remains low compared to oral routes.^[18]

Endogenous Causes

Moon face, characterized by facial rounding due to fat redistribution, is most commonly associated with endogenous hypercortisolism in Cushing's syndrome, where the body produces excessive cortisol internally.^[19] This condition arises from dysregulation in the hypothalamic-pituitary-adrenal (HPA) axis or autonomous cortisol secretion, leading to characteristic adipose deposition in the face among other systemic effects.^[20] In patients with Cushing's syndrome, moon face manifests in 81-90% of cases, often as one of the earliest visible signs of prolonged cortisol elevation.^[21] The primary subtypes of endogenous Cushing's syndrome include Cushing's disease, accounting for approximately 70% of cases, which results from adrenocorticotropic hormone (ACTH)-secreting pituitary adenomas that stimulate excessive cortisol production by the adrenal glands.^[22] Adrenal tumors, such as adenomas or carcinomas, represent about 20-25% of endogenous cases and cause cortisol overproduction independently of ACTH regulation.^[23] Ectopic ACTH production, comprising the remaining 10-15%,^[24] typically stems from non-pituitary malignancies like small cell lung cancer, leading to rapid and severe hypercortisolism.^[25] These subtypes share the core mechanism of cortisol excess but differ in onset and associated features, with pituitary-dependent cases often presenting more gradually. Beyond true Cushing's syndrome, rare endogenous causes can mimic moon face through transient or milder HPA axis perturbations. Severe chronic stress or major depressive disorder may elevate cortisol levels, contributing to pseudo-Cushing's states with facial rounding in susceptible individuals.^[26] Alcoholism similarly induces pseudo-Cushing's syndrome via hepatic and HPA dysregulation, occasionally resulting in moon-like facial changes that resolve with abstinence.^[27] In obesity, chronic low-grade inflammation can dysregulate the HPA axis, promoting subtle cortisol elevations and central fat accumulation, including mild facial fullness, though full moon face remains uncommon without overt hypercortisolism.^[28] Endogenous causes of moon face are distinguished by accompanying systemic manifestations of hypercortisolism, such as buffalo hump, central obesity, proximal muscle weakness, and cutaneous striae, which extend beyond isolated facial changes and contrast with the more targeted effects seen in exogenous steroid exposure.^[1]

Other Causes

Moon face may also arise from conditions unrelated to cortisol excess, such as hypothyroidism. In hypothyroidism, insufficient thyroid hormone production leads to myxedema, a form of non-pitting edema causing fluid retention and puffy facial features resembling moon face.^[4] This typically improves with thyroid hormone replacement therapy.^[29]

Clinical Presentation

Symptoms

Moon face manifests primarily as a noticeable rounding and puffiness of the face, which patients often describe as a significant alteration in their appearance, leading to self-consciousness and emotional distress.^[1] This subjective change can affect daily self-perception, with individuals reporting feelings of embarrassment or discomfort in social settings due to the perceived cosmetic shift.^[30] In addition to the facial changes, patients commonly report associated complaints such as central weight gain, persistent fatigue, mood disturbances including irritability and depression, proximal muscle weakness, and easy bruising.^[1] These symptoms contribute to an overall sense of unwellness, with fatigue and mood changes often exacerbating the emotional burden of the facial alterations.^[31] The development of these symptoms, including the progressive facial rounding, typically occurs gradually over weeks to months in the context of chronic glucocorticoid excess.^[4] The psychological impact is profound, with many patients experiencing heightened anxiety or social withdrawal stemming directly from the visible changes in facial appearance.^[2]

Physical Examination Findings

Moon face is characterized by symmetrical rounding of the face due to adipose tissue accumulation, particularly in the cheeks and temporal regions, resulting in a full, puffy appearance.^[6] This facial rounding is often accompanied by prominent supraclavicular fat pads, which contribute to the overall cushingoid habitus observed during physical examination.^[32] The condition typically presents bilaterally without asymmetry, distinguishing it from unilateral facial swelling caused by other pathologies.^[1] Additional objective signs frequently noted include facial plethora, manifesting as a ruddy or flushed complexion due to telangiectasias and increased vascularity.^[19] In women, hirsutism may be evident as coarse facial hair growth along the upper lip, chin, or sideburns.^[32] Other associated findings encompass a buffalo hump, representing dorsal cervical fat pad enlargement, and wide, purple striae on the abdomen or thighs, which are often tender and reflect skin atrophy from cortisol excess.^[6] These features are characteristic of moon face due to hypercortisolism. In contrast, moon face from hypothyroidism typically involves mucinous edema leading to fluid retention, which may show pitting on palpation and lacks cushingoid features like plethora, hirsutism, or striae.^[2] Assessment of moon face relies primarily on qualitative visual inspection, with clinicians evaluating the degree of facial fullness and comparing serial photographs to monitor progression or response to treatment.^[1] In research settings, quantitative methods such as caliper measurements of bizygomatic width or 3D photogrammetry have been employed to objectively characterize facial morphology, though these are not routine in clinical practice.^[33] Differentiation from mimics like cardiac or renal edema involves confirming the absence of pitting edema upon palpation, as moon face in hypercortisolism predominantly involves fat redistribution rather than fluid retention.^[4]

Diagnosis

Clinical Evaluation

Clinical evaluation of moon face begins with a detailed patient history to identify potential underlying causes, particularly exogenous glucocorticoid exposure or endogenous hypercortisolism. Clinicians inquire about the duration and dosage of corticosteroid use, such as oral prednisone for autoimmune conditions, as prolonged high-dose therapy is a common iatrogenic trigger.^[34] Recent weight gain, often central in distribution, is noted in up to 75-95% of cases, alongside associated symptoms of Cushing's syndrome like hypertension (70-85% prevalence), new-onset diabetes, fatigue, and mood disturbances.^[34] For endogenous causes, history explores menstrual irregularities in women or hirsutism, which may point to adrenal or pituitary origins.^[6] Physical examination focuses on systematic assessment to confirm facial changes and screen for systemic involvement. Inspection reveals characteristic rounding of the face due to subcutaneous fat redistribution, often accompanied by facial plethora (redness) in 70-90% of patients, distinguishing it from simple obesity.^[34] Palpation evaluates fat pads in the supraclavicular and dorsocervical regions (buffalo hump), while checking for thin, easily bruised skin or violaceous striae on the abdomen. Vital signs are essential, with hypertension detected in 68-90% of cases warranting immediate attention.^[19] Sequential photographs may aid in documenting progression over time.^[19] Differential diagnosis requires distinguishing moon face from mimicking conditions through targeted history and exam findings. Allergies or angioedema can cause transient facial swelling but lack the chronic fat deposition and systemic signs.^[6] Hypothyroidism presents with periorbital puffiness and generalized myxedema, often with dry skin and bradycardia, unlike the plethora of hypercortisolism. Nephrotic syndrome leads to facial edema from hypoalbuminemia, typically pitting and dependent, resolving with diuresis. Superior vena cava syndrome causes acute, unilateral swelling with visible neck veins, contrasting the bilateral, gradual facial rounding in moon face.^[6] Red flags in the history signal urgency and guide prioritization of causes. Rapid onset of facial rounding within weeks suggests acute ectopic ACTH production or high-dose exogenous steroids, whereas gradual development over months to years is more indicative of chronic pituitary or adrenal pathology.^[19] The pathological basis lies in glucocorticoid excess promoting visceral fat accumulation, as detailed in the pathophysiology section.^[6]

Laboratory and Imaging Tests

Diagnosis of moon face as a manifestation of Cushing's syndrome requires objective confirmation of hypercortisolism through laboratory testing, following initial clinical suspicion. The primary screening tests include measurement of 24-hour urinary free cortisol (UFC), which assesses cortisol excretion over a full day and is elevated in most cases of endogenous hypercortisolism; late-night salivary cortisol, reflecting the loss of normal diurnal rhythm with elevated midnight levels; and the low-dose dexamethasone suppression test (DST), typically involving 1 mg of dexamethasone administered overnight, where failure of cortisol suppression to below 1.8 μg/dL indicates autonomous cortisol production.^[35]^[36] At least two abnormal screening tests are recommended to confirm the diagnosis, as single tests may yield false positives due to factors like stress or obesity.^[35] Once hypercortisolism is established, plasma adrenocorticotropic hormone (ACTH) levels help differentiate the etiology: low ACTH suggests an adrenal source, normal or elevated ACTH points to pituitary or ectopic origins, guiding further evaluation.^[37]^[35] Imaging studies are pursued after biochemical confirmation to localize potential tumors. Magnetic resonance imaging (MRI) of the pituitary is preferred for detecting microadenomas in ACTH-dependent cases, while computed tomography (CT) is often used for adrenal imaging to identify nodules or hyperplasia; inferior petrosal sinus sampling may be employed if pituitary MRI is inconclusive.^[36]^[37] In chronic cases, dual-energy X-ray absorptiometry (DEXA) scanning evaluates bone mineral density to assess osteoporosis risk associated with prolonged cortisol excess.^[38] For exogenous causes, such as prolonged glucocorticoid therapy leading to iatrogenic moon face, diagnosis relies primarily on clinical history, with laboratory tests often showing suppressed endogenous cortisol and ACTH; drug level monitoring is applicable for certain synthetic glucocorticoids but is not routinely required.^[39]^[40]

Epidemiology

Incidence and Prevalence

Moon face, a characteristic facial rounding due to adipose tissue redistribution, manifests in up to 90% of patients with untreated endogenous Cushing's syndrome.^[21] In contrast, among individuals on long-term systemic corticosteroid therapy, the prevalence varies significantly by dose and duration; a prospective study of patients receiving high doses (≥20 mg/day prednisone equivalent) for at least 3 months reported cumulative incidence rates of 61% at 3 months and 69% at 12 months.^[41] Lower doses and shorter durations yield lower rates, with one observational study in patients starting oral prednisolone for rheumatic or renal conditions showing cumulative incidences of 11.1% at 1 month, 19.4% at 4 months, 25.0% at 8 months, and 37.6% at 24 weeks.^[7] Endogenous Cushing's syndrome, the primary non-iatrogenic cause of moon face, remains rare, with an estimated annual incidence of 1.8–4.5 cases per million individuals worldwide and a prevalence of 57–79 cases per million.^[42] The condition disproportionately affects females, with a female-to-male ratio of approximately 3:1.^[43] Iatrogenic moon face linked to corticosteroids appears to be increasing in certain populations due to expanded use in managing chronic inflammatory diseases. For instance, in rheumatoid arthritis, the proportion of patients initiating glucocorticoids within 6 months of diagnosis rose from 67% in 1999–2008 to 71% in 2009–2018, representing a 29% relative increase.^[44] This trend aligns with broader rises in corticosteroid prescriptions for autoimmune disorders, potentially elevating moon face occurrence in affected groups. Geographically, endogenous Cushing's syndrome shows consistent low incidence across regions, but iatrogenic cases are more prevalent in areas with high long-term corticosteroid utilization, such as post-organ transplant settings where steroids are a mainstay of immunosuppression.^[45]

Risk Factors

Moon face, a hallmark of Cushing's syndrome, is influenced by various risk factors that heighten susceptibility, including both modifiable and non-modifiable elements. Modifiable risk factors primarily revolve around exogenous glucocorticoid use, where high-dose and long-duration therapy—such as more than 20 mg of prednisone equivalent daily for over one month—significantly increases the likelihood of fat redistribution leading to facial rounding. Obesity, defined as a body mass index greater than 30, further amplifies this risk by exacerbating central fat deposition in the face and trunk. Non-modifiable factors include demographic and genetic predispositions. Females are at higher risk due to hormonal influences that may enhance cortisol sensitivity, while individuals over age 40 face elevated susceptibility as age-related changes in metabolism contribute to symptom expression. Genetic conditions, such as multiple endocrine neoplasia type 1 (MEN1) syndrome, predispose to endogenous Cushing's through pituitary or adrenal tumors, thereby increasing moon face occurrence. Certain underlying diseases heighten risk by necessitating chronic treatments or mimicking hypercortisolism. Conditions like asthma or systemic lupus erythematosus often require prolonged systemic corticosteroids, elevating the chance of iatrogenic moon face. Similarly, chronic alcohol abuse can induce pseudo-Cushing's states, leading to transient moon face through alcohol-related cortisol elevations. Protective strategies against moon face development include minimizing glucocorticoid exposure through brief courses or alternate-day dosing regimens, which reduce cumulative cortisol effects and lower the incidence of facial changes.

Management

Treatment of Underlying Cause

Although moon face is most commonly associated with hypercortisolism, management for other causes includes thyroid hormone replacement, such as levothyroxine, for hypothyroidism-related cases, and weight loss interventions for obesity-associated fat accumulation.^[2] The treatment of moon face primarily involves addressing the underlying hypercortisolism, distinguishing between exogenous causes from prolonged glucocorticoid use and endogenous causes such as Cushing's syndrome.^[36] For exogenous moon face due to iatrogenic Cushing's syndrome, the cornerstone is gradual tapering of corticosteroids to restore hypothalamic-pituitary-adrenal axis function and prevent adrenal insufficiency, typically involving a 10% dose reduction weekly or 5-10 mg prednisone equivalent every 1-2 weeks under close supervision.^[46]^[47] In cases where steroids are used for underlying autoimmune conditions like rheumatoid arthritis, transitioning to steroid-sparing agents such as biologics (e.g., TNF inhibitors) or immunosuppressants (e.g., cyclophosphamide) allows for dose minimization while controlling the primary disease.^[48] For endogenous causes, surgical resection of the cortisol-secreting tumor is the first-line therapy, with transsphenoidal surgery for pituitary adenomas achieving long-term remission rates of approximately 80% when performed at experienced centers.^[49] Adrenal tumors are managed via laparoscopic adrenalectomy, while ectopic ACTH-secreting tumors may require thoracic or abdominal surgery depending on location.^[36] If surgery is incomplete or not feasible, medical therapies target cortisol synthesis or action, including ketoconazole or metyrapone to inhibit adrenal steroidogenesis, osilodrostat (an 11β-hydroxylase inhibitor) or levoketoconazole (a steroidogenesis inhibitor), and pasireotide to suppress ACTH secretion from pituitary tumors.^[36]^[19] In inoperable cases, such as persistent pituitary microadenomas, radiation therapy (e.g., stereotactic radiosurgery) may be employed, often combined with medical therapy, though remission can take months to years.^[36] Bilateral adrenalectomy serves as a definitive option for refractory Cushing's disease, eliminating cortisol production but necessitating lifelong glucocorticoid and mineralocorticoid replacement.^[36] A multidisciplinary approach, led by endocrinologists in collaboration with neurosurgeons and other specialists, is essential for optimizing outcomes and monitoring for post-treatment hypocortisolism.^[36]

Symptom Management

Symptom management for moon face focuses on lifestyle strategies to mitigate facial swelling and discomfort, complementing the resolution of the underlying cause. A low-sodium diet restricting intake to less than 2 grams per day helps control fluid retention and reduces puffiness associated with corticosteroid use.^[50] Increasing daily water intake supports hydration and prevents exacerbation of swelling from dehydration.^[4] Regular aerobic exercise, such as walking or cycling under medical supervision, promotes overall fat loss that may lessen facial rounding over time.^[51] Optimizing sleep to 7-9 hours per night minimizes inflammation and potential cortisol fluctuations contributing to the condition.^[2] In cases of notable fluid retention, a healthcare provider may prescribe diuretics like spironolactone if deemed appropriate, though evidence specific to moon face is limited. Patients should avoid nonsteroidal anti-inflammatory drugs (NSAIDs), as they can interact adversely with corticosteroids and indirectly worsen retention effects.^[10] Cosmetic options include makeup techniques to contour and minimize the appearance of fullness, though these provide only temporary relief. Facial exercises offer limited efficacy in altering fat distribution or reducing swelling. For moon face linked to obesity, participation in supervised weight loss programs can aid in gradual improvement.^[51] Regular monitoring, such as through serial photographs, allows patients to track changes in facial appearance over 3-6 months following dosage adjustments.^[4]

Complications and Prognosis

Potential Complications

Moon face, resulting from prolonged exposure to excess glucocorticoids either endogenously in Cushing's syndrome or exogenously from corticosteroid therapy, is associated with several serious health risks due to the underlying hypercortisolism. These complications arise from the metabolic, skeletal, cardiovascular, and immunological disruptions caused by elevated cortisol levels. In cases linked to long-term corticosteroid use, osteoporosis is a prominent concern, with up to 40% of patients developing bone loss that increases fracture risk. This skeletal fragility stems from glucocorticoids inhibiting bone formation and promoting resorption, leading to a higher incidence of vertebral and hip fractures. Additionally, impaired glucose tolerance and new-onset type 2 diabetes occur frequently, affecting glucose metabolism and insulin sensitivity in a substantial proportion of patients. Hypertension is another common steroid-related issue, driven by cortisol's effects on vascular tone and sodium retention, which can exacerbate cardiovascular strain. Immunosuppression further heightens susceptibility to infections, including opportunistic ones like pneumonia and fungal diseases, due to reduced white blood cell function and impaired immune response. For endogenous Cushing's syndrome, cardiovascular disease poses a significant threat, with patients facing approximately a threefold higher risk of myocardial infarction compared to the general population, attributable to factors like hypertension, dyslipidemia, and endothelial dysfunction. Psychiatric disorders, including depression, anxiety, and less commonly psychosis (reported in approximately 8% of cases), arise from cortisol's neurotoxic effects on the brain, potentially leading to cognitive impairment and mood instability. Proximal myopathy, characterized by muscle weakness particularly in the limbs, results from glucocorticoid-induced protein catabolism and affects mobility in many patients. The persistent cosmetic changes of moon face can contribute to prolonged facial disfigurement, which, if untreated, may worsen psychological distress and lead to depression through impacts on self-esteem and social functioning. Rarely, abrupt cessation of exogenous corticosteroids can precipitate adrenal crisis, a life-threatening condition involving severe hypotension, electrolyte imbalances, and shock due to acute adrenal insufficiency.

Prognosis and Recovery

The prognosis for moon face is generally favorable, with facial changes typically resolving once the underlying cause—such as prolonged corticosteroid use or Cushing's syndrome—is addressed through appropriate management. In cases related to corticosteroid therapy, tapering the medication under medical supervision often leads to improvement, though complete resolution may take several weeks to a year depending on the duration and dosage of prior use. For individuals with Cushing's syndrome, successful treatment, such as surgical removal of a pituitary adenoma, results in symptom reversal in the majority of patients, with moon face and associated facial puffiness diminishing as cortisol levels normalize. Recovery may be slower in patients with longer disease duration or older age.^[51]^[4]^[52] Recovery timelines vary but commonly span 6 to 24 months following steroid discontinuation or Cushing's treatment, during which patients may experience gradual reduction in facial fat redistribution and swelling, often aided by dietary adjustments and weight management. Most treated patients experience reversal of moon face, though some may have persistent changes, especially those developing adrenal insufficiency post-treatment, where inadequate hormone replacement may sustain subtle facial alterations. Early intervention significantly enhances outcomes by minimizing cumulative effects on fat metabolism and fluid retention.^[52]^[2]^[53] Prevention of moon face focuses on optimizing corticosteroid regimens and vigilant monitoring in at-risk populations. Clinicians recommend using the minimal effective dose of steroids for the shortest duration necessary, alongside regular assessments of patients on long-term therapy to detect early signs of Cushingoid features. For those with suspected endogenous causes, prompt screening for Cushing's syndrome—via tests like late-night salivary cortisol or dexamethasone suppression—can avert progression to overt moon face. Lifestyle measures, such as reducing dietary salt intake and maintaining hydration, may further mitigate fluid-related swelling during therapy.^[2]^[4]^[51] In the long term, some patients require lifelong hormone replacement therapy following Cushing's surgery, particularly if pituitary function is compromised, leading to secondary adrenal insufficiency that necessitates ongoing glucocorticoid supplementation like hydrocortisone to prevent symptom recurrence. This approach ensures stable cortisol levels and supports sustained recovery, though regular endocrine follow-up is essential to adjust dosing and monitor for residual effects.^[53]^[52]

References

[1]
Cushing syndrome - Symptoms and causes - Mayo Clinic
Jun 7, 2023 · Weight gain in the face. This is sometimes called moon face. A fatty lump between the shoulders. This may be referred to as a buffalo hump. Pink ...
[2]
Moon Face: What It Is, Causes, and Treatments - Healthline
Dec 15, 2020 · Swelling that makes your face round, full, and puffy is known as moon face. It's often the result of taking steroids such as prednisone for an extended period ...Definition · Causes · Prevention · Risks
[3]
Moon Facies: Causes and Treatment - WebMD
Sep 20, 2023 · Moon facies occurs when extra fat builds up on the sides of the face. It is often related to obesity but can be from Cushing's syndrome.
[4]
Moon Face: Causes & Treatment - Cleveland Clinic
Jun 24, 2024 · Moon face (moon facies) is swelling that makes the sides of your face look puffy and round like a full moon. It's also sometimes called ...
[5]
Moon facies (Concept Id: C0332601) - NCBI
Definition. A rounded, puffy face with fat deposits in the temporal fossa and cheeks, a double chin. [ from HPO]
[6]
Cushing Disease - StatPearls - NCBI Bookshelf - NIH
[1] Physical manifestations of excess cortisol levels include moon facies, buffalo hump, easy bruising, abdominal striae, obesity, facial plethora, and ...
[7]
Moon-like Facies by Glucocorticoid Is Associated With the ...
Moon-like facies (MLF) are a typical side effect of glucocorticoid (GC) therapy; however, its predisposing factors, relationship with GC-induced complications, ...
[8]
Physiology, Glucocorticoids - StatPearls - NCBI Bookshelf
Jul 17, 2023 · Furthermore, glucocorticoids activate hormone-sensitive lipase ... face -moon face- and decrease of adipose tissue in extremities). The ...
[9]
Regulation of triglyceride metabolism by glucocorticoid receptor
May 28, 2012 · Glucocorticoids and insulin also act together to increase the expression of lipoprotein lipase (LPL), which hydrolyzes extracellular TG to FFA. ...
[10]
Corticosteroid Adverse Effects - StatPearls - NCBI Bookshelf
Jul 3, 2023 · Cardiovascular Adverse Effects. Mineralocorticoid effects, especially as seen with cortisol and cortisone, can lead to fluid retention, edema ...
[11]
Mechanisms involved in the side effects of glucocorticoids
Single or multiple side effects can occur. A typical combination is evident in the case of Cushing's syndrome, characterized by a moon face, buffalo hump, ...
[12]
Glucocorticoids & Mineralocorticoids: Video, Causes, & Meaning
Finally, when glucocorticoids are given at high doses, they can also act on mineralocorticoid receptors, causing sodium and water retention, which may result in ...
[13]
Glucocorticoid-Induced Skin Atrophy: The Old and the New - NIH
Dec 30, 2020 · The catabolic nature of GC is an important part for this side effect, as GC determine protein degradation, enhance lipolysis, increases ...
[14]
The molecular basis of glucocorticoid-induced skin atrophy - PubMed
Our study provides a solid molecular basis for glucocorticoid-induced dermal atrophy, which results from the decrease in functional collagen mRNA in the skin.Missing: thinning catabolism
[15]
glucocorticoids [TUSOM | Pharmwiki] - TMedWeb
Mar 28, 2017 · Lipid Metabolism. Chronically elevated glucocorticoids can produce a dramatic redistribution of body fat. ... increased facial fat (moon face).
[16]
Corticosteroids - StatPearls - NCBI Bookshelf - NIH
May 1, 2023 · Clinicians should use the lowest effective dose for the shortest duration of time to minimize the risk of adverse effects and consider once ...Missing: face | Show results with:face
[17]
Topical steroid-induced Cushing syndrome - PMC - NIH
Cushing syndrome refers to a group of signs and symptoms that develop as a result of either endogenous overproduction or exogenous treatment with adrenal ...
[18]
Inhalational Steroids and Iatrogenic Cushing's Syndrome - PMC
CS can be due to endogenous causes such as pituitary tumour, ectopic ACTH production, adrenal tumour or exogenous causes like exogenous steroid administration.Fate Of Ics In The Body · Metabolism Of Steroids In... · Investigations
[19]
Cushing's Syndrome - Endotext - NCBI Bookshelf - NIH
Sep 5, 2024 · Cushing's syndrome results from chronic exposure to excessive circulating levels of glucocorticoids.
[20]
Endogenous Cushing Syndrome - Medscape Reference
Sep 5, 2024 · Cushing syndrome is caused by prolonged exposure to elevated levels of either endogenous glucocorticoids or exogenous glucocorticoids.
[21]
Cushing's syndrome: epidemiology and developments in disease ...
Table 1. Clinical features of Cushing's syndrome. Signs/symptoms, Prevalence (%). General. Obesity or weight gain, 70–95. Rounded face (moon face), 81–90.
[22]
Cushing Disease - DynaMed
Apr 25, 2025 · Cushing disease is reported to causes about 60%-70% of endogenous Cushing syndrome.Missing: percentage | Show results with:percentage
[23]
Endogenous Cushing syndrome - Orphanet
CS may occur in rare genetic conditions such as multiple endocrine neoplasia type 1 and 2, Carney complex, McCune-Albright syndrome, Li-Fraumeni syndrome, ...
[24]
Cushing's Syndrome and Cushing Disease | Endocrine Society
Jan 24, 2022 · There are two types of Cushing syndrome: exogenous (caused by factors outside the body) and endogenous (caused by factors within the body).
[25]
Approach to patients with pseudo-Cushing's states - PubMed Central
The patient had a round face and was overweight, with central adipose distribution and hirsutism, features that are commonly seen in CS patients, but of lower ...
[26]
Pseudo-Cushing Syndrome: Overview, Causes and Complications ...
Oct 7, 2025 · Others may present with the features of full-blown Cushing syndrome, which include the following: Truncal obesity. Plethoric moon face.
[27]
Interleukin-1 Antagonism Decreases Cortisol Levels in Obese ...
Moon face ... This suggests a direct interaction between the pathologic activation of the innate immune system and stimulation of the HPA axis in obesity.
[28]
Cushing Syndrome: Causes, Symptoms & Treatment
Rapid weight gain in the face (sometimes called “moon face”), abdomen, back of the neck (sometimes called “buffalo hump”) and chest. A red, round face. Wounds ...Moon Face · Cushing Disease · Adrenal Cancer
[29]
Cushing's: A master of disguise - Harvard Health
Jun 1, 2025 · A swollen face, along with excess belly weight and fatigue, is a hallmark of the condition, which affects women up to five times as often as men.
[30]
Neuropsychiatric symptoms in a patient with Cushing's syndrome
Cushing's syndrome (CS) may present with different neurological and/or psychiatric symptoms including anxiety, depression, cognitive impairment and psychosis.
[31]
Endogenous Cushing Syndrome Clinical Presentation
Sep 5, 2024 · Obesity. Patients may have increased adipose tissue in the face (moon facies), in the upper back at the base of neck (buffalo hump), ...
[32]
The Face of Excess Cortisol: Clinical and Morphological Insights into ...
Oct 28, 2025 · Cushing's syndrome (CS) is characterized by excess cortisol and distinct facial features, including moon face and facial fat accumulation.Missing: prevalence | Show results with:prevalence
[33]
Approach to the Patient: Diagnosis of Cushing Syndrome - PMC
At physical examination, she had a cushingoid phenotype with a moon face with plethora and moderate hirsutism, central obesity, proximal muscle atrophy of ...Exogenous Steroids · Acth-Dependent Cs · Diagnosis Of Cs In Pregnancy
[34]
https://pmc.ncbi.nlm.nih.gov/articles/PMC9681610/
[35]
Cushing syndrome - Diagnosis and treatment - Mayo Clinic
Jun 7, 2023 · Imaging tests. CT or MRI scans can take pictures of the pituitary and adrenal glands to see if anything shows up, such as tumors. Inferior ...
[36]
Endogenous Cushing Syndrome Workup - Medscape Reference
Sep 5, 2024 · 4 methods are accepted for the diagnosis of Cushing syndrome: urinary free cortisol level, low-dose dexamethasone suppression test, evening serum and salivary ...Approach Considerations · Laboratory Studies · Imaging Studies
[37]
The Significance of Dual-Energy X-ray Absorptiometry (DXA ... - MDPI
The article discusses the use of the most important indicators obtained from a DXA test (FMI, VAT, ALMI, BMD, T-score, Z-score, VFA, TBS) and their clinical ...1. Introduction · 3. Importance Of Dxa... · 3.1. 3. Bone Tissue...<|control11|><|separator|>
[38]
Iatrogenic Cushing Syndrome - Medscape Reference
May 23, 2024 · Excess glucocorticoids can arise from increased endogenous production or prolonged exposure to exogenous use of glucocorticoid products. While ...
[39]
Cushing Syndrome - Endocrine and Metabolic Disorders
Typical symptoms and signs include moon face and truncal obesity, easy bruising, and thin arms and legs. ... Usually, very slender distal extremities and fingers.
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Incidence and risk factors for corticosteroid-induced lipodystrophy
All consecutive patients starting long-term systemic corticosteroid therapy at an initial daily dosage of 20 mg or more were enrolled in this study. Three ...
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Cushing's syndrome - ScienceDirect.com
Dec 15, 2023 · The estimated global incidence of Cushing's syndrome is 1·8–4·5 cases per million individuals per year, and its estimated prevalence is 57–79 ...
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Understanding Cushing's Disease - Prevalence & Impact - Isturisa
Cushing's disease (CD) is the most common type of endogenous Cushing's syndrome (CS) · Estimated prevalence of nearly 22 cases per million · The annual incidence ...
[43]
Time Trends in Glucocorticoid Use in Rheumatoid Arthritis ... - PubMed
May 5, 2023 · GC use was initiated within 6 months of meeting RA criteria in 67% of patients in 1999-2008 and 71% of patients in 2009-2018, corresponding to a 29% increase ...<|control11|><|separator|>
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Drug Therapy in the Heart Transplant Recipient | Circulation
Cosmetic effects include hirsutism, acne, easy bruising, skin fragility, moon face, buffalo hump, weight gain, and truncal obesity. Important metabolic effects ...Missing: prevalence | Show results with:prevalence
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Iatrogenic Cushing Syndrome Treatment & Management
May 23, 2024 · The appropriate treatment for exogenous Cushing syndrome is gradual withdrawal of the causative drug, with the aim of discontinuing this agent if possible.
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The Glucocorticoid Taper: A Primer for the Clinicians
Initial rapid tapering: In patients on high dose GC (>20-40 mg/day PE), the dose can be reduced by 5-10 mg at weekly intervals or by 30-50% every 2-4 weeks, ...
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Glucocorticoid Therapy and Cushing Syndrome Treatment ...
Jun 4, 2025 · If the primary disease activity does not permit dose reduction, then consider adding steroid-sparing agents (eg, cyclophosphamide in steroid- ...
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Transsphenoidal surgery for Cushing's disease: a review of success ...
When a transsphenoidal adenomectomy is performed at experienced transsphenoidal surgery centers, long-term remission rates average 80% overall.
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ILD Nutrition Manual: Prednisone and Weight Gain - UCSF Health
Fluid retention can be controlled by eating a diet low in sodium – no more than 2,000 mg a day – and higher in potassium. You can find a list of high-sodium ...Missing: moon | Show results with:moon
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Got Moon Face? Tips on Causes and Fixes - Verywell Health
Oct 1, 2025 · "Moon face" is swelling that makes the face look puffy and round, like a full moon. It's often caused by long-term use of a steroid medication ...Causes · Effects · Treatment<|control11|><|separator|>
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Recovery From Cushing's and Coping With Recovery - CSRF
I also tell patients that it usually takes 6 to 12 months (and dieting to loose the weight) to recover from Cushing's. I point out that it took a long time to ...Physician Comments · What Patients Had To Say · Adrenal Patients
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Treatment for Cushing's - Pituitary Foundation
You may have to take replacement cortisol (which is called 'hydrocortisone' when it is in tablet form) or another steroid tablet such as prednisolone, for some ...