[Durgical](https://durgical.com/en/) › [DurgiPedia](https://durgical.com/en/durgipedia/) › [Clinical exam](https://durgical.com/en/clinical-exam/) › [Systemic syndromes](https://durgical.com/en/clinical-exam/#a-systemic) › Cushing syndrome and adrenal insufficiency: the signs [Clinical exam](https://durgical.com/en/clinical-exam/) · [Systemic syndromes](https://durgical.com/en/clinical-exam/#a-systemic) # Cushing syndrome and adrenal insufficiency: the signs - Syndrome Too much cortisol (Cushing) or too little adrenal hormone (Addison): two opposite pictures you can recognize on examination. Updated 2026-11-01 **See it in 3D:** [Left adrenal gland](https://durgical.com/en/anatomy/suprarenal-gland/) · [Right adrenal gland](https://durgical.com/en/anatomy/suprarenal-gland-abdomen/) · [Pituitary gland](https://durgical.com/en/anatomy/pituitary-gland/) · [Hypothalamus](https://durgical.com/en/anatomy/hypothalamus/) · [Adrenal arteries](https://durgical.com/en/anatomy/middle-suprarenal-artery/) · [Skin](https://durgical.com/en/anatomy/skin/) ## Key points - Cushing: central obesity, a round, plethoric face, dorsocervical fat pad, wide violet striae, thin skin with bruising and proximal muscle weakness. - The signs that best separate Cushing from ordinary obesity: wide violet striae, easy bruising, facial plethora and proximal weakness. - The commonest cause of Cushing is long-term glucocorticoid use; the commonest endogenous cause is an ACTH-secreting pituitary adenoma (Cushing disease). - Addison (primary): tiredness, weight loss, orthostatic hypotension, salt craving and hyperpigmentation of creases, gums, scars and knuckles. - Hyperpigmentation and hyperkalemia are absent in secondary insufficiency (pituitary, or after stopping corticosteroids). - Adrenal crisis: shock, abdominal pain, vomiting and confusion. ## What it is Cushing syndrome is the set of signs produced by prolonged glucocorticoid excess, and adrenal insufficiency is a lack of cortisol, sometimes with a lack of aldosterone. Their signs are nearly opposite: central weight gain, hypertension and fragile skin in one; weight loss, hypotension and hyperpigmentation in the other. Adrenal crisis is an emergency that can mimic an acute abdomen or sepsis. ## Key findings - Cushing: moon face, buffalo hump, supraclavicular fullness, wide violet striae, ecchymoses, acne and hirsutism, edema and poor wound healing. - Cushing in children: weight gain with slowed growth. - Blood pressure: high in Cushing, low with an orthostatic drop in adrenal insufficiency. - Addison: hyperpigmentation of palmar creases, oral mucosa, recent scars and knuckles. - Addison: weight loss, nausea, abdominal pain and dehydration. - Proximal strength: ask the patient to rise from a chair without using the arms. ## Pathophysiology - The hypothalamus releases CRH, the pituitary ACTH and the adrenal cortex cortisol, which suppresses both. - Excess cortisol breaks down protein (muscle and collagen): proximal weakness, thin skin, striae and bruising; it shifts fat to the trunk, face and nape; it raises glucose and blood pressure and suppresses immunity. - In primary insufficiency the cortex is destroyed: cortisol and aldosterone are lacking and the pituitary releases a lot of ACTH. - ACTH shares a precursor with melanocyte-stimulating hormone, so ACTH excess darkens the skin. - Lack of aldosterone causes renal sodium loss and potassium retention: hypotension, hyponatremia, hyperkalemia and salt craving. ## Common causes - Exogenous Cushing: oral, inhaled, topical or injected glucocorticoids used for a long time. - Endogenous Cushing: ACTH-secreting pituitary adenoma, ectopic ACTH production (for example, small cell lung carcinoma) and adrenal tumors. - Primary insufficiency: autoimmune (the commonest in high-income countries), tuberculosis, HIV-related infections, metastases and adrenal hemorrhage in meningococcemia. - Secondary insufficiency: abrupt withdrawal of long-term glucocorticoids and pituitary disease. - Newborns: congenital adrenal hyperplasia can cause a salt-wasting crisis. ## Tests that confirm it - Cushing: 24-hour urinary free cortisol, late-night salivary cortisol or a dexamethasone suppression test; then ACTH to locate the source. - Adrenal insufficiency: morning cortisol, ACTH and an ACTH stimulation test; sodium and potassium. - Pituitary or adrenal imaging only after the hormonal disorder is confirmed. ## Memory aid 'Cushing gains and tears; Addison loses and darkens.' ## Test yourself Think of the answer, then tap the question to see it. ## Why does primary adrenal insufficiency darken the skin while secondary does not? In primary disease cortisol is lacking and the pituitary releases a lot of ACTH, which shares a precursor with melanocyte-stimulating hormone; in secondary disease ACTH is low. ## Which signs best separate Cushing syndrome from ordinary obesity? Wide violet striae, easy bruising, facial plethora and proximal muscle weakness. ## What is the commonest cause of Cushing syndrome? Long-term glucocorticoid use (exogenous Cushing); among endogenous causes, an ACTH-secreting pituitary adenoma. ## Why does primary adrenal insufficiency cause hyperkalemia? Destruction of the cortex also removes aldosterone, which normally makes the kidney retain sodium and excrete potassium. [Add to my cards (4)](https://durgical.app/estudiar/?add=/en/clinical-exam/cushing-syndrome-and-adrenal-insufficiency-the-signs/) ## See it in 3D The structures of Durgical's 3D anatomy where it is found. - [Left adrenal gland](https://durgical.com/en/anatomy/suprarenal-gland/) - [Right adrenal gland](https://durgical.com/en/anatomy/suprarenal-gland-abdomen/) - [Pituitary gland](https://durgical.com/en/anatomy/pituitary-gland/) - [Hypothalamus](https://durgical.com/en/anatomy/hypothalamus/) - [Adrenal arteries](https://durgical.com/en/anatomy/middle-suprarenal-artery/) - [Skin](https://durgical.com/en/anatomy/skin/) ## Related - [Diagnostic facies](https://durgical.com/en/clinical-exam/diagnostic-facies/) - [Skin examination: primary and secondary lesions](https://durgical.com/en/clinical-exam/skin-examination-primary-and-secondary-lesions/) - [Blood pressure measurement](https://durgical.com/en/clinical-exam/blood-pressure-measurement/) - [Orthostatic vital signs](https://durgical.com/en/clinical-exam/orthostatic-vital-signs/) - [Motor examination: bulk, tone and strength grading](https://durgical.com/en/clinical-exam/motor-examination-bulk-tone-and-strength-grading/) - [Dehydration and fluid overload](https://durgical.com/en/clinical-exam/dehydration-and-fluid-overload/) ## Related conditions - [Cushing syndrome](https://durgical.com/en/conditions/cushing-syndrome/) - [Adrenal insufficiency](https://durgical.com/en/conditions/adrenal-insufficiency/) - [Adrenal crisis](https://durgical.com/en/conditions/adrenal-crisis/) - [Meningococcal disease (meningococcemia)](https://durgical.com/en/conditions/meningococcal-disease/) - [Congenital adrenal hyperplasia due to 21-hydroxylase deficiency](https://durgical.com/en/conditions/congenital-adrenal-hyperplasia-due-to-21-hydroxylase-deficiency/) [← All of the clinical exam](https://durgical.com/en/clinical-exam/) Educational content on the clinical exam; it is learned and practised under supervision. It does not replace assessment by a health professional and is not for self-diagnosis. Sources: [Cushing Syndrome | Hypercortisolism | MedlinePlus](https://medlineplus.gov/cushingssyndrome.html) (MedlinePlus, U.S. National Library of Medicine, 2026); [Addison Disease | Adrenal Insufficiency | MedlinePlus](https://medlineplus.gov/addisondisease.html) (MedlinePlus, U.S. National Library of Medicine, 2026); [17.6 The Adrenal Glands - Anatomy and Physiology 2e | OpenStax](https://openstax.org/books/anatomy-and-physiology-2e/pages/17-6-the-adrenal-glands) (OpenStax, Rice University, 2022). ## **Spotted a mistake?** We are always improving for the community. Tell us what is wrong and our team will review it. Report a mistake Representative model, for educational purposes only. --- Source: https://durgical.com/en/clinical-exam/cushing-syndrome-and-adrenal-insufficiency-the-signs/ License: CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). Cite as: DurgiPedia (durgical.com), https://durgical.com/en/clinical-exam/cushing-syndrome-and-adrenal-insufficiency-the-signs/