What is the next step in treatment if hydrocortisone (cortisol) cream is not effective?

From the Guidelines

If hydrocortisone cream is not effective, the next step in treatment typically involves stepping up to a more potent topical corticosteroid such as triamcinolone 0.1%, fluocinonide 0.05%, or betamethasone dipropionate 0.05%. These medium to high-potency steroids should be applied thinly to affected areas twice daily for 1-2 weeks. For facial or intertriginous areas, consider lower potency options like desonide 0.05% to minimize side effects, as noted in the guidelines of care for the management of psoriasis and psoriatic arthritis 1.

Some key points to consider when treating psoriasis that is unresponsive to hydrocortisone cream include:

• The use of vitamin D analogs, such as calcipotriene, calcipotriol, and calcitriol, which inhibit keratinocyte proliferation and enhance keratinocyte differentiation, and can be used in combination with topical corticosteroids to enhance efficacy and reduce the risk of atrophy 1.
• The consideration of topical calcineurin inhibitors, such as tacrolimus 0.1% or pimecrolimus 1% cream, which may be beneficial for sensitive areas or long-term use since they don't cause skin thinning, especially in the treatment of inverse psoriasis 1.
• The potential for tachyphylaxis to the action of topically applied corticosteroids, although a more recent explanation for the perceived “tachyphylaxis” observed in the clinical setting is poor patient adherence rather than the long-held view of down-regulation of receptor function as the major cause 1.

For severe or widespread conditions, oral medications such as prednisone (starting at 20-40mg daily with a taper over 1-2 weeks), antihistamines, or referral to a dermatologist for consideration of systemic immunomodulators might be necessary. More potent corticosteroids work by providing stronger anti-inflammatory effects through greater suppression of inflammatory mediators and immune cell activity, addressing conditions that are resistant to hydrocortisone's milder effects.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Next Steps in Treatment

If hydrocortisone cream is not effective, the next steps in treatment may include:

• Considering other topical corticosteroids with different potencies or formulations, as suggested by 2
• Using topical calcineurin inhibitors, such as tacrolimus or pimecrolimus, which have been shown to be effective in treating atopic dermatitis 3
• Trying other topical anti-inflammatory treatments, such as phosphodiesterase-4 inhibitors or janus kinase inhibitors, which have been ranked as effective in network meta-analyses 3
• Using systemic treatments, such as oral corticosteroids or immunomodulators, in severe cases of eczema or atopic dermatitis

Considerations for Treatment

When considering the next steps in treatment, it is essential to take into account:

• The severity of the eczema or atopic dermatitis, as well as the patient's medical history and current medications
• The potential risks and benefits of different treatments, including the risk of adverse effects such as skin thinning, adrenal insufficiency, and increased risk of infections 2, 4
• The patient's preferences and values, as well as their ability to adhere to the treatment regimen

Alternative Treatments

Alternative treatments that may be considered if hydrocortisone cream is not effective include:

• Topical corticosteroids with different potencies or formulations, such as very potent or mild corticosteroids 2
• Topical calcineurin inhibitors, such as tacrolimus or pimecrolimus, which have been shown to be effective in treating atopic dermatitis 3
• Other topical anti-inflammatory treatments, such as phosphodiesterase-4 inhibitors or janus kinase inhibitors, which have been ranked as effective in network meta-analyses 3