From the Guidelines
For patients with hemorrhoids who do not respond to hydrocortisone cream, the next step typically involves trying other topical treatments, increasing dietary fiber and water intake, and considering more advanced treatments such as rubber band ligation or surgical options if necessary. According to the American Gastroenterological Association medical position statement 1, the cornerstone of medical therapy for hemorrhoids is adequate intake of fiber and water, and topical corticosteroids and analgesics are useful for managing perianal skin irritation. However, prolonged use of potent corticosteroid preparations may be harmful and should be avoided.
Some key considerations for the next steps include:
- Trying other topical treatments such as prescription-strength steroid creams (like triamcinolone 0.1%) or combination products containing local anesthetics (like lidocaine) and astringents
- Oral pain relievers like acetaminophen or ibuprofen to help manage discomfort
- Increasing dietary fiber (25-30g daily) and water intake
- Sitz baths 2-3 times daily for 10-15 minutes to help reduce symptoms
- Considering more advanced treatments such as rubber band ligation, sclerotherapy, infrared coagulation, or surgical options for severe cases, as suggested by the American Gastroenterological Association technical review on the diagnosis and treatment of hemorrhoids 1 and the guidelines for anorectal emergencies 1.
It's also important to note that surgery should be recommended only for a small minority of patients, as stated in the American Gastroenterological Association medical position statement 1, and the decision between non-operative management and early surgical excision should be based on physician’s expertise and patient’s preference, as suggested by the guidelines for anorectal emergencies 1. Patients should seek immediate medical attention if they experience severe pain, heavy bleeding, or fever, as these may indicate complications requiring urgent intervention.
From the FDA Drug Label
When using this product ... Stop use and ask a doctor if condition worsens, symptoms persist for more than 7 days or clear up and occur again within a few days The FDA drug label does not answer the question.
From the Research
Next Steps for Hemorrhoid Treatment
If hydrocortisone cream is not effective for hemorrhoids, the next steps may include:
- Medical management with stool softeners, topical over-the-counter preparations, or topical nitroglycerine 2
- Dietary modifications such as increased fiber and water intake 2, 3
- Behavioral therapies like sitz baths 2
- Office-based treatment of grades I to III internal hemorrhoids with rubber band ligation, which has a lower failure rate than infrared photocoagulation 2, 4
- Injection sclerotherapy or infrared coagulation for non-operative management of hemorrhoidal disease 4
Surgical Options
If non-operative approaches have failed or complications have occurred, surgical options may be considered:
- Open or closed (conventional) excisional hemorrhoidectomy, which leads to greater surgical success rates but also incurs more pain and a prolonged recovery 2, 3
- Closed hemorrhoidectomy with diathermic or ultrasonic cutting devices to decrease bleeding and pain 2
- Stapled hemorrhoidopexy to elevate grade III or IV hemorrhoids to their normal anatomic position 2, 3
- Hemorrhoidal artery ligation for grade II or III hemorrhoids, which may result in less pain and quicker recovery 2
Considerations
The choice of treatment depends on the severity of the hemorrhoids, patient preference, and the presence of any complications or comorbidities 5, 2, 6, 3. It is essential to assess the patient's condition and discuss the potential benefits and risks of each treatment option 2, 4.