Systemic Absorption of Hydrocortisone 1% Topical Preparation
Hydrocortisone 1% cream is absorbed systemically at a rate of approximately 1-7% when applied to normal skin, but this absorption can increase significantly to 15-30% in patients with acute dermatitis, damaged skin barrier, or when applied under occlusion.
Factors Affecting Systemic Absorption
Skin Condition
- Normal skin: Minimal absorption (1-7%)
- Acute dermatitis/damaged skin barrier: Significantly increased absorption (15-30%) 1, 2
- During acute dermatitis, plasma cortisol increases can range from 47-961 nmol/L (median 248 nmol/L) after application 1
- In remission phase, absorption decreases significantly with plasma cortisol increases of only 0-114 nmol/L (median 16 nmol/L) 2
Application Method
- Without occlusion: Minimal systemic effects on normal skin 3
- With occlusion: Significantly increased absorption with potential systemic effects including:
- Decreased circulating eosinophils
- Decreased blood corticosteroid levels
- Decreased urinary 17-OHCS excretion 3
Application Frequency
- Plasma cortisol levels rise after the first applications, reaching maximum at 24 hours
- Levels begin to fall after continued use, suggesting restoration of skin barrier function
- Once-daily application may be sufficient after the first day of treatment 4
Body Sites and Risk of Absorption
- Higher absorption areas: Face, genitals, skin folds, intertriginous areas
- Lower absorption areas: Palms, soles, elbows, knees
Special Populations at Risk
- Infants and young children: More vulnerable to systemic effects due to:
- Higher ratio of body surface area to weight
- Thinner skin barrier
- Greater potential for occlusion with diapers 5
Potential Systemic Effects
- Iatrogenic hypercorticism with prolonged and extensive use
- Impaired stress response
- Temporary suppression of the pituitary-adrenal axis
- Growth interference in children with potent and very potent preparations 6
Clinical Implications
- Systemic effects are typically temporary, with values returning to normal approximately 2 days after discontinuation 3
- The skin can act as a reservoir for hydrocortisone, with the medication detectable in the horny layer up to 24 hours after application 3
- When treating acute dermatitis, be aware that systemic absorption is significantly higher than during remission phases 1, 2
Practical Recommendations
- Use the lowest effective potency and amount needed
- Apply thinly using the fingertip unit method (15-30g is sufficient for 2 weeks of treatment for both hands and face) 6
- Consider once-daily application after the first day of treatment 4
- Be particularly cautious with occlusive dressings, as they significantly increase absorption 3
- Monitor for signs of systemic absorption in high-risk patients (children, extensive application, prolonged use)
By understanding these absorption characteristics, clinicians can optimize the benefit-risk ratio when prescribing hydrocortisone 1% for dermatological conditions.