What to do for a worsening rash in a 20-month-old treated with hydrocortisone (cortisol)

Management of Worsening Rash in a 20-Month-Old Treated with Hydrocortisone

For a worsening rash in a 20-month-old that is not responding to hydrocortisone, discontinue the hydrocortisone and seek medical evaluation, as continued use may worsen the condition and hydrocortisone is not recommended for diaper rash or for children under 2 years without physician guidance. 1

Assessment of the Worsening Rash

When a rash is worsening despite hydrocortisone treatment in a young child, several important considerations must be addressed:

• Inappropriate use: The FDA label clearly states that hydrocortisone should not be used in children under 2 years of age without physician guidance 1
• Possible causes of worsening:
  • Secondary infection (bacterial, viral, or fungal)
  • Allergic reaction to hydrocortisone itself (occurs in up to 4.8% of patients) 2
  • Incorrect diagnosis of the underlying condition
  • Increased percutaneous absorption during acute phase of dermatitis 3

Immediate Steps to Take

1. Stop using hydrocortisone immediately

   • FDA labeling specifically warns against use in children under 2 years without physician guidance 1
   • Continuing use may worsen the condition if there is an allergy to hydrocortisone 2

2. Seek medical evaluation

   • A healthcare provider should examine the rash to determine the underlying cause
   • This is particularly important as the rash is worsening rather than improving

3. Temporary measures while awaiting medical care:

   • Keep the area clean with gentle, fragrance-free cleansers
   • Apply emollients with cream or ointment-based, fragrance-free products 4
   • Avoid potential irritants (harsh soaps, fragrances, rough fabrics)
   • Use cool compresses if the area is inflamed or itchy 4

Medical Evaluation and Treatment Options

When evaluated by a healthcare provider, the following approach is recommended:

For Suspected Infection

• If signs of infection are present (increased redness, warmth, swelling, yellow crusting):
  • Bacterial culture may be needed
  • Consider combination therapy with antibiotics if Staphylococcus aureus infection is suspected 5
  • Mupirocin combined with appropriate anti-inflammatory treatment has shown 74% improvement in infants with atopic dermatitis 5

For Suspected Allergic Contact Dermatitis

• If the rash appears to worsen specifically after hydrocortisone application:
  • Consider patch testing to confirm hydrocortisone allergy 2
  • Switch to alternative non-steroid treatments such as emollients 4

For Atopic Dermatitis

• If the underlying condition is atopic dermatitis:
  • Consider alternative treatments appropriate for infants
  • Emollients are the cornerstone of therapy 6
  • For moderate to severe cases, a dermatology referral may be needed 6

Important Cautions and Considerations

• Increased absorption risk: Percutaneous absorption of hydrocortisone is significantly higher during the acute phase of dermatitis in children, with plasma cortisol increases up to 961 nmol/L reported 3

• Duration limitations: Even when appropriate, topical hydrocortisone should not be used for more than 7 days without physician guidance 1

• Potency concerns: Children are particularly susceptible to side effects from topical corticosteroids, and potent agents should be avoided 7

• Monitoring: Close follow-up is essential when treating skin conditions in young children

When to Seek Urgent Care

Seek immediate medical attention if:

• The rash covers >30% body surface area
• There are signs of skin sloughing or blistering
• The child develops systemic symptoms like fever or appears ill
• There is significant discomfort affecting sleep or feeding 4

Remember that in children under 2 years of age, all medication use should be under the direct supervision of a healthcare provider, especially for skin conditions that are not improving with initial treatment.