Can hydrocortisone (corticosteroid) exacerbate a fungal infection?

Hydrocortisone Can Exacerbate Fungal Infections

Yes, hydrocortisone will make fungal infections worse and should be avoided in patients with active fungal infections. Corticosteroids like hydrocortisone suppress the immune response and can allow fungal infections to proliferate and potentially become invasive 1, 2.

Mechanism of Action and Risk

Hydrocortisone and other corticosteroids increase susceptibility to fungal infections through several mechanisms:

• Mask signs of infection while allowing the infection to progress 1
• Decrease resistance to infection and impair the body's ability to localize infections 1
• Suppress the immune response necessary to control fungal growth 2
• May accelerate fungal growth due to decreased local immune reaction 3

Evidence from Clinical Guidelines

Multiple clinical guidelines confirm this risk:

• The FDA drug label for hydrocortisone explicitly warns that corticosteroids may mask infection signs and decrease resistance to infections 1
• European position papers on rhinosinusitis state that topical corticosteroids do not play a role in managing invasive fungal rhinosinusitis 4
• Ophthalmology guidelines caution that if a corneal ulcer is associated with fungal infection, outcomes of corticosteroid therapy are likely to be poor 4
• Infectious Diseases Society of America guidelines note that corticosteroid use is more commonly associated with fungal infections, particularly Candida species 4

Specific Fungal Conditions and Corticosteroid Use

Invasive Fungal Infections

• A systematic review and meta-analysis found that corticosteroid therapy was associated with worse clinical outcomes in multiple fungal diseases including:
  • Invasive aspergillosis (HR: 2.50)
  • Chronic pulmonary aspergillosis (HR: 2.74)
  • Invasive candidiasis and candidemia (OR: 2.13)
  • Mucormycosis (OR: 4.19) 5

Fungal Keratitis

• Using corticosteroids early in the course of fungal keratitis was associated with worse visual outcomes (OR: 2.99) 5
• Ophthalmology guidelines recommend avoiding corticosteroids until fungal infection has been ruled out 4

Dermatophyte Infections

• Corticosteroid-containing combinations for dermatophyte infections may cause fungal growth to accelerate and potentially invade deeper tissues 3
• Contraindicated in immunosuppressed patients and should never exceed 2 weeks for tinea cruris or 4 weeks for tinea pedis/corporis 3

Special Considerations

Topical vs. Systemic Use

• Even inhaled corticosteroids have been associated with invasive pulmonary fungal infections 6
• Topical application under occlusive conditions increases risk of fungal proliferation 3

Duration and Dosage

• Higher doses of corticosteroids (>2 mg/kg/day of prednisolone equivalents) significantly increase mortality in fungal infections 5
• Doses equivalent to ≥20 mg of prednisolone for ≥2 weeks significantly increase infection risk 4, 7

Management Recommendations

If a patient has a suspected or confirmed fungal infection:

1. Avoid initiating corticosteroid therapy until the fungal infection has been adequately treated 4
2. Discontinue or reduce existing corticosteroid therapy if possible 4
3. Initiate appropriate antifungal treatment based on the type and location of infection 4
4. Monitor closely for signs of worsening infection if corticosteroids cannot be discontinued 1

In rare cases where both antifungal and anti-inflammatory therapy are needed (such as certain cases of chronic candidiasis with significant inflammation), antifungal therapy should be started first, with careful monitoring if corticosteroids are subsequently added 4.

Conclusion

Based on the strongest and most recent evidence, hydrocortisone and other corticosteroids should be avoided in patients with fungal infections as they can significantly worsen outcomes, increase the risk of dissemination, and potentially lead to treatment failure.