What to use for hemorrhoids if 1% hydrocortisone (cortisol) is not effective?

Management of Hemorrhoids When Hydrocortisone 1% Is Not Effective

If 1% hydrocortisone is not helping with hemorrhoid symptoms, you should progress to more advanced treatment options based on the hemorrhoid grade, including fiber supplementation, sitz baths, office-based procedures like rubber band ligation, or surgical interventions for severe cases. 1

Assessment and Conservative Management

When hydrocortisone 1% cream is ineffective, first reassess the hemorrhoid grade:

• Grade I: Bleed but don't protrude
• Grade II: Protrude with defecation but reduce spontaneously
• Grade III: Protrude and require manual reduction
• Grade IV: Permanently prolapsed and cannot be reduced 1

First-line conservative measures:

• Increase fiber intake to 25-30g daily
• Ensure adequate hydration
• Take sitz baths 2-3 times daily
• Avoid straining during defecation
• Avoid prolonged sitting
• Engage in regular physical activity 1

Manage constipation:

• Use osmotic laxatives (polyethylene glycol or lactulose) as first-line treatment
• Consider stimulant laxatives (senna or bisacodyl) as second-line if osmotic laxatives are insufficient 1

Office-Based Procedures

If conservative measures fail, consider the following non-surgical interventions based on hemorrhoid grade:

For Grade I-II hemorrhoids:

• Rubber band ligation: First-line procedural treatment with 89% symptom resolution (though 20% may need repeated procedures) 1
• Sclerotherapy: Alternative with 70-85% short-term efficacy 1
• Infrared coagulation: Alternative with 70-80% efficacy in reducing bleeding and prolapse 1

For Grade II-III hemorrhoids:

• Hemorrhoidal artery ligation: Effective with less pain and quicker recovery 1

Surgical Interventions

For Grade III-IV hemorrhoids that fail conservative and office-based treatments:

• Excisional hemorrhoidectomy: Gold standard for grade IV hemorrhoids with low recurrence rates (2-10%) but longer recovery (9-14 days) 1
• Stapled hemorrhoidopexy: Alternative for grade III-IV with less postoperative pain but higher recurrence rates 1

Special Considerations

• Post-treatment care: Pain management with NSAIDs, fiber supplements, sitz baths 2-3 times daily, stool softeners 1
• Monitor for complications: Bleeding (0.03-6%), urinary retention (2-36%), infection (0.5-5.5%) 1
• Caution in special populations:
  • Immunocompromised patients: Higher infection risk
  • Cirrhosis/portal hypertension: Distinguish from rectal varices
  • Pregnancy: Conservative management preferred
  • Inflammatory bowel disease: High risk of postoperative complications 1

Alternative Therapeutic Options

Some evidence suggests that oral supplements may help improve vascular integrity:

• Micronized purified flavonoid fraction (MPFF) for control of acute bleeding 2
• Calcium dobesilate 2

However, these should be considered adjunctive treatments while pursuing more definitive therapy based on hemorrhoid grade and symptom severity.