What is the safety of topical hydrocortisone (corticosteroid) use during pregnancy?

From the Guidelines

Topical hydrocortisone is generally considered safe to use during pregnancy when needed for skin conditions. The most recent and highest quality study, 1, published in 2018, suggests that topical steroids can be safely continued during pregnancy and in the postdelivery period, if needed. Low to moderate potency topical corticosteroids like hydrocortisone 1% or 2.5% are preferred first-line treatments for pregnant women with dermatologic conditions requiring steroid therapy.

When using topical hydrocortisone during pregnancy, it's recommended to:

• Apply the minimum effective amount to the smallest affected area for the shortest duration necessary to control symptoms
• Use a thin layer to affected areas 1-2 times daily until symptoms improve, usually within 1-2 weeks
• Avoid applying large amounts over extensive body surface areas or using occlusive dressings which can increase systemic absorption

The safety profile of topical hydrocortisone in pregnancy is favorable because systemic absorption is minimal when used appropriately, resulting in very low fetal exposure. Higher potency corticosteroids carry more theoretical risk, so hydrocortisone is often preferred during pregnancy. If treating sensitive areas or if treatment is needed for extended periods, consulting with a healthcare provider for monitoring is advisable, as supported by 1, which provides information on the safety of various corticosteroids during pregnancy.

Key considerations for the use of topical hydrocortisone during pregnancy include:

• Minimal systemic absorption when used appropriately
• Low fetal exposure
• Preference for low to moderate potency topical corticosteroids
• Avoidance of large amounts or occlusive dressings
• Monitoring by a healthcare provider for extended or sensitive area treatment.

From the Research

Safety of Topical Hydrocortisone Use During Pregnancy

• The safety of topical hydrocortisone (corticosteroid) use during pregnancy has been investigated in several studies 2, 3, 4, 5, 6.
• Most studies found no significant associations between maternal exposure to topical corticosteroids of any potency and pregnancy outcomes, including mode of delivery, congenital abnormalities, preterm delivery, and stillbirth 3, 5, 6.
• However, some studies suggested a possible association between very potent topical corticosteroids and low birthweight 2, 3, 4, 5, 6.
• A study found that maternal exposure to potent/very potent topical corticosteroids shortly before and during pregnancy was significantly associated with fetal growth restriction 2.
• Another study found that mild/moderate topical corticosteroids should be preferred to potent/very potent ones in pregnancy, and that the well-known topical side-effects of corticosteroids on the mother's side need to be considered as well 4.
• The current evidence shows no statistically significant difference between pregnant women who use and those who do not use topical corticosteroids, but there does appear to be an association of very potent topical corticosteroids with low birthweight 3, 5, 6.
• Further cohort studies with comprehensive outcome measures, consideration of corticosteroid potency, dosage and indications, and a large sample size are needed to fully assess the safety of topical corticosteroids in pregnancy 3, 5, 6.

Potency of Topical Corticosteroids

• Stratified analyses based on steroid potency found no association between maternal use of topical corticosteroids of any potency and an increase in adverse pregnancy outcomes, including mode of delivery, congenital abnormality, preterm delivery, fetal death, and low Apgar score 6.
• However, there was a probable association between low birth weight and maternal use of potent to very potent topical corticosteroids, especially when the cumulative dosage of topical corticosteroids throughout the pregnancy is very large 6.
• Mild to moderate potency topical corticosteroids were associated with a decreased risk of fetal death, but this effect was not observed with potent to very potent topical corticosteroids 6.

Quality of Evidence

• The quality of evidence was generally low to very low due to methodological heterogeneity, imprecision, and inconsistency in the studies 3, 5, 6.
• The Grades of Recommendation, Assessment, Development and Evaluation (GRADE) Working Group approach was used to rate the overall quality of the evidence, which started at low quality and was further downgraded due to imprecision and inconsistency 6.