What are the contraindications for hydrocortisone (corticosteroid)?

Contraindications for Hydrocortisone

Hydrocortisone is contraindicated in patients with systemic fungal infections, as it may worsen fungal disease outcomes and increase mortality. 1

Absolute Contraindications

• Systemic fungal infections: Corticosteroids significantly worsen outcomes in invasive aspergillosis, chronic pulmonary aspergillosis, invasive candidiasis, candidemia, and mucormycosis 1
• Untreated bacterial infections: Hydrocortisone may mask signs of infection and decrease resistance to localization of infection 2
• Active tuberculosis: Should be restricted to cases of fulminating or disseminated tuberculosis when used in conjunction with appropriate antituberculous regimen 2
• Viral infections: Particularly concerning with varicella (chickenpox) and measles, which can have a more serious or fatal course in patients on corticosteroids 2

Relative Contraindications (Use with Caution)

• Pregnancy: Use only when potential benefits outweigh potential hazards to mother and fetus, as adequate human reproduction studies have not been done 2
• Nursing mothers: Requires weighing benefits against potential risks 2
• Immunocompromised patients: Increased susceptibility to infections due to immune suppression 2
• Fungal keratitis: Topical corticosteroids associated with worse visual outcomes in early course of disease 1
• Diabetes mellitus: Can cause hyperglycemia and worsen glycemic control 3
• Hypertension: May cause elevation of blood pressure, salt and water retention 2
• Osteoporosis: Long-term use associated with bone density loss 3
• Glaucoma: May increase intraocular pressure and potentially damage optic nerves 2
• Peptic ulcer disease: May increase risk of gastrointestinal perforation 3
• Psychiatric disorders: May exacerbate existing psychiatric conditions 3

Special Considerations

Dermatologic Applications

• Fungal skin infections: Avoid using hydrocortisone on suspected fungal skin lesions as it may worsen infection 4
• Diaper area: Contraindicated in children under 12 years of age on diaper or other occluded areas 4
• Facial lesions: Not recommended for prolonged use on facial skin 4
• Occlusive dressings: Avoid using under occlusive conditions as this increases systemic absorption and risk of adverse effects 4

Pediatric Considerations

• Growth: Long-term use may suppress growth in children 3
• Immunizations: Patients on corticosteroid therapy should not receive smallpox vaccination or other immunization procedures due to risk of neurological complications and lack of antibody response 2

Drug Interactions

• Antifungal agents: Corticosteroids may interfere with therapeutic actions of antifungal medications 4
• Anticoagulants: May increase risk of gastrointestinal bleeding when used concomitantly 5
• NSAIDs: Increased risk of gastrointestinal adverse effects when used together 5

Management Recommendations When Hydrocortisone Is Necessary

• Tuberculosis screening: Consider testing for latent/active tuberculosis before initiating therapy in high-risk patients 5
• Prophylaxis: Consider prophylaxis against pneumocystis jiroveci pneumonia in patients receiving prednisone equivalent of ≥20 mg/day for 4 or more weeks 5
• Fungal prophylaxis: Consider fluconazole for patients receiving prednisone equivalent of ≥20 mg/day for 6 or more weeks 5
• Gastric protection: Use histamine-2 blockers or proton pump inhibitors during steroid therapy, especially in patients taking NSAIDs or anticoagulants 5
• Calcium and vitamin D: Supplement to reduce risk of osteoporosis 5
• Blood glucose monitoring: Regular monitoring recommended, especially in diabetic patients 5

Remember that hydrocortisone is available in different formulations (topical, oral, injectable) with varying potency and risk profiles. Systemic hydrocortisone is less potent than other corticosteroids like prednisone, methylprednisolone, and dexamethasone, but still carries significant contraindication concerns 6.