What is the proper way to write a prescription for hydrocortisone (corticosteroid) cream for external vaginal itching?

Hydrocortisone Prescription for External Vaginal Itching

Do not prescribe hydrocortisone cream for external vaginal itching if the patient has vaginal discharge, as this requires evaluation for infectious causes like vulvovaginal candidiasis, which should be treated with topical azole antifungals instead. 1

Critical Initial Assessment

Before writing any hydrocortisone prescription for vulvar symptoms, you must:

• Rule out vaginal discharge - if present, hydrocortisone is contraindicated per FDA labeling and the patient needs evaluation for infectious vaginitis 1
• Confirm the diagnosis - hydrocortisone is appropriate only for non-infectious inflammatory conditions (contact dermatitis, lichen planus, desquamative inflammatory vaginitis), not for candidiasis or other infections 2, 3
• Verify the patient is ≥12 years old - children under 12 require physician consultation before use 1

When Hydrocortisone IS Appropriate

If the patient has external vulvar itching without discharge and you've excluded infectious causes, hydrocortisone can be prescribed for inflammatory dermatoses. 1, 4

Prescription Details

For external vulvar application:

• Hydrocortisone 1% cream or ointment (low-potency formulation appropriate for genital area) 4
• Quantity: 30-60 grams depending on treatment duration 4
• Directions: "Apply thin layer to affected external vulvar area 3-4 times daily" 1
• Duration: Maximum 7 days for OTC-strength hydrocortisone; if symptoms persist beyond 7 days, patient must return for reassessment 1

Key Prescription Instructions to Include:

• "For external use only" 1
• "Avoid contact with eyes" 1
• "Do not insert into vagina" 1
• "Stop use and contact physician if condition worsens or persists beyond 7 days" 1
• "Clean area with mild soap and warm water, rinse thoroughly, and gently pat dry before applying" 1

Critical Pitfalls to Avoid

Never prescribe hydrocortisone when:

• Vaginal discharge is present (requires antifungal treatment for likely candidiasis) 5, 1
• The diagnosis is uncertain (may delay appropriate treatment) 5
• For intravaginal use without specific compounded suppository formulation 2

Genital skin considerations:

• The vulvar area has thinner skin with increased absorption and higher risk of adverse effects (atrophy, striae) 4
• Use only low-potency formulations (hydrocortisone 1%) for genital application 4
• Higher potency steroids should be avoided on genital skin due to increased risk of atrophy 4

Alternative Approach for Vaginal Symptoms

If the patient has vaginal (not just external vulvar) symptoms with discharge, the correct treatment is:

• First-line: Topical azole antifungals (clotrimazole 1% cream 5g intravaginally for 7-14 days, or miconazole 2% cream 5g intravaginally for 7 days) 5, 6
• Alternative: Fluconazole 150mg oral tablet, single dose 5
• These achieve 80-90% symptom relief and negative cultures 5

Special Clinical Scenarios

For chronic inflammatory conditions (lichen planus, desquamative inflammatory vaginitis):

• Higher concentration hydrocortisone suppositories (10-25mg intravaginally) may be needed 2, 3
• These require compounding and specialist consultation 2, 3
• Long-term maintenance therapy is frequently required (median 8 weeks to several months) 3

Follow-up requirements:

• Patient must return if symptoms persist after 7 days of treatment 1
• Reassess for alternative diagnoses if no improvement with appropriate therapy 7
• Any symptom recurrence within 2 months requires medical re-evaluation 7, 6