What is the recommended dosage and administration of hydrocortisone (cortisol) injections for a patient with severe or chronic itching?

Hydrocortisone Injections Are Not Recommended for Itching

Injectable hydrocortisone is not a standard or recommended treatment for pruritus (itching). The evidence overwhelmingly supports topical corticosteroids, oral antihistamines, and systemic oral corticosteroids—not injectable hydrocortisone—as appropriate therapies for itch management.

Why Injectable Hydrocortisone Is Not Used for Pruritus

• No guideline support exists for using injectable hydrocortisone (IV or IM) as a treatment for itching in any clinical context 1, 2.

• Injectable corticosteroids are reserved for severe systemic inflammatory conditions (e.g., grade 4 immune-related adverse events requiring hospitalization), not for symptomatic itch control 1.

• The only documented use of injectable hydrocortisone for pruritus is in a highly specialized intradermal injection protocol combining methylene blue, hydrocortisone, and lignocaine specifically for refractory pruritus ani—this is not generalizable to other forms of itching 3.

Correct Treatment Approach for Itching

Mild to Moderate Localized Itching (Grade 1-2)

• First-line: Topical corticosteroids are the standard of care 1, 2.

  • Use moderate-to-high potency topical steroids (triamcinolone 0.1%, betamethasone valerate 0.1%, mometasone furoate 0.1%) for body surfaces 1, 2.
  • Use low-potency hydrocortisone 2.5% on the face to avoid skin atrophy 1, 2.
  • Topical tacrolimus 0.1% is an alternative for localized symptomatic redness or itching 1.

• Adjunctive therapy: Oral antihistamines 1, 4.

  • Non-sedating second-generation antihistamines (loratadine 10 mg daily) for daytime use 1.
  • First-generation sedating antihistamines (hydroxyzine 25-50 mg, diphenhydramine 25-50 mg) at bedtime for nighttime pruritus 1, 5.

Severe or Widespread Itching (Grade 2-3)

• Oral corticosteroids are indicated for severe, widespread, or intolerable pruritus 1, 6.

  • Prednisone 0.5-1 mg/kg/day for moderate severity 1, 6.
  • Prednisone 1-2 mg/kg/day for severe cases (grade 3-4) 1.
  • Taper over 4 weeks minimum to prevent adrenal suppression 1, 6.

• Second-line agents for refractory cases 1, 2:

  • GABA agonists (gabapentin 900-3600 mg/day, pregabalin 25-150 mg/day) 1, 2.
  • Antidepressants (sertraline, doxepin) for neuropathic itch 2.
  • Aprepitant (NK-1 receptor antagonist) for drug-induced pruritus 1.

Neuropathic Itching

• Topical neuropathic agents are first-line 2:

  • Menthol 0.5%, pramoxine, or lidocaine 1, 2.
  • Can be combined with topical corticosteroids for mixed etiology 2.

• Systemic neuropathic agents for refractory cases 2:

  • Gabapentin or pregabalin 1, 2.
  • Opioid receptor modulators (naltrexone, butorphanol) 2.

Critical Pitfalls to Avoid

• Never use IV/IM hydrocortisone for routine itch management—this is not evidence-based and exposes patients to unnecessary systemic corticosteroid risks without proven benefit 1, 2.

• Avoid prolonged systemic corticosteroids (>2 weeks) for dermatologic pruritus due to risks of hypertension, glucose intolerance, weight gain, and HPA axis suppression 6.

• Always taper oral corticosteroids over at least 4 weeks to prevent rebound flare and adrenal insufficiency 1, 6.

• Rule out underlying systemic causes (chronic kidney disease, liver disease, malignancy, thyroid disease) in patients with chronic pruritus lasting >6 weeks, especially without primary skin lesions 2, 4, 7.

When to Escalate Therapy

• If no response to topical steroids and antihistamines after 2 weeks, escalate to oral corticosteroids or GABA agonists 1.

• If inadequate response within 12 weeks of treatment initiation, consider referral to dermatology for systemic immunomodulators (dupilumab, methotrexate, mycophenolate mofetil) 1, 2.

• For refractory cases, consider phototherapy (PUVA, UVB) or biologic agents 1, 2.