Hydrocortisone
Corticosteroid hormone replacement and anti-inflammatory medication
📊 Quick facts about Hydrocortisone
💡 The most important things you need to know
- Hydrocortisone replaces a vital hormone: For people with adrenal insufficiency, hydrocortisone replaces the cortisol that the body cannot produce on its own
- Never stop oral hydrocortisone suddenly: Abrupt discontinuation can trigger a life-threatening adrenal crisis requiring emergency treatment
- Dose must increase during illness: Patients with adrenal insufficiency must increase their dose (stress dosing) when ill, injured or undergoing surgery
- Topical and oral forms serve different purposes: Cream and ointment treat skin inflammation locally, while tablets replace the body's missing cortisol systemically
- Regular monitoring is essential: Children especially need growth monitoring, and all patients require periodic checks of electrolytes and hormone levels
What Is Hydrocortisone and What Is It Used For?
Hydrocortisone is a synthetic version of cortisol, the body's primary stress hormone produced by the adrenal glands. It is prescribed as hormone replacement therapy for adrenal insufficiency and as a topical anti-inflammatory for skin conditions including eczema, dermatitis and insect bites.
Hydrocortisone belongs to a group of medicines called corticosteroids, specifically the glucocorticoid subclass. Cortisol is one of the most important hormones in the human body, playing critical roles in regulating blood sugar, metabolism, immune function and the stress response. When the adrenal glands fail to produce sufficient cortisol – a condition known as adrenal insufficiency – hydrocortisone serves as a life-sustaining replacement therapy.
Adrenal insufficiency can be primary (Addison's disease, where the adrenal glands themselves are damaged), secondary (caused by pituitary gland problems), or caused by an inherited genetic condition called congenital adrenal hyperplasia (CAH). In CAH, enzyme deficiencies prevent the adrenal glands from producing cortisol normally, and hydrocortisone is typically the first-line treatment from birth. The Endocrine Society and the European Society for Paediatric Endocrinology both recommend hydrocortisone as the preferred glucocorticoid for children with CAH because its short half-life allows more physiological dosing patterns.
Beyond hormone replacement, hydrocortisone is widely used in topical formulations (creams, ointments and lotions) to treat inflammatory skin conditions. At concentrations of 0.5% to 1%, topical hydrocortisone reduces redness, itching, swelling and irritation associated with eczema (atopic dermatitis), contact dermatitis, insect bites and mild allergic skin reactions. In many countries, low-strength hydrocortisone cream (typically 1%) is available without a prescription for short-term use.
Hydrocortisone is listed on the WHO Model List of Essential Medicines, underscoring its critical role in global healthcare. Its relatively short duration of action (biological half-life of 8–12 hours) makes it particularly suitable for replacement therapy, as it more closely mimics the body's natural cortisol rhythm compared to longer-acting synthetic corticosteroids like dexamethasone or prednisolone.
Hydrocortisone and cortisol are chemically identical molecules. The name "hydrocortisone" is used for the pharmaceutical preparation, while "cortisol" refers to the hormone as it is produced naturally in the body. When you take hydrocortisone as a medicine, it functions exactly like the cortisol your body would normally produce.
How does hydrocortisone work?
Hydrocortisone exerts its effects by binding to glucocorticoid receptors inside cells. Once bound, the drug-receptor complex moves to the cell nucleus, where it influences gene transcription – essentially turning certain genes on or off. This mechanism produces multiple physiological effects:
- Anti-inflammatory action: Reduces the production of inflammatory chemicals (prostaglandins, leukotrienes and cytokines), decreasing redness, swelling and pain
- Immunosuppressive action: Modulates immune cell activity, which is beneficial in autoimmune and allergic conditions but requires caution regarding infection risk
- Metabolic regulation: Helps maintain blood sugar levels, supports cardiovascular function and regulates protein and fat metabolism
- Stress response: Enables the body to respond appropriately to physical stress such as illness, injury or surgery
For topical applications, hydrocortisone acts locally on the skin, penetrating the outer layers to reduce inflammation at the site of application. Because it is classified as a mild (Group I) corticosteroid in topical form, it carries a lower risk of skin-related side effects compared to more potent topical steroids like betamethasone.
What Should You Know Before Taking Hydrocortisone?
Before taking hydrocortisone, tell your doctor about all allergies, current illnesses, planned surgeries or vaccinations. Never stop oral hydrocortisone suddenly. If you have adrenal insufficiency, always carry a steroid emergency card and ensure you know the sick day rules for dose adjustments.
Contraindications
Do not take hydrocortisone if you are allergic to hydrocortisone or any of the other ingredients in the formulation. For oral granule formulations designed for children (such as Alkindi), the granules must not be given to premature infants who are not yet able to take food by mouth, or to anyone who has difficulty swallowing.
While there are few absolute contraindications for hydrocortisone replacement therapy (since it replaces an essential hormone), certain conditions require careful medical supervision:
- Active systemic infections: Hydrocortisone can suppress immune responses, potentially worsening untreated infections
- Live vaccines: High-dose corticosteroid therapy may reduce vaccine efficacy. However, replacement-dose hydrocortisone for adrenal insufficiency should not prevent vaccination
- Known hypersensitivity: Some patients who are allergic to other medications may develop cross-sensitivity to hydrocortisone
Warnings and Precautions
Several important warnings apply to hydrocortisone use, particularly for oral formulations used in adrenal insufficiency:
Never stop taking oral hydrocortisone suddenly without medical supervision. If you have adrenal insufficiency, your body cannot produce cortisol on its own. Abrupt discontinuation can lead to an adrenal crisis – a life-threatening medical emergency characterised by severe weakness, low blood pressure, confusion, vomiting and potentially loss of consciousness. Always carry a steroid emergency card and wear a medical alert bracelet or necklace.
Sick day rules (stress dosing): During illness, fever, significant physical stress, injury or surgery, the body normally increases cortisol production. Since people with adrenal insufficiency cannot do this naturally, the dose of hydrocortisone must be increased. Typical sick day guidance includes:
- For minor illness with fever: double the usual oral dose for the duration of the illness
- For major illness, surgery or trauma: the dose may need to be tripled or given by injection
- If vomiting prevents oral medication: an emergency hydrocortisone injection (intramuscular) is required
Your endocrinologist should provide detailed written instructions for sick day management and teach you (or your family) how to administer an emergency hydrocortisone injection.
Growth monitoring in children: Excessive doses of hydrocortisone can suppress growth in children. Paediatric endocrinologists carefully monitor height velocity and adjust doses according to the child's body surface area. The Endocrine Society recommends keeping the hydrocortisone dose between 8–15 mg/m²/day for children with CAH to balance adequate cortisol replacement against growth suppression.
Bone health: Long-term use of glucocorticoids, even at replacement doses, may affect bone mineral density. Regular bone density assessments may be recommended, particularly for adults on long-term therapy.
Psychological effects: Some patients taking hydrocortisone may experience mood changes, including anxiety, depression, euphoria or confusion. While these effects are more commonly associated with higher pharmacological doses, they can occur at replacement doses. Inform your doctor if you notice any behavioural or mood changes.
Vision changes: Contact your doctor if you experience blurred vision or other visual disturbances during hydrocortisone treatment, as these may indicate increased intraocular pressure or cataracts.
Switching between formulations: When switching from one hydrocortisone product to another (for example, from standard tablets to modified-release granules), differences in bioavailability may mean the effective dose changes. Your doctor will monitor you closely during the first week after any switch and may adjust the dose accordingly.
Pregnancy and Breastfeeding
Hydrocortisone can and should be used during pregnancy when it is needed as hormone replacement therapy for adrenal insufficiency. Adequate cortisol levels are essential for both mother and baby. Women with adrenal insufficiency should continue their replacement therapy throughout pregnancy, and the dose may need to be increased, particularly during the third trimester and during labour and delivery.
Hydrocortisone is considered compatible with breastfeeding. Only small amounts pass into breast milk, and at replacement doses, this is not expected to cause adverse effects in the nursing infant. The Endocrine Society guidelines support continued hydrocortisone use during breastfeeding.
For topical hydrocortisone, mild formulations can generally be used safely during pregnancy for limited periods. However, avoid applying topical hydrocortisone directly to the breasts shortly before breastfeeding.
How Does Hydrocortisone Interact with Other Drugs?
Several medicines can increase or decrease how hydrocortisone works in the body. Drugs that speed up liver metabolism (such as phenytoin, carbamazepine and rifampicin) may reduce hydrocortisone levels, requiring a dose increase. CYP3A4 inhibitors (such as itraconazole and ritonavir) can raise hydrocortisone levels, potentially requiring a dose reduction.
Hydrocortisone is primarily metabolised in the liver by the cytochrome P450 enzyme system, particularly CYP3A4. Drugs that affect these enzymes can significantly alter hydrocortisone blood levels, which is especially important for patients relying on hydrocortisone as hormone replacement therapy. Both increased and decreased hydrocortisone levels can be clinically significant.
Drugs That May Decrease Hydrocortisone Levels
The following medications induce CYP3A4 and other liver enzymes, accelerating the breakdown of hydrocortisone. Your doctor may need to increase your hydrocortisone dose if you start taking any of these:
| Drug | Category | Interaction | Clinical Action |
|---|---|---|---|
| Phenytoin | Antiepileptic | Induces CYP3A4, increases hydrocortisone metabolism | May require dose increase |
| Carbamazepine | Antiepileptic | Strong CYP3A4 inducer | May require dose increase |
| Oxcarbazepine | Antiepileptic | Moderate CYP3A4 inducer | Monitor and adjust dose |
| Rifampicin | Antibiotic (TB) | Potent CYP3A4 inducer, can reduce cortisol levels by up to 50% | Significant dose increase likely needed |
| Rifabutin | Antibiotic | Moderate CYP3A4 inducer | May require dose increase |
| Phenobarbital / Primidone | Barbiturate / Antiepileptic | Induces hepatic enzymes | May require dose increase |
| Efavirenz / Nevirapine | Antiretroviral (HIV) | CYP3A4 inducers | May require dose increase |
Drugs That May Increase Hydrocortisone Levels
The following medications inhibit CYP3A4, slowing the breakdown of hydrocortisone and potentially leading to excessive cortisol effects. Your doctor may need to decrease your hydrocortisone dose if you start taking any of these:
| Drug | Category | Interaction | Clinical Action |
|---|---|---|---|
| Itraconazole | Antifungal | Strong CYP3A4 inhibitor | May require dose reduction |
| Posaconazole | Antifungal | Strong CYP3A4 inhibitor | May require dose reduction |
| Voriconazole | Antifungal | CYP3A4 inhibitor | May require dose reduction |
| Erythromycin | Antibiotic (macrolide) | Moderate CYP3A4 inhibitor | Monitor for excess cortisol effects |
| Clarithromycin | Antibiotic (macrolide) | Strong CYP3A4 inhibitor | May require dose reduction |
| Ritonavir | Antiretroviral (HIV) | Potent CYP3A4 inhibitor | Significant dose reduction may be needed |
Food and Drink Interactions
Grapefruit juice inhibits CYP3A4 in the gut wall and can increase hydrocortisone absorption. Regular consumption may lead to elevated cortisol levels. Your doctor may advise reducing the hydrocortisone dose if you drink grapefruit juice regularly.
Liquorice (licorice) contains glycyrrhizin, which inhibits the enzyme 11-beta-hydroxysteroid dehydrogenase type 2. This enzyme normally inactivates cortisol in certain tissues. Consuming significant amounts of real liquorice while taking hydrocortisone can lead to enhanced cortisol effects, including fluid retention, high blood pressure and low potassium levels. Avoid large quantities of liquorice-containing products.
What Is the Correct Dosage of Hydrocortisone?
Hydrocortisone dosage varies significantly depending on the condition being treated. For adrenal insufficiency, typical adult replacement doses are 15–25 mg daily in divided doses. For children, doses are calculated by body surface area (8–15 mg/m²/day). Topical hydrocortisone cream is applied thinly 1–2 times daily. Always follow your doctor's specific instructions.
The dose of hydrocortisone is highly individualised and depends on the condition being treated, the patient's age, weight (or body surface area for children), severity of illness and individual response. The following are general guidelines – always follow the specific instructions given by your doctor, nurse or pharmacist.
Adults
Adrenal Insufficiency (Oral Replacement)
Typical dose: 15–25 mg daily, divided into 2–3 doses. The largest dose is usually taken in the morning (10–15 mg upon waking) to mimic the body's natural cortisol rhythm, with smaller doses at midday and in the late afternoon. Modified-release tablets (e.g., Plenadren) may be taken once daily.
Topical (Skin Conditions)
Typical dose: Apply a thin layer of hydrocortisone cream or ointment (0.5%–1%) to the affected area 1–2 times daily. Use the minimum amount needed and for the shortest duration possible. For mild eczema and dermatitis, treatment courses are typically 1–2 weeks.
Children
Adrenal Insufficiency / Congenital Adrenal Hyperplasia (Oral)
Typical dose: 8–15 mg/m²/day divided into 3–4 doses. Specialised paediatric formulations such as Alkindi (granules in capsules designed to be opened) are available in 0.5 mg, 1 mg, 2 mg and 5 mg strengths to allow precise dosing for infants and young children. The dose is adjusted as the child grows, based on clinical response, growth velocity and hormone levels.
Topical (Skin Conditions in Children)
Typical dose: Apply a thin layer of 0.5%–1% hydrocortisone cream to affected areas once or twice daily. Use the fingertip unit (FTU) method to measure the correct amount. Avoid prolonged use on large body areas or under occlusive dressings. Special care is needed when applying to the face or skin folds.
Elderly
Elderly patients may require lower maintenance doses due to age-related changes in metabolism. Bone mineral density should be monitored, as older adults are at higher risk of corticosteroid-induced osteoporosis. Blood pressure and blood glucose levels should also be checked regularly.
Missed Dose
If you forget to take a dose of oral hydrocortisone, take it as soon as you remember. If it is nearly time for your next scheduled dose, take the missed dose immediately – it is important to maintain cortisol levels. You may take two doses close together if necessary. Do not skip a dose entirely, as this could lead to symptoms of adrenal insufficiency.
For topical hydrocortisone, if you forget an application, apply it as soon as you remember and then continue with your regular schedule. Do not apply a double layer to compensate.
Overdose
A single large dose of hydrocortisone is unlikely to cause serious harm. However, chronic overdosing (taking too much over a prolonged period) can lead to Cushing's syndrome symptoms, including weight gain (particularly around the face and trunk), skin thinning, easy bruising, high blood sugar, high blood pressure and muscle weakness.
In children, chronic overdosing can suppress growth. If you suspect an overdose, contact your doctor, pharmacist or poison control centre immediately.
Do not stop taking oral hydrocortisone without your doctor's guidance, even if you feel well. People with adrenal insufficiency need hydrocortisone to survive. Stopping suddenly can make you seriously ill within hours, with symptoms including severe fatigue, weakness, nausea, vomiting, low blood pressure and potentially adrenal crisis. If your child with adrenal insufficiency vomits and cannot keep tablets down, an emergency hydrocortisone injection may be required.
What Are the Side Effects of Hydrocortisone?
When used at correct replacement doses for adrenal insufficiency, side effects are uncommon because hydrocortisone simply replaces hormones the body lacks. Excessive doses, however, can cause growth suppression in children, mood changes, stomach irritation, metabolic changes and bone loss. Topical hydrocortisone may cause skin thinning with prolonged use.
Like all medicines, hydrocortisone can cause side effects, although not everyone experiences them. It is important to distinguish between side effects from physiological replacement doses (which are generally well tolerated) and those from pharmacological (higher) doses used for inflammatory conditions.
When hydrocortisone is used as hormone replacement therapy at the correct dose, side effects are less likely because the medicine is replacing hormones that the body normally produces. Most reported side effects are associated with doses that are too high or prolonged use of topical formulations.
Oral Hydrocortisone Side Effects
Common side effects (at excessive doses)
- Weight gain, particularly in the face and abdomen
- Increased appetite
- Mood changes (irritability, anxiety, restlessness)
- Difficulty sleeping (insomnia)
- Stomach discomfort or nausea (gastritis)
Uncommon side effects
- Growth suppression in children (with excessive doses)
- Changes in blood potassium levels (hypokalaemic alkalosis)
- Elevated blood sugar (hyperglycaemia)
- Increased susceptibility to infections
- Muscle weakness
Rare side effects
- Psychosis with hallucinations and delirium
- Mania (extreme excitement and overactivity)
- Euphoria (feelings of intense happiness)
- Reduced bone mineral density (osteoporosis with long-term use)
- Blurred vision or cataracts
- Adrenal suppression (if doses exceed physiological needs)
Topical Hydrocortisone Side Effects
Common side effects
- Skin thinning (atrophy) at the application site
- Burning or stinging sensation on application
- Dryness of the treated skin
Uncommon side effects
- Stretch marks (striae) with prolonged use
- Changes in skin colour (hypopigmentation or hyperpigmentation)
- Contact dermatitis (allergic reaction to the cream itself)
- Acne or folliculitis at the application site
Rare side effects
- Systemic absorption (particularly with large-area or occlusive use)
- Adrenal suppression (very rare with standard topical use)
Contact your endocrinologist or doctor if you notice unexpected weight gain, changes in your child's growth rate, persistent mood or behavioural changes, stomach pain or nausea, blurred vision, or signs of infection (fever, sore throat) while taking hydrocortisone. If you experience severe symptoms such as difficulty breathing, facial swelling, or rash after taking hydrocortisone, seek emergency medical attention as this may indicate an allergic reaction.
If you are concerned about any side effects or notice symptoms not listed here, report them to your doctor or pharmacist. Monitoring adverse reactions helps improve drug safety knowledge for all patients.
How Should You Store Hydrocortisone?
Store hydrocortisone at room temperature below 25–30°C, away from direct light and moisture. Keep all medications out of reach of children. Once opened, granule capsules (e.g., Alkindi) should be used within 60 days. Do not use after the expiry date.
Proper storage of hydrocortisone is important to maintain the medicine's effectiveness and safety. The following guidelines apply to most hydrocortisone formulations:
- Temperature: Store at room temperature, typically below 25–30°C (77–86°F). Do not freeze
- Light: Store in the original container to protect from light. This is particularly important for granule formulations
- Moisture: Keep away from damp environments such as bathrooms. Store in a dry place
- Children's safety: Keep all medications out of the sight and reach of children
- Expiry date: Check the expiry date on the packaging. Do not use the medicine after the last day of the month shown
For Alkindi granules: once the container is opened, the capsules should be used within 60 days. Keep the container tightly closed between uses.
For hydrocortisone cream or ointment: check the period-after-opening symbol on the tube (typically shown as an open jar icon with a number of months). Most topical hydrocortisone products should be used within 6–12 months of first opening.
Dispose of unused or expired medicines safely. Do not flush them down the toilet or put them in household waste. Return them to your pharmacy for proper disposal to protect the environment.
What Does Hydrocortisone Contain?
The active ingredient in all hydrocortisone products is hydrocortisone itself. Inactive ingredients (excipients) vary by formulation and manufacturer but commonly include microcrystalline cellulose, hypromellose and magnesium stearate in oral forms, and paraffin, cetostearyl alcohol and water in topical preparations.
The composition of hydrocortisone medicines varies depending on the formulation and manufacturer. Here are the typical ingredients for common formulations:
Oral Tablets
Active ingredient: hydrocortisone (5 mg, 10 mg or 20 mg per tablet). Common excipients include lactose monohydrate, maize starch, pregelatinised starch, magnesium stearate and colloidal silicon dioxide.
Oral Granules (Alkindi)
Active ingredient: hydrocortisone (0.5 mg, 1 mg, 2 mg or 5 mg per capsule). The granules are white to off-white, contained in transparent colourless hard capsules designed to be opened (not swallowed). Excipients include microcrystalline cellulose, hypromellose, magnesium stearate and ethylcellulose. The capsule shells are made of hypromellose. Printing inks on capsules contain shellac, propylene glycol, iron oxide pigments and/or indigo carmine, depending on the strength.
Topical Cream (1%)
Active ingredient: hydrocortisone (10 mg per gram). Common excipients in cream formulations include cetomacrogol emulsifying wax, white soft paraffin, liquid paraffin, chlorocresol (preservative) and purified water.
Topical Ointment
Active ingredient: hydrocortisone (typically 10 mg per gram). Ointment bases commonly contain white soft paraffin and liquid paraffin. Ointments are preservative-free and suitable for dry or lichenified skin.
If you have known allergies to any excipients (such as lactose, lanolin, chlorocresol or certain dyes), check the full list of ingredients in the patient information leaflet that comes with your specific product. Your pharmacist can help you identify suitable formulations.
Frequently Asked Questions About Hydrocortisone
Medical References
This article is based on current international guidelines and peer-reviewed medical literature. All medical claims are verified against the following sources:
- Bornstein SR, Allolio B, Arlt W, et al. Diagnosis and Treatment of Primary Adrenal Insufficiency: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2016;101(2):364-389. doi:10.1210/jc.2015-1710
- Speiser PW, Arlt W, Auchus RJ, et al. Congenital Adrenal Hyperplasia Due to Steroid 21-Hydroxylase Deficiency: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2018;103(11):4043-4088. doi:10.1210/jc.2018-01865
- European Medicines Agency (EMA). Alkindi – Summary of Product Characteristics. EMA/680323/2017. Updated 2024.
- World Health Organization. WHO Model List of Essential Medicines – 23rd List. Geneva: World Health Organization; 2023.
- National Institute for Health and Care Excellence (NICE). Hydrocortisone – Corticosteroid replacement therapy. BNF. Updated 2025.
- Prete A, Taylor AE, Bancos I, et al. Prevention of Adrenal Crisis: Cortisol Responses to Major Stress Compared to Stress Dose Hydrocortisone Delivery. J Clin Endocrinol Metab. 2020;105(7):2262-2274. doi:10.1210/clinem/dgaa133
- Bornstein SR. Predisposing Factors for Adrenal Insufficiency. N Engl J Med. 2009;360(22):2328-2339. doi:10.1056/NEJMra0804635
- Husebye ES, Pearce SH, Krone NP, et al. Adrenal insufficiency. Lancet. 2021;397(10274):613-629. doi:10.1016/S0140-6736(21)00136-7
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