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TNF inhibitors adalimumab and infliximab have evidence-based efficacy for the treatment of hidradentitis suppurativa (HS). Anti-interleukin inhibitors ustekinumab and anakinra also being evaluated in small studies for treatment of HS. Antibiotics, hormones, retinoids, steroids and laser therapies directly targeting the lesions round out an effective treatment plan for HS patients.
Dr. MichelettiAlthough hidradenitis suppurativa is a disease that is extremely impactful and burdensome several medical therapies have been proven to be effective and safe.
“People go on average 7 years without a diagnosis,” says Robert Micheletti, M.D., an assistant professor of dermatology and medicine at the University of Pennsylvania in Philadelphia. “Hidradenitis suppurativa (HS) is also probably the worst systematically studied disease in dermatology with respect to quality of life.”
Symptoms of depression and anxiety as well as several important medical comorbidities are also part of the mix, including increased cardiovascular risk.
Dr. Micheletti, who spoke with Dermatology Times in advance of his presentation on the latest in HS at the 2017 American Academy of Dermatology (AAD) annual meeting in March in Orlando, Fla., says historically HS has been a challenging disease for both patients and providers.
“Treatment can be frustrating, with less than desirable results,” Dr. Micheletti says. “But now there is a message of hope, thanks to agents with reasonable data to justify treating very severe HS.”
The most recent notable development is FDA approval, in September 2015, of the biologic adalimumab (Humira, Abbott Laboratories), which is a tumor necrosis factor (TNF) inhibitor.
“This is the first medication FDA approved for HS,” Dr. Micheletti states. “We now have an expensive biologic medicine that you can actually prescribe to your patients because it is FDA approved.”
The dosing for adalimumab is also significantly greater than for psoriasis.
“The dosing is similar to Crohn’s disease,” Dr. Micheletti says.
The dosing protocol for the self-administered subcutaneous injection begins at 160 mg at week 0, then 80 mg at week 2, followed by 40 mg weekly starting at week 4, which is ongoing.
“The loading dose appears to help induce a response,” Dr. Micheletti says.
The FDA studies for adalimumab found a clinically relevant response in about 50% of patients, compared to roughly 25% of placebo patients.
Infliximab, not only for psoriasis
A second TNF inhibitor for HS is infliximab (Remicade, Janssen), also used to treat psoriasis. The investigational drug involves an intravenous infusion, usually 5 mg/kg every 8 weeks, but sometimes higher, lasting a few hours, at either an infusion center or an outpatient hospital setting.
“The largest published study of infliximab showed a greater than 25% improvement in 87% of patients versus only 11% in the placebo group,” Dr. Micheletti reports.
“Anecdotally, we see patients with moderate or severe disease respond to one of these two medications, so both of these medications are reasonable options,” he says. “If one does not work, you can try the other and vice versa.”
Besides infliximab, there are two other investigational biologics for HS, but with different mechanisms of action. Ustekinumab (Stelara, Janssen), used for psoriasis and inflammatory bowel disease (IBD, is an anti-interleukin-12/23 (anti-IL-12/23) inhibitor, whereas anakinra (Kineret, Sobi), for rheumatoid arthritis (RA) and rare autoinflammatory conditions, is an anti-IL-1 inhibitor.
Both of these agents have been evaluated in small studies,” Dr. Micheletti says.
Like adalimumab, both ustekinumab and anakinra are subcutaneous injections “that are potential options for people who have failed the two TNF inhibitors,” Dr. Micheletti says.
All four biologics “tend to be fairly well tolerated,” Dr. Micheletti says. However, there are infection risks; for example, with the TNF inhibitors, “there is a risk of reactivation of tuberculosis.”
Like the evolving development of medical therapy for psoriasis, “it is a good sign that we now have a couple of HS drugs that seem to help, and maybe there will be more in the future,” Dr. Micheletti says. “With the passing of time, as with psoriasis, we hope to have more and more options that benefit patients who do not respond to one or another drug, especially in the most severe forms of HS.”
For less severe disease, there are topical antibiotics and topical antibacterial washes, as well as oral antibiotics like doxycycline, or combination clindamycin and rifampin. “This combination can work reasonably well for people with moderate or even severe disease, without resorting to a biologic,” Dr. Micheletti notes.
Hormonal treatments such as spironolactone may also help, especially for female patients who present with polycystic ovarian syndrome (PCOS).
Oral retinoids (isotretinoin, acitretin) also sometimes have benefit.
“But from an evidence-based perspective, we have evidence for topical clindamycin, some of the antibacterial washes and clindamycin/rifampin,” Dr. Micheletti says. “While there is no evidence for doxycycline, it is often effective in those with mild hidradenitis and is still recommended by experts.”
Certain types of laser therapy, minor bedside surgical procedures, and injecting inflamed lesions with steroids can be useful in combination with other therapies. Together, these combinations “constitute an effective overall treatment plan,” Dr. Micheletti says.
Dr. Micheletti reports no relevant financial disclosures.