Biologics can be antibiotic alternative for hidradenitis suppurativa

Montreal - A variety of treatments aside from antibiotics have shown some efficacy in managing hidradenitis suppurativa (HS), according to a clinician speaking at the Dermatology Update 2013 meeting.

John Kraft, M.D., F.R.C.P.C., a dermatologist at the Lynde Centre for Dermatology, Markham, Ontario, reviewed data on the evidence for numerous medical therapies that have been employed to manage a chronic condition that is not uncommon in premenopausal women.

HS is caused by a defect of the follicular epithelium, leading to follicular occlusion and subsequent follicular rupture in areas rich in apocrine glands. Clinicians make the diagnosis by recognizing typical lesions at typical sites where there is recurrence, Dr. Kraft notes.

“First-line therapy for mild-to-moderate disease is antibiotics,” Dr. Kraft says.

Non-antibiotic options

Given the hormonal involvement of the condition, one of the non-antibiotic options for treating hidradenitis suppurativa is the anti-androgen finasteride. There have been more studies in adults to support its evidence, but recent data suggest it can be administered to teenagers as well, Dr. Kraft says.

“We know it’s effective in the pediatric setting,” he says.

A case series of three pediatric patients published in June 2013 demonstrated reduced frequency and severity of disease flares without any serious side effects (Randhawa HK, Hamilton J, Pope E. JAMA Dermatol. 2013;149(6):732-735).

Biologic agents have also been used to treat HS. A study looked at the efficacy of infliximab in a randomized, placebo-controlled crossover trial of patients with moderate to severe HS. Patients who received infliximab showed a 50 percent decline from baseline HS Severity Index score (Grant A, Gonzalez T, Montgomery MO, et al. J Am Acad Dermatol. 2010;62(2):205-217).

The investigators of that infliximab study conducted a post-hoc analysis confirming the benefit of using infliximab, Dr. Kraft adds.

Dr. Kraft notes that etanercept, another biologic agent, has been used to treat HS, pointing to a 2010 investigation that showed that after therapy, there was no benefit in using etanercept compared to placebo (Adams DR, Yankura JA, Fogelberg AC, Anderson BE. Arch Dermatol. 2010;146(5):501-504).

“They found no statistically significant difference in any of the outcomes at 12 and 24 weeks,” Dr. Kraft says. “The authors even said to look at other treatment options rather than pursue etanercept for hidradenitis suppurativa.”

Additional studies

Adalimumab is likely one of the therapies that is the most well-studied for the treatment of HS, he says.

Dr. Kraft points to a prospective, randomized study in which patients who were administered adalimumab by injection every two weeks experienced a decrease in Sartorius score after six weeks and at 12 weeks, had close to a significant reduction in that score compared to patients who received placebo (Miller I, Lynggaard CD, Lophaven S, et al. Br J Dermatol. 2011;165(2):391-398).

Another study examining the impact of adalimumab involved three arms of patients, involving two different dosing regimens of adalimumab and placebo. It found 17.6 percent of patients dosed weekly achieved a HS Physician Global Assessment of clear, minimal or mild disease (Kimball AB, Kerdel F, Adams D, et al. Ann Internal Med. 2012;157(12):846-855).

“This is not a high percentage, but the finding is valid,” Dr. Kraft says. “It was significant for the 40 mg per week (group), but not (the group dosed) every other week.”

There have been variable results in the use of ustekinumab to manage HS. One investigation of three patients found complete remission in one patient, some improvement in another patient, and no response in the third patient (Gulliver WP, Jemec GBE, Baker KA. JEur Acad Dermatol Venereol. 2012;26(7):911-914).

Colchicine has been studied to manage HS, with one study finding no improvement in disease severity (Van der Zee HH, Prens EP. Dermatology. 2011;223(2):169-173). A retrospective review found a small positive impact with colchicine, but no bigger an effect than antibiotics such as clindamycin or rifampin, Dr. Kraft says.

When patients with HS prove unresponsive, dermatologists should keep a therapy such as cyclosporine in their back pockets, he says.

Because of the large variability in design of studies looking at the management of HS, it can be a challenge to establish which therapies will be effective for a given patient, Dr. Kraft says.

Disclosures: Dr. Kraft is a speaker, adviser and investigator for AbbVie and Janssen. He is an adviser and investigator for Amgen.