Hidradenitis Suppurativa in Pregnancy

Challenging to treat in the general patient population, hidradenitis suppurativa (HS) can cause serious, even lethal, complications for pregnant patients. Results of a recent study¹ found that pregnant patients with HS have an increased risk of obstetric and pregnancy complications, including lower odds of a live birth, which underscores the need to proactively manage this disease. HS is characterized by recurrent painful nodules, abscesses, draining dermal fistula tracts, and scarring with a predilection for intertriginous sites such as the axillae, groin, gluteal, and submammary regions. It can significantly affect a patient’s quality of life. Associated comorbidities in more severe cases include metabolic syndrome, follicular occlusion disorders, inflammatory bowel diseases such as Crohn disease, and spondyloarthropathy.

Lyons et al state that HS disproportionally affects women of childbearing age.² Nevertheless, although the effect of pregnancy on the clinical course of HS has been evaluated in the literature, there is a dearth of research on the effect of HS on pregnancy outcomes.²

“Similar to the increased risks of pregnancy seen in female patients with psoriasis, rheumatoid arthritis, systemic lupus erythematosus, scleroderma, and other inflammatory diseases, pregnant patients with HS also can have a higher rate of pregnancy complications,” said Joslyn Sciacca Kirby, MD, MS, MEd, an associate professor in the Department of Dermatology at Penn State College of Medicine, Pennsylvania State University in Hershey. “There is an opportunity here for us as dermatologists to think about all our patients holistically. Although they might not be pregnant at the visit, it might be something they are thinking about, and more information could help them.”

FEWER LIVE BIRTHS, MORE CESAREAN DELIVERIES

Kirby and colleagues recently conducted a study¹ investigating the maternal and obstetric outcomes and treatment utilization among women with HS. The researchers used the IBM MarketScan Commercial Claims and Encounters Database to identify a cohort of 998 pregnant women with HS and a cohort of 5065 age-matched pregnant women without HS. Retrospective analysis data on diagnoses, procedures, and medications were analyzed.

Pregnancies were assigned to 1 of 6 types: live birth, ectopic/molar pregnancy, elective termination, spontaneous abortion, unspecified abortion, and stillbirth. Only women with live births were evaluated for pregnancy complications, which included vaginal and cesarean delivery and treatments. The most common comorbidities represented in both the HS and non-HS cohorts were overweight/obesity, anxiety, and depression.

Compared with women without HS, the inves- tigators found that pregnant women with HS had significantly lower odds of having live childbirth (odds ratio [OR], 0.45; 95% CI, 0.39-0.51) and significantly higher odds of having elective terminations (OR, 2.51; 95% CI, 2.13-2.96), cesarean deliveries (OR, 1.28; 95% CI, 1.06-1.55), or gestational hypertension (OR, 1.44; 95% CI, 1.12-1.84).²

After adjusting for confounders, data showed higher odds for having cesarean delivery, which significantly diverges from another recent retrospective cohort study² performed by Lyons et al. However, results showing preeclampsia/eclampsia and gestational hypertension were proportion- ally higher in women with HS echoed similar data from the Lyons study.

COMPLICATIONS AND COMORBIDITIES

A flaring of HS symptoms is likely to occur in pregnant patients, according to Kirby. She advised clinicians to watch for these flares but also to make their pregnant patients aware of symptoms such as itchy or painful bumps found mostly in the armpits, groin, under the breasts or in the anal and genital areas that could indicate a pending eruption. She recommended physicians also discuss with pregnant patients with HS disease and symptom control management during the postpartum period.

Hormone dysfunctions are thought to play a role in the underlying pathogenesis, development, and chronicity of HS, given the association of the disease with hormonal acne, polycystic ovarian syndrome, and fluctuations in HS disease severity associated with the menstrual cycle.

“There is an old rule for pregnancy and what to expect from skin conditions stating that [approximately] one-third of patients get better, one-third stay the same, and one-third get worse,” Kirby said. “This is also partially true for HS patients in that it seems that HS may improve in one-third of women who get pregnant. However, of the remaining two-thirds of patients, there are more who may worsen than stay the same.”

Investigators also found that pregnant women with HS had a higher usage of topical and oral antibiotics and a higher prevalence of cutaneous surgeries during pregnancy compared with pregnant women without HS. According to Kirby, this finding reflects the fact that patients with HS commonly are prescribed multiple medications and may require a higher rate of procedures and/or surgeries to manage the disease.

IS THIS TREATMENT SAFE?

Decisions on HS treatment become more complex in the context of pregnancy. Kirby said she asks patients to tell her as soon as they know they are pregnant so that they can work together to develop the optimal pregnancy and postpartum treatment regimen.

That may mean switching therapies. For example, she pointed out that therapies such as systemic retinoids, finasteride, and spironolactone that are used in managing HS are contraindicated in pregnancy, and many medications have safety profiles that are not clearly defined yet.

Kirby recommended consideration of a multidisciplinary management approach for pregnant patients with HS, underscoring the importance of dermatologists and obstetrical providers collaborating on a patient’s care throughout the pregnancy. Working with a team can be particularly beneficial for patients with HS because therapy management can require a different dynamic in each trimester, she added.

“Sometimes we will alter the therapy with some medications such as the biologics during the third trimester because many agents can cross the placenta into the baby,” she said. “This reinforces the need to communicate with the obstetrician and to work with the patient and help them understand the implications of continuing the medication through the third trimester.”

Pregnancy in patients with acne offers the same kind of challenge as with those with HS because they share a similar etiological background, Kirby noted. She said that, fortunately, there are different classes of topical and oral antibiotics as well as topical antiseptics that can be used safely. In her view, that list includes metformin for milder cases of HS and biologics, especially tumor necrosis factor inhibitors, for more severe disease.

“Hidradenitis suppurativa can get worse when associated with pregnancy and it is important to continue to manage the disease both medically and, when necessary, with surgical procedures with the guidance of both the dermatologist and obstetrician,” she said. “Heightened attention of care for these patients can help us better control the disease and significantly improve patients’ qual- ity of life.”

Disclosures

Kirby is a consultant and speaker for AbbVie, receives honoraria for participat- ing on an advisory board for AbbVie, and receives honoraria as a consultant for ChemoCentryx, Incyte, Janssen, Novartis, and UCB.

References

1. Sakya SM, Hallan DR, Maczuga SA, Kirby JS. Outcomes of pregnancy and childbirth in women with hidradenitis suppurativa. J Am Acad Dermatol. 2022;86(1):61-67. doi:10.1016/j.jaad.2021.05.059
2. Lyons AB, Peacock A, McKenzie SA, et al. Retrospective cohort study of preg- nancy outcomes in hidradenitis suppurativa. Br J Dermatol. 2020;183(5):945- 947. doi:10.1111/bjd.19155