Traditional Systemic Therapies in Hidradenitis Suppurativa

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Robert G. Micheletti, MD: I think the other classes of medications that dermatologists think about for hidradenitis are the retinoids and also more traditional systemic immunosuppressives. The retinoids have typically been rather disappointing for hidradenitis. Isotretinoin in retrospective studies, very few patients actually think it’s helpful, and so it’s not one that we tend to use a whole lot. Acitretin can be effective. There are some studies showing efficacy in patients, but, typically, the doses that you need for efficacy are high enough to cause unpleasant side effects, like dry eyes and dry mouth. And the most common demographic we’re talking about is women in their 20s. Acitretin is teratogenic, isotretinoin is teratogenic, so it’s not a great long-term option. I tend to think that if I find something that’s working, I will leave the patient on it until I feel like I’ve gotten good utility out of it before trying to back off. So, this is a long-term solution that we’re looking for here, and retinoids at higher doses, with all the monitoring parameters and teratogenicity issues, they may not be the best option.

And then, when we talk about systemic immunosuppressive options, I actually find prednisone, anecdotally, can be useful. It’s not, again, a great long-term solution because you have many side effects to think about with systemic steroids, things like hyperglycemia and bone health to name just two. But in the acute phases, if there is a patient who is acutely inflamed, if I’m starting another therapy but it’s not going to take effect just yet, I will sometimes use a steroid taper to calm that acute phase and inflammation as I’m ramping up another therapy. And I think that is one useful pearl that can be applied.

Other systemic immunosuppressive agents—methotrexate, cyclosporine, azathioprine—these really don’t have a role in hidradenitis. There are limited data that are not very exciting in terms of efficacy. And when you think about the side effect profile, again, they’re not great long-term solutions, especially if they’re not particularly efficacious. So, we’re typically not using them. There’s a last agent some people do add on, which is zinc. There are some data suggesting that maybe that can be helpful, possibly affecting immunity, but there are some gastrointestinal side effects that can be limiting.

If you talk about just the traditional systemic agents, not even talking about biologics, there are many different things that can be used, many different combinations that can be employed. I think one has to understand monitoring parameters and other things that could be relevant for individual agents, but there are quite a number of things that can be done. And, again, maybe I don’t choose the right thing at the beginning, but eventually we’ll get a combination or a particular therapy that hopefully will be effective for a patient.

Transcript Edited for Clarity