Researchers Highlight Special Considerations for Managing HS in Certain Populations

Researchers of a new paper have outlined treatment strategies for certain patients with hidradenitis suppurativa (HS) whose treatment requires further considerations, such as those who are pregnant or those with comorbid conditions such as inflammatory bowel disease (IBD).

As potential new treatment options continue to emerge for the inflammatory condition, the researchers emphasized the importance of clinicians being prepared to manage these patients that have additional health factors.

“An increased interest in the management of HS has elucidated potential new avenues of treatment and provided clinicians the opportunity to curate a treatment regimen appropriate for their patients,” wrote the group. “In special populations, such as those who are pregnant, lactating, or suffering from a comorbid condition (IBD, cancer), clinicians must identify appropriately safe treatment agents.”

Pregnancy and lactation

HS is disproportionately prevalent among women of childbearing age, and treatment is further complicated in this population as many first-line options are contraindicated for patients who are pregnant or lactating. According to the researchers, retinoids must be avoided in all pregnant or lactating patients.

Use of oral tetracyclines is not advised after 5 weeks of pregnancy because tetracyclines cross the placenta and bind to calcium in the fetus, causing congenital defects. For patients breastfeeding, short-term use of tetracyclines is considered acceptable due to there being low levels in breast milk.

Systemic antibiotics like clindamycin is considered safe for both groups, and intravenous ertapenem is considered acceptable if needed and if there are no better options available. The combination of clindamycin with rifampin may also be considered in cases of mild to moderate HS. Rifampin has been studied in observational studies of over 2000 pregnant women, which showed no teratogenic effects at normal dosages. The treatment is also considered safe during lactation. With a risk of postnatal hemorrhage associated with rifampin, the researchers suggest coadministration of Vitamin K.

For topical treatments, various options, including chlorhexidine and benzol peroxide, are considered generally safe in both types of patients.

Among biologics, the researchers explained, “Clinicians should evaluate the individual risk of biologic agents for their HS patients during pregnancy and lactation. Tumor necrosis factor (TNF)-a inhibitors that have been shown to be effective in HS include adalimumab and infliximab, both classified as category B. Based on current evidence, adalimumab is deemed compatible for pregnancy and lactation given no increased rate of adverse effects on the developing fetus or nursing infant.”

Comorbidities

Special considerations of HS are also warranted in the case of cancer or IBD. There has been some evidence suggesting that immune-suppressing agents can increase the risk of cancer; for example, some research has indicated that TNF inhibitors may increase the risk of skin cancer, although more recent studies—albeit mainly among patients with IBD and inflammatory arthritis—have indicated that there is no increased risk of developing cancer.

To date, there have been nearly 140 cases of cutaneous squamous cell carcinoma (SCC)—a rare, potentially life-threatening complication of long-term HS—although the reason behind the predisposition is not understood.

“A recent theory known as the ‘immunocompromised cutaneous district’ states that chronically diseased regions of skin have dysfunctional immune control, thus predisposing the area of skin to an increased risk of malignant transformation,” wrote the researchers, who noted that the disease has mainly been seen in male smokers with chronic HS of the gluteal region. “In the case of HS, dysfunctional immune control manifests as chronic lymphedema and may play an important role in the development of SCC. Smoking, chronic inflammation, and HPV infection are factors that are also thought to contribute to the risk of developing SCC in HS.”

Significant associations between HS and IBD have also been documented, with treatment of patients with both conditions varies based on disease location and severity as well as treatment response. TNF inhibitors, such as adalimumab and infliximab, are effective in both conditions and are typically used when patients do not respond to more conventional treatment.

Reference

Aldana I, Sanyi A, Mayo T. Treating hidradenitis suppurativa in special populations: Pregnancy, lactation, and comorbid conditions. Dermatol Rev. Published online March 28, 2022. doi: 10.1002/der2.125