Options to Consider in Hidradenitis Suppurativa

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Robert G. Micheletti, MD: I think an important thing to tell patients is that hidradenitis is a chronic condition. We don’t necessarily know the right thing for that individual patient, and that can be frustrating. We might have to try several things before we get it right. That being said, there is a treatment ladder. There are quite a few things that we can try, and I tell patients, “If you stick it out with me, I’ll stick it out with you, and we’ll find something that works eventually.” So, starting from mild topical and oral treatments, ranging all the way to the most heavy-duty or aggressive treatments, we can tackle these one by one.

I like to put every patient on a good topical regimen, and usually this means some sort of cleanser—the thought process being that we’re breaking up the bacterial biofilm—so chlorhexidine wash or benzoyl peroxide wash. There are some data to support benzoyl peroxide, in particular, for use in the shower daily to affected areas. And then, I tell them to apply clindamycin solution twice daily to any active inflammatory lesions.

Again, there are some data against placebo to show that clindamycin solution or gel is efficacious. There are other topical agents people talk about—mupirocin or topical dapsone. There really are limited data there. There’s another one, topical resorcinol, that has to be compounded, and there are some data to support that, mostly out of Europe. But the point is that some topical treatment to help break up biofilms, to help decrease inflammation locally, those things can be effective.

For patients who are getting more inflammatory lesions, I do think putting them on an oral agent is appropriate. And I have a low threshold for doing that because, again, I realize that even mild disease is very distressing to the patient.

When we talk about the first classes of medications for hidradenitis, really we’re thinking mostly about antibiotics. So, the tetracycline class—doxycycline, minocycline—those are medications that might be appropriate for a Hurley stage 1 patient. I usually will start with something like doxycycline, 100 mg twice daily. And we don’t actually have data to support it; it’s really anecdotal. We’re very comfortable with the medicine; it’s well tolerated. There is a study that showed tetracycline was not superior to clindamycin solution alone, but I think many of us believe that doxycycline and minocycline can be effective.

Moving on from that in the antibiotic class, so clindamycin and rifampin in combination, both of them are 300 mg twice daily. There’s a fairly large study of 116 patients looking at that combination. The study was 10 weeks, and only 8 patients had to stop due to side effects. It’s very well tolerated, and I do think it works well, particularly for patients with moderate or more severe disease. And this is a really good treatment to have in your back pocket for patients who are breaking through doxycycline, but maybe aren’t quite severe enough for a more heavy-duty medication.

There are various other antibiotic combinations that have been described—moxifloxacin, rifampin, metronidazole. But many of these are not so well tolerated, and, again, these are small studies. Some of them are retrospective reports, but they’re not necessarily well tolerated. There are some other IV regimens—ertapenem, ceftriaxone—and some people have had success with those things. But, again, they may not be as easily implemented or as well tolerated as doxycycline or clindamycin/rifampin.

I think the other avenue of therapy that is important to talk about is the hormonal avenue. There are some reasons to think that hormone levels play a role: the idea that patients are coming with hidradenitis or getting hidradenitis after puberty—and then post menopause, it tends to peter out—and that it’s more common in women. So, we think that hormonal factors can play a role, and particularly for female patients who are saying, “My hidradenitis flares up with menses,” those patients can be good candidates for either oral contraceptives or spironolactone. And there are some data lumping together a bunch of these hormonal treatments and showing even superiority to various antibiotic regimens. There’s not a study about spironolactone, but, again, many of us think it is useful and tend to use it, tend to do something, like 50 mg twice daily. But I look at these treatments as an adjunct to a good antibiotic regimen that may be incompletely effective or as a good antibiotic regimen, but the patient is breaking through, say, with menses.

There are even some data to support the use of metformin or even finasteride, thinking about some of the hormonal factors, as well as acknowledging that there is often a connection with metabolic syndrome, diabetes, and polycystic ovarian syndrome with metformin as a therapy. Again, as an adjunct to other things that you’re doing, I often find that adding one of these hormonal agents can be useful. Whether I’m treating with an antibiotic or even a biologic therapy, these things can be a useful addition to a regimen that we’re using.

Transcript Edited for Clarity