A double-blind placebo-controlled randomized trial of adalimumab in the treatment of hidradenitis suppurativa

Patient-reported outcomes in hidradenitis suppurativa

Hidradenitis suppurativa, also known as acne inversa, is a chronic recurrent inflammatory disease of the skin making management challenging and continuously evolving. A large number of modalities exist aimed at quantifying the efficacy of treatment in studies on hidradenitis suppurativa. Both physician-reported and patient-reported outcomes are used as endpoints in these studies; however, the vast majority of the modalities used to survey these reported outcomes lack validation and congruence between studies. Heterogeneity of outcome measures and lack of standardization from study to study make it difficult to design future hidradenitis suppurativa trials and to compare results. This high variability between studies further contributes to the lack of high-quality evidence available to guide clinical management decisions of this inflammatory skin disease. Therefore this review aims to assess the modalities frequently used to assess patient-reported treatment outcomes in hidradenitis suppurativa. Patient-reported outcomes in hidradenitis suppurativa include outcomes regarding symptoms and disease progression, measures of treatment satisfaction, quality of life surveys, impairment of function, pain, and patient-reported outcomes combined with physician-reported outcomes. Nearly all surveys demonstrate significant heterogeneity, lack standardization, and many are not validated or constructed specifically for the assessment of hidradenitis suppurativa. Yet patient-reported outcomes on symptoms and disease severity, treatment satisfaction, and quality of life are instrumental in evaluating hidradenitis suppurativa treatment efficacy in clinical trials. As such, standardization and validation of patient-reported outcome instruments are essential for comparability among studies and improved quality of evidence.

Hidradenitis suppurativa/acne inversa: a practical framework for treatment optimization - systematic review and recommendations from the HS ALLIANCE working group

Hidradenitis suppurativa (HS)/acne inversa is a debilitating chronic disease that remains poorly understood and difficult to manage. Clinical practice is variable, and there is a need for international, evidence‐based and easily applicable consensus on HS management. We report here the findings of a systematic literature review, which were subsequently used as a basis for the development of international consensus recommendations for the management of patients with HS. A systematic literature review was performed for each of nine clinical questions in HS (defined by an expert steering committee), covering comorbidity assessment, therapy (medical, surgical and combinations) and response to treatment. Included articles underwent data extraction and were graded according to the Oxford Centre for Evidence‐based Medicine criteria. Evidence‐based recommendations were then drafted, refined and voted upon, using a modified Delphi process. Overall, 5310 articles were screened, 171 articles were analysed, and 65 were used to derive recommendations. These articles included six randomized controlled trials plus cohort studies and case series. The highest level of evidence concerned dosing recommendations for topical clindamycin in mild disease (with systemic tetracyclines for more frequent/widespread lesions) and biologic therapy (especially adalimumab) as second‐line agents (following conventional therapy failure). Good‐quality evidence was available for the hidradenitis suppurativa clinical response (HiSCR) as a dichotomous outcome measure in inflammatory areas under treatment. Lower‐level evidence supported recommendations for topical triclosan and oral zinc in mild‐to‐moderate HS, systemic clindamycin and rifampicin in moderate HS and intravenous ertapenem in selected patients with more severe disease. Intralesional or systemic steroids may also be considered. Local surgical excision is suggested for mild‐to‐moderate HS, with wide excision for more extensive disease. Despite a paucity of good‐quality data on management decisions in HS, this systematic review has enabled the development of robust and easily applicable clinical recommendations for international physicians based on graded evidence.

Efficacy of adalimumab in moderate to severe hidradenitis suppurativa: Real life data

Hidradenitis suppurativa (HS) is a relapsing, inflammatory disease characterized by painful nodules, abscesses, sinuses track formation and scarring. HS has a great impact on patients’ quality of life and its treatment may be really challenging. Adalimumab provides a new therapeutic option for HS. Our aim was to assess the therapeutic potential of adalimumab on patients with HS based on the data from the daily clinical practice of an HS Outpatient Clinic. 19 patients with clinically evident moderate to severe HS, under adalimumab treatment for at least 24 week, participated in this observational, retrospective study. The Hidradenitis Suppurativa Physician’s Global Assessment scale, Modified Santorius scale and Dermatology Life Quality Index (DLQI) at baseline, week 4, week 12 and week 24 were retrieved from the records. Both Modified Santorius score and DLQI were significantly decreased during the weeks of evaluation (Friedman’s test; P < 0.001). The proportion of patients who achieved clinical response was 10.5% (n = 2) at week 4, 42.1% (n = 8) at week 12 and 63.2% (n = 12) at week 24. Treatment with adalimumab was linked with both clinical remission of HS and improvement of patients’ quality of life.

Apremilast for moderate hidradenitis suppurativa: Results of a randomized controlled trial

BACKGROUND

Effective anti-inflammatory treatments for hidradenitis suppurativa (HS) are limited.

OBJECTIVE

To evaluate the efficacy and short-term safety of apremilast in patients with moderate HS.

METHODS

A total of 20 patients with moderate HS were randomized in a 3:1 ratio to receive blinded treatment with apremilast, 30 mg twice daily, or placebo for 16 weeks. The primary outcome was the Hidradenitis Suppurativa Clinical Response at week 16. Linear mixed effects modeling (analysis of covariance) was used to assess secondary clinical outcomes between treatment groups.

RESULTS

The HS clinical response was met in 8 of 15 patients in the apremilast group (53.3%) and none of 5 patients in the placebo group (0%) (P = .055) at week 16. Moreover, the apremilast-treated patients showed a significantly lower abscess and nodule count (mean difference, -2.6; 95% confidence interval, -6.0 to -0.9; P = .011), NRS for pain (mean difference, -2.7; 95% -4.5 to -0.9; P = .009), and itch (mean difference, -2.8; 95% confidence interval, -5.0 to -0.6; P = .015) over 16 weeks compared with the placebo-treated patients. There was no significant difference in the Dermatology Life Quality Index over time between the 2 treatment groups (mean difference, -3.4; 95% confidence interval, -9.0 to 2.3; P = .230). The most frequently reported adverse events in the apremilast-treated patients were mild-to-moderate headache and gastrointestinal symptoms, which did not result in dropouts.

LIMITATIONS

Small number of patients, relatively short study duration.

CONCLUSION

Apremilast, at a dose of 30 mg twice daily, demonstrated clinically meaningful efficacy and was generally well tolerated in patients with moderate HS.

Prevalence of positive QuantiFERON gold in-tube testing in hidradenitis suppurativa

AIM

Hidradenitis suppurativa (HS) is a chronic, recurrent, inflammatory disease of the apocrine sweat glands. Tumor necrosis factor-alpha (TNF-α) inhibitors are commonly used to treat HS. However, prior to initiating therapy patients must be screened for mycobacterium tuberculosis (mTB) exposure. Several mTB screening tests based on interferon gamma release assays are commercially available, but the performance of these assays in the HS population is unknown. The purpose of this study was to investigate the performance of the QuantiFERON gold in-tube assay (QFT-GIT) in a cohort of patients with HS.

METHODS

This prospective study was conducted through the Wound Etiology and Healing (WE-HEAL) study. QFTGIT testing was performed using a commercial laboratory. Patients with positive test results underwent follow-up testing to evaluate for latent tuberculosis infection (LTBI). Data were collected on demographics and disease activity scores including Hurley stage, HS Sartorius score (HSS) and active nodule (AN) count.

RESULTS

Of the 69 patients with a confirmed diagnosis of HS, seven (10.1%) tested QFT-GIT positive and 5.8% were diagnosed with LTBI.

CONCLUSIONS

QFT-GIT results did not correlate with demographic characteristics or HS disease activity.

Outcomes After Combined Radical Resection and Targeted Biologic Therapy for the Management of Recalcitrant Hidradenitis Suppurativa

BACKGROUND

Trials demonstrating the efficacy of biologic therapy for moderate to severe hidradenitis suppurativa (HS) have inspired new multidisciplinary treatment strategies. We present our experience with combined biologic and surgical therapy for recalcitrant HS.

METHODS

Between 2011 and 2014, 21 patients (57 cases) with Hurley Stage III HS underwent radical resection with delayed primary closure alone, or in combination with adjuvant biologic therapy. Demographic data, treatment regimen, outcomes, and complications were retrospectively reviewed for all cases.

RESULTS

Eleven patients underwent combined surgical and biologic therapy, whereas radical resection alone was performed in 10 patients. The average soft tissue deficit, before closure, for the combined and surgery-only patients was 56 cm and 48.5 cm, respectively (P = 0.66). Biologic agents including infliximab (n = 8) and ustekinumab (n = 3) were initiated 2 to 3 weeks after closure and were continued for an average of 10.5 months. Recurrence was noted in 19% (4/29) and 38.5% (10/26) of previously treated sites for combined and surgery-only patients (P < 0.01). For the combined cohort, the disease-free interval was approximately 1 year longer on average (P < 0.001); however, this difference was reduced to 4.5 months when considering time to recurrence after cessation of biologic therapy (P = 0.09). New disease developed in 18% (2/11) and 50% (5/10) of combined and surgery-only patients, respectively (P < 001). No adverse events were noted among patients who received biologic therapy.

CONCLUSIONS

Lower rates of recurrence and disease progression, as well as a longer disease-free interval may be achieved with the use of adjuvant biologic therapy after radical resection for recalcitrant HS.

Approach to the Management of Patients With Hidradenitis Suppurativa: A Consensus Document

BACKGROUND

Hidradenitis suppurativa (HS) is a painful, debilitating, and poorly understood condition, which is suboptimally diagnosed, managed, and treated. Evidence supporting various treatment modalities is sparse.

OBJECTIVES

To incorporate scientific evidence and expert opinions to develop useful guidance for the evaluation and management of patients with HS.

METHODS

An expert panel of Canadian dermatologists and surgeons developed statements and recommendations based on available evidence and clinical experience. The statements and recommendations were subjected to analysis and refinement by the panel, and voting was conducted using a modified Delphi technique with a prespecified cutoff agreement of 75%.

RESULTS

Ten specific statements and recommendations were accepted by the expert panel. These were grouped into 4 domains: diagnosis and assessment, treatment and management, comorbidities and a multidisciplinary approach, and education.

CONCLUSIONS

These statements and recommendations will serve to increase awareness of HS and provide a framework for decisions involving diagnosis and management. Evidence suggests that antibacterial and anti-tumour necrosis factor therapies are effective in the treatment of HS. This is supported by the clinical experience of the authors. Further clinical research and the establishment of multidisciplinary management teams will continue to advance management of HS in Canada.

Non-surgical treatments for hidradenitis suppurativa: A systematic review

INTRODUCTION

The management of hidradenitis suppurativa is multidisciplinary, involving general measures, medical treatment and surgery. Non-surgical treatments, often first-line procedures, mainly concern forms of low-to-moderate severity or, conversely, very severe forms in non-operable patients or those refusing surgery. While many treatments have been attempted, few randomized controlled trials have been conducted, so the choice of treatments is most often based on the personal experience of the clinicians. The objective of this systematic review is to propose a synthetic analysis of the currently available non-surgical procedures.

METHODS

This systematic review of the literature was conducted in accordance with the PRISMA criteria. We searched for articles in the Medline^®, PubMed Central, Embase and Cochrane databases published between January 2005 and September 2015.

RESULTS

Sixty-four articles were included. They generally had a low level of evidence; indeed, the majority of them were retrospective observational studies. They involved biotherapy (44%), dynamic phototherapy (16%), antibiotics (11%), Laser (8%), retinoids (6%) and immunosuppressive therapies, anti-inflammatory drugs, zinc, metformin, gammaglobulins and fumarates.

CONCLUSIONS

None of the non-surgical treatments can treat all stages of the disease and offer long-term remission. Antibiotics and biotherapy seem to have real effectiveness but their effect remains suspensive and the disease is almost certain to reappear once they are stopped. As regards antibiotics, no association has shown their superiority in a study with a high level of evidence. And while some biotherapies seem quite effective, due to their side effects they should be reserved for moderate-to-severe, resistant or inoperable forms of the disease. Randomized controlled studies are needed before valid conclusions can be drawn. In the resistant or disabling forms, it is consequently advisable to orientate to the greatest possible extent towards radical surgery, which is the only treatment allowing hope for cure.

Autoinflammatory syndromes associated with hidradenitis suppurativa and/or acne

Autoinflammatory syndromes associated with hidradenitis suppurativa (HS) and/or acne are rare but potentially debilitating disorders if not diagnosed and treated correctly. They share a common pathogenesis involving a dysregulated innate immune system with abnormal interleukin (IL)-1 signaling leading to sterile neutrophilic inflammation. The clinical features are recurrent episodes of fever, painful arthritis, and skin lesions consistent with HS, acne, and pyoderma gangrenosum (PG) accompanied by elevated systemic inflammatory markers in blood. So far, several clinically different syndromes have been reported in the literature including pyoderma gangrenosum, acne, and pyogenic arthritis (PAPA), pyoderma gangrenosum, acne, and hidradenitis suppurativa (PASH), pyoderma gangrenosum, acne, and spondyloarthritis (PASS), pyoderma gangrenosum, acne, pyogenic arthritis, and hidradenitis suppurativa (PAPASH), psoriatic arthritis, pyoderma gangrenosum, acne, and hidradenitis suppurativa (PsAPASH), and pyoderma gangrenosum, acne, and ulcerative colitis (PAC). The rarity of the syndromes complicates the establishment of evidence-based treatment guidelines. Furthermore, treatment can be challenging due to lack of response to standard treatment modalities. Therefore, it is important to increase the awareness about these diseases in order to optimize disease management and ultimately improve the quality of life of patients.

Medical and Surgical Treatment of Hidradenitis Suppurativa: A Review

Hidradenitis suppurativa (HS) is a chronic inflammatory skin disease presenting with painful nodules, abscesses, sinus tracts, and scarring primarily affecting apocrine gland-rich intertriginous areas. HS prevalence ranges from 0.05 to 1%. The central pathogenic event in HS is believed to be the occlusion of the upper part of the folliculopilosebaceous unit, leading to the rupture of the sebofollicular canal with the consequent development of perifollicular lymphohistiocytic inflammation. The HS treatment choices are influenced by disease severity and its individual subjective impact, involving both medical and surgical interventions. However, given the chronic nature of HS, its destructive impact on social, working, and daily life of patients, its management is often frustrating for both the patient and physician. Hence, prompt and effective management strategies are urgently needed and a multidisciplinary approach is advocated. Therefore, in this article, we highlighted the main features of HS (clinical aspects, epidemiology, pathogenesis, diagnostic criteria, classifications, comorbidities, and treatments), so that awareness of this disease might be heightened in primary care physicians and surgeons, who may be the first health care providers to see patients with this disease owing to its characteristic clinical presentation (inflammatory nodules, abscesses, sinus tract, etc.).

A Case of Relapsing Polyarthritis Associated With Hidradenitis Suppurativa: Case Report and Review of Literature

Hidradenitis suppurativa (HS) is a chronic, inflammatory follicular skin disease with recurrent skin nodules, sinus tracts, and scarring. We observed a case of HS associated with relapsing polyarthritis. On presentation the patient had a flare of polyarthritis with an increase in the number and size of pustular nodules. He has had similar episodes 1 to 2 times yearly subsiding with antibiotic treatment. Radiographs revealed erosions and demineralization. Symptoms improved following institution of anti-inflammatory and antibiotic therapy. HS is associated with several inflammatory conditions, and dysregulation in innate immunity may play an important role in etiopathogenesis. Spondyloarthritis/sacroiliitis is the most common joint manifestation in HS and mechanism(s) underlying arthropathy is unknown. Treatment of arthritis in HS is anecdotal.

Interferon-gamma (IFN-γ) is Elevated in Wound Exudate from Hidradenitis Suppurativa

Hidradenitis suppurativa (HS) is a chronic recurrent inflammatory disease of apocrine glands which affects 1-4% of young adults. The purpose of this study was to investigate inflammatory cytokines in effluent from HS lesions and to identify potential local drivers of inflammation in HS. Wound fluid specimens from HS patients (n = 8) and age-matched chronic wound patients (n = 8) were selected for analysis. The hidradenitis suppurativa score (HSS) was used to determine the extent of HS activity. Cytokine analysis was conducted using Meso Scale Discovery cytokine and proinflammatory panels. Interferon-gamma (IFN-γ) was significantly elevated in the HS effluent compared to chronic wounds (1418 ± 1501 pg/ml compared to 102.5 ± 138 pg/ml, p = 0.027). HS effluent also had significantly higher levels of tumor necrosis factor-β (TNF-β) (9.24 ± 7.22 pg/ml compared to 1.65 ± 2.14 pg/ml, p = 0.03). There was no significant difference in any other cytokines. There was no significant difference in demographics in the HS compared to chronic wound cohorts. Mean HSS in the HS cohort was 68.88 (SD ± 41.45). In this proof-of-concept pilot study, IFN-γ was significantly elevated in HS effluent. TNF-β/LT-α levels were also elevated in HS, although the levels were more modest. Further studies should focus on molecular drivers of tissue injury in HS and the relationship between HS effluent cytokine profile and disease activity.

Treatments for hidradenitis suppurativa

Hidradenitis suppurativa (HS) is not easily treated. Although not uncommon, HS is often misdiagnosed outside specialized clinics and inappropriately treated as a simple boil or abscess. In recent years, guidelines have been developed on the basis of expert opinion and the available literature. A multifaceted approach is necessary as HS lesions include both inflammation (amenable to medical treatment) as well as fibrosis (amenable to surgery only). The recommended antiinflammatory therapies encompass both antimicrobials and regular anti-inflammatory drugs. We have, therefore, reviewed treatments with the following agents: clindamycin, tetracycline, rifampicin, ertapenem, dapsone, triamcinolone, infliximab, adalimumab, and anakinra. The development of new medical treatments, however, is an ongoing effort, and important new data have been presented since the publication of the guideline. The current approach to the management of fibrotic lesions is surgery. It is important, as manifest fibrosis is generally not susceptible to medical treatment. Here minor excision, carbon dioxide-laser, and major surgery are discussed, and current evidence supporting their use is provided. A comprehensive three-pronged approach with adjuvant therapy, medical therapy, and surgery is recommended. The importance of adjuvant therapy, that is, pain management, wound care, and attention, is stressed. Adjuvant therapy not only plays a major role in patients' perception of a successful treatment but also is of practical importance to their coping and self-management. HS presents a significant unmet need, and this review provides a mechanistic update on the current real-world therapeutic option for the management of this distressing disease.

Spotlight on adalimumab in the treatment of active moderate-to-severe hidradenitis suppurativa

Hidradenitis suppurativa (HS) is a chronic, recurrent, inflammatory skin disease that affects the hair follicles of the aprocrine gland-bearing anatomical areas of the body. It is characterized by deep painful nodules and abscesses that rupture and contribute to the formation of sinus tracks and scarring. The management of HS is based on the assessment of disease severity and a combination of medical and surgical treatment according to the European Guidelines. Adalimumab, a recombinant, fully humanized, anti-tumor necrosis factor alpha (anti-TNF-α) monoclonal antibody, is the only officially approved treatment for the management of moderate-to-severe HS. Case reports, concerning 42 patients who received adalimumab for severe HS (with the standard dose regimen for psoriasis), reported a cumulative response rate of 58% (≥50% in 23 patients) with a relapse rate of 71% (10 out of 14 patients). The most recent and most well-powered phase III, randomized placebo-controlled trials for the evaluation of the efficacy and safety of adalimumab in treatment of moderate-to-severe HS (PIONEER studies I and II) showed that the Hidradenitis Suppurativa Clinical Response (HiSCR) rate at week 12 was significantly higher for patients randomized to adalimumab compared to placebo. Adverse events were comparable to placebo. In conclusion, adalimumab, to date, holds the most robust data regarding treatment efficacy in HS. Larger, registry-based studies are needed to further establish the efficacy and safety profile of this anti-TNF-α agent in HS.

An Update on Medical Treatment Options for Hidradenitis Suppurativa

Hidradenitis suppurativa (HS) is a chronic inflammatory skin disease characterized by recurrent inflammatory nodules mostly located in the armpits and groin. Over the years multiple treatments for HS have been proposed; however, to date a cure is still lacking. In this update we provide an overview of most drug treatments reported on for HS, where possible with their mode of action and side effects. In mild cases, clindamycin lotion or resorcinol cream have proven effective. Tetracyclines are a first-line systemic option in more widespread or severe cases, followed by the combination of clindamycin and rifampicin. However, the recurrence rate is high after discontinuation of clindamycin plus rifampicin combination therapy. Long-term treatment with retinoids, especially acitretin is feasible, although teratogenicity has to be taken into account in females of reproductive age. Multiple anti-inflammatory drugs have been suggested for HS, such as dapsone, fumarates or cyclosporine. However, their effectiveness in HS is based on small case series with varying results. If most common treatments have failed, biologics (e.g., infliximab or adalimumab) are the next step. Although not addressed in this review, surgical interventions are often needed to achieve remission.

Intralesional triamcinolone for flares of hidradenitis suppurativa (HS): A case series

BACKGROUND

Hidradenitis suppurativa (HS) is a chronic inflammatory disease of the hair follicle. Standard practice of managing acute flares with corticosteroid injection lacks scientific evidence.

OBJECTIVE

We sought to assess the outcomes of routine treatment using intralesional triamcinolone (triamcinolone acetonide 10 mg/mL) in the management of acute flares in HS.

METHODS

This was a prospective case series evaluating the effect of intralesional corticosteroids for alleviation of acute flares in HS. Physician- and patient-reported outcomes were noted.

RESULTS

Significant reductions in physician-assessed erythema (median score from 2-1, P < .0001), edema (median score from 2-1, P < .0001), suppuration (median score from 2-1, P < .0001), and size (median score from 3-1, P < .0001) was demonstrated at follow-up. A significant difference in patient-reported pain visual analog scale scores occurred after 1 day (from 5.5-2.3, P < .005) and from day 1 to day 2 (from 2.3-1.4, P < .002).

LIMITATIONS

Small study size, open single-arm design, and short follow-up time are the limitations of this study.

CONCLUSION

Intralesional injection of corticosteroids is perceived as beneficial by physicians and patients in the management of HS flares by reducing pain after 1 day and signs of inflammation approximately 7 days later.

Inflammatory Mechanisms in Hidradenitis Suppurativa

Hidradenitis suppurativa (HS) is a chronic relapsing disease of follicular occlusion that causes immense clinical and psychosocial morbidity when refractory to treatment. HS is no longer considered a disease of primary infectious etiology, although bacteria play a role. There is increasing evidence that HS is associated with immune dysregulation, based on its clinical association with other immune-mediated disorders, by its response to biologic therapy in the clinical arena, and from molecular research. This article summarizes what is known in relation to the inflammatory pathways in HS.

Interventions for hidradenitis suppurativa: a Cochrane systematic review incorporating GRADE assessment of evidence quality

More than 50 interventions have been used to treat hidradenitis suppurativa (HS), and so therapy decisions can be challenging. Our objective was to summarize and appraise randomized controlled trial (RCT) evidence for HS interventions in adults. Searches were conducted in Medline, Embase, CENTRAL, LILACS, five trials registers and abstracts from eight dermatology conferences until 13 August 2015. Two review authors independently assessed study eligibility, extracted data and assessed methodological quality. Primary outcomes were quality of life and adverse effects of the interventions. Twelve trials, from 1983 to 2015, investigating 15 different interventions met our inclusion criteria. The median trial duration was 16 weeks and the median number of participants was 27. Adalimumab 40 mg weekly improved the Dermatology Life Quality Index (DLQI) by 4·0 points, which equates to the minimal clinically important difference for the scale, compared with placebo (95% confidence interval -6·5 to -1·5 points). Evidence quality was reduced to 'moderate' because the results are based on only a single study. Adalimumab 40 mg every other week was ineffective in a meta-analysis of two studies comprising 124 participants. Infliximab 5 mg kg(-1) improved the DLQI score by 8·4 points after 8 weeks in a moderate-quality study completed by 33 of 38 participants. Etanercept 50 mg twice weekly was ineffective. Inclusion of a gentamicin sponge prior to primary closure did not improve outcomes. Other interventions, including topical and oral antibiotics, were investigated by relatively small studies, preventing treatment recommendations due to imprecision. More, larger RCTs are required to investigate most HS interventions, particularly oral treatments and surgical therapy. Moderate-quality evidence suggests that adalimumab given weekly and infliximab are effective, whereas adalimumab every other week is ineffective.

Hidradenitis suppurativa (HS): An unrecognized paradoxical effect of biologic agents (BA) used in chronic inflammatory diseases

BACKGROUND

Paradoxical hidradenitis suppurativa (HS) induced by biologic agents (BA) is scarcely reported.

OBJECTIVE

We sought to describe the clinical characteristics and outcome of patients developing paradoxical HS under BA.

METHODS

This was a multicenter nationwide retrospective study asking physicians to report all cases of HS, confirmed by a dermatologist, occurring during treatment of an inflammatory disease by a BA.

RESULTS

We included 25 patients (15 inflammatory rheumatism, 9 Crohn's disease, 1 psoriasis) treated by 5 BA (adalimumab = 12, infliximab = 6, etanercept = 4, rituximab = 2, tocilizumab = 1). Median duration of BA exposure before HS onset was 12 (range 1-120) months. Patients were mostly Hurley stage I (n = 13) or II (n = 11). Simultaneously to HS or within 1 year, 11 patients developed additional inflammatory diseases, including paradoxical reactions (psoriasis = 9, Crohn's disease = 3, alopecia areata = 1, erythema elevatum diutinum = 1). Complete improvement of HS was more frequently obtained after BA discontinuation or switch (n = 6/10, 60%) rather than maintenance (n = 1/14, 7%). Reintroducing the same BA resulted in HS relapse in 3 of 3 patients.

LIMITATIONS

Retrospective nature and lack of complete follow-up for some patients are limitations.

CONCLUSION

HS is a rare paradoxical adverse effect of BA, but fortuitous association cannot be excluded in some cases. We observed a trend toward better outcome when the BA was discontinued or switched.

Pathophysiology of hidradenitis suppurativa: An update

The pathogenesis of hidradenitis suppurativa (HS) or acne inversa is not completely understood. Recent research has led to greater insight into the mechanisms involved in the disease. The primary defect in HS pathophysiology rests with the hair follicle. Follicular occlusion, followed by follicular rupture, and a foreign body-type immune response are necessary conditions for the development of clinical HS. A specific genetic signature and environmental factors, such as cigarette smoking, microbial colonization, and adiposity, all contribute to the HS phenotype. Translational research focused on the inflammatory mechanisms involved in HS is needed to develop novel therapeutic options for this debilitating disease.

Treatment of hidradenitis suppurativa with biologic medications

Given the absence of significant improvement in the treatment of hidradenitis suppurativa (HS) with traditional medical and surgical therapies, biologics have piqued the interest of research investigators. The efficacy of biologics in the treatment of inflammatory conditions like psoriasis and rheumatoid arthritis is well-documented. More recently, success with biologics has been demonstrated in atopic dermatitis, another dermatological condition associated with inflammatory states. Researchers have begun to probe the utility of biologic agents in less prevalent conditions that feature inflammation as a key characteristic, namely, hidradenitis suppurativa. Five agents in particular adalimumab, anakinra, etanercept, infliximab, and ustekinumab, have been explored in the setting of HS. Results to date put forward adalimumab and infliximab as biologic treatments that can safely be initiated with some expectant efficacy. Other biologic agents require more rigorous examination before they are worthy of addition to the treatment armamentarium.

Hidradenitis Suppurativa: A Guide for the Practicing Physician

Hidradenitis suppurativa is a chronic inflammatory disease of apocrine gland-bearing skin. Although immunologic derangements, genetic predisposition, obesity, and smoking are likely important factors, the pathogenesis of the disease and the effect of available treatments on disease course have not been fully elucidated. In the absence of proper treatment, chronic inflammation results in diffuse scarring and a wide array of complications, including the development of cutaneous squamous cell carcinoma. This severe and chronic disease can have detrimental effects on self-esteem and quality of life. No ideal treatment regimen has been defined, but several therapies have been found to reduce lesion severity and improve symptoms. We reviewed the literature through July 2014 for existing treatments. Published articles were obtained via systematic review of medical databases (PubMed, Embase, Google Scholar) and scrutiny of citation lists using the search terms "hidradenitis suppurativa" and "acne inversa". Given the scarce literature on treatment strategies, we also reviewed data from any case reports or prospective and retrospective studies that were located. On the basis of the existing literature, we provide an evidence-based algorithm for the management of this disease in the primary care setting. More research is needed to evaluate the comparative effectiveness of topical and systemic treatments and to better understand the pathogenesis, natural history, and subtypes of hidradenitis suppurativa.

Observational case series on adalimumab-induced paradoxical hidradenitis suppurativa

INTRODUCTION

Although the efficacy of TNF blockers has been demonstrated in hidradenitis suppurativa (HS), many paradoxical effects have also been described with TNF antagonists. We wished to describe patients with adalimumab (ADA)-induced paradoxical HS.

METHODS

This is a retrospective descriptive case series of four patients with ADA-induced paradoxical HS.

RESULTS

All the patients had a good response to TNFa antagonist therapy at the time of HS occurrence. The time from TNFa antagonist initiation to HS onset or exacerbation ranged from a few weeks to 24 months. The outcome of HS was variable. Systemic antibiotics were required in all the cases to control HS. TNF blockers were continued in three cases with a switch to another anti-TNF class in one case. Switch to ustekinumab was prescribed in one patient with SA and Crohn's disease.

CONCLUSION

Although the imputability of TNF blockers in paradoxical HS is still debatable, further research and observation are needed to confirm and distinguish patients with genetic and clinical predisposition in the onset or exacerbation of HS during anti-TNF treatment.

Interventions for hidradenitis suppurativa

BACKGROUND

Hidradenitis suppurativa (HS) is a chronic inflammatory skin condition characterised by recurrent painful boils in flexural sites, such as the axillae and groin, that affects about 1% of the population, with onset in early adulthood.

OBJECTIVES

To assess the effects of interventions for HS in people of all ages.

SEARCH METHODS

We searched the following databases up to 13 August 2015: the Cochrane Skin Group Specialised Register, CENTRAL in the Cochrane Library (Issue 7, 2015), MEDLINE (from 1946), EMBASE (from 1974), and LILACS (from 1982). We also searched five trials registers and handsearched the conference proceedings of eight dermatology meetings. We checked the reference lists of included and excluded studies for further references to relevant trials.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of all interventions for hidradenitis suppurativa.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed study eligibility and methodological quality and performed data extraction. Our primary outcomes were quality of life, measured by a validated dermatology-specific scale, and adverse effects of the interventions.

MAIN RESULTS

Twelve trials, with 615 participants, met our inclusion criteria. The median number of participants in each trial was 27, and median trial duration was 16 weeks. The included studies were conducted over a 32-year time period, from 1983 to 2015. A single RCT that was underpowered to detect clinically meaningful differences investigated most interventions.There were four trials of anti-TNF-α (tumour necrosis factor-alpha) therapies, which included etanercept, infliximab, and adalimumab. Adalimumab 40 mg weekly improved the Dermatology Life Quality Index (DLQI) score in participants with moderate to severe HS by 4.0 points relative to placebo (95% confidence interval (CI) -6.5 to -1.5 points), an effect size approximately equal to the DLQI minimal clinically important difference. We reduced the evidence quality to 'moderate' because the effect size was based on the results of only one study. In a meta-analysis of two studies with 124 participants, standard dose adalimumab 40 mg every other week was ineffective compared with placebo (moderate quality evidence). In a smaller study of 38 participants, of whom only 33 provided efficacy data, infliximab 5 mg/kg treatment improved DLQI by 8.4 DLQI points after eight weeks. Etanercept 50 mg twice weekly was well tolerated but ineffective.In a RCT of 200 participants, no difference was found in surgical complications (week one: risk ratio (RR) 0.78, 95% CI 0.58 to 1.05, moderate quality evidence) or risk of recurrence (after three months: RR 0.96, 95% CI 0.68 to 1.34, moderate quality evidence) in those randomised to receive a gentamicin-collagen sponge prior to primary closure compared with primary closure alone.RCTs of other interventions, including topical clindamycin 1% solution; oral tetracycline; oral ethinylestradiol 50 mcg with either cyproterone acetate 50 mg or norgestrel 500 mcg; intense pulsed light; neodymium-doped yttrium aluminium garnet (Nd:YAG) laser; methylene blue gel photodynamic therapy; and staphage lysate, were relatively small studies, preventing firm conclusions due to imprecision.

AUTHORS' CONCLUSIONS

Many knowledge gaps exist in RCT evidence for HS. Moderate quality evidence exists for adalimumab, which improves DLQI score when 40 mg is given weekly, twice the standard psoriasis dose. However, the 95% confidence interval includes an effect size of only 1.5 DLQI points, which may not be clinically relevant, and the safety profile of weekly dosing has not been fully established. Infliximab also improves quality of life, based on moderate quality evidence.More RCTs are needed in most areas of HS care, particularly oral treatments and the type and timing of surgical procedures. Outcomes should be validated, ideally, including a minimal clinically important difference for HS.

Cyclosporine treatment of severe Hidradenitis suppurativa--A case series

BACKGROUND

Hidradenitis suppurativa (HS) is an overlooked but common disease severely affecting both genders. HS is generally perceived as difficult to treat and although a number of treatments are available, the need for more effective treatment is apparent.

OBJECTIVES

Cyclosporine A (CsA) has been suggested as an effective treatment in four smaller case series. It was therefore decided to review a larger series of cases, reporting all outcomes in order to provide a less biased base for evaluating the potential of CsA for use in HS.

METHODS

An exploratory retrospective review of case notes was performed at three departments of dermatology with a special interest in HS, where HS had been treated with CsA in the period 2009-2012.

RESULTS

In total, 18 HS patients treated with CsA were identified and analysed and 50% reported some benefit. All patients had previously been treated with multiple various other modalities.

LIMITATIONS

This is an exploratory retrospective review with a limited number of patients.

CONCLUSIONS

This retrospective review found some effect of CsA in the recalcitrant cases studied, mainly reported as "slight improvement". This may be due to a number of factors which may have overestimated (e.g., concommitant therapy) or underestimated (e.g., case selection of recalcitrant cases) the effect, and indicates the need for prospective evaluation of the claims. The present data provide a basis for power calculations in future studies investigating the potential for treating HS with CsA in a randomised controlled trial.

Acne inversa: difficulties in diagnostics and therapy

Acne inversa (hidradenitis suppurativa) is a potentially severe and chronic inflammatory disease with a significant negative influence on the quality of life. Usually, lesions are located in the areas of skin folds and it is characterized by the presence of painful nodules and fistulas with a tendency to tissue fibrosis. Currently, it is suggested that follicular occlusion by infundibular hyperkeratosis plays a crucial role in pathogenesis and an occupation of apocrine sweat glands is a secondary phenomenon. Most often, it refers to men after puberty. This article tries to present the latest theory concerning the etiology of inverted acne and methods of its treatment. It also describes the most common errors in diagnostic and therapeutic procedures, which are mainly connected with repeated and long antibiotic therapy and not radical surgical treatment.

Coagulation Status in Hidradenitis Suppurativa: A Danish Population- and Hospital-Based Cross-Sectional Study

BACKGROUND

Chronic inflammatory diseases other than hidradenitis suppurativa (HS) have been associated with prothrombotic/hypercoagulable status.

OBJECTIVE

To investigate a possible association between the chronic inflammatory skin disease HS and prothrombotic/hypercoagulable state.

METHODS

We performed a hospital- and population-based cross-sectional study investigating the coagulation status (thrombocytes, mean platelet volume [MPV], international normalized ratio [INR] and activated partial thromboplastin time [APTT]).

RESULTS

32 hospital HS subjects, 430 population HS subjects and 20,780 population non-HS control subjects were identified. The adjusted analyses showed no differences in the levels of thrombocytes, MPV, INR or APTT between the HS groups (hospital HS group, population HS group) when compared to controls (p = 0.089, p = 0.3078; p = 0.5499, p = 0.0659; p = 0.0932; p = 0.3432).

CONCLUSION

We did not find an association between HS and prothrombotic/hypercoagulable status. Thus, thrombocytes may not be activated in HS. Furthermore, INR may not be affected in HS, suggesting that intrinsic and vitamin K-dependent coagulation factors appear unaffected.

Hidradenitis Suppurativa Management in the United States: An Analysis of the National Ambulatory Medical Care Survey and MarketScan Medicaid Databases

PURPOSE

To present nationally representative data demonstrating how frequently hidradenitis suppurativa (HS) occurs in specific groups and how it is currently managed.

METHODS

We analyzed data from the 1990-2009 National Ambulatory Medical Care Survey (NAMCS) and the 2003-2007 MarketScan Medicaid databases for patients with a diagnosis of HS (ICD-9-CM code 705.83). Visits per 100,000 population of each race and ethnicity were calculated using the 2000 US Census data for specific demographics.

RESULTS

There were 164,000 patient visits (95% CI: 128,000-200,000) annually with a diagnosis of HS in the NAMCS, and 17,270 HS patients were found in the MarketScan Medicaid over the 5-year period. Antibiotics were the most common treatment, followed by pain medications, topical steroids, and isotretinoin. Prescriptions of biologics and systemic methotrexate, cyclosporine, and acitretin were not observed in the NAMCS. Physicians prescribed medications in 74% of visits and used procedures in 11% of visits. African Americans, females, and young adults had higher numbers of visits for HS.

CONCLUSIONS

Our data showing a maximum of 0.06% of the population being treated for HS in a given year are consistent with the low estimates of HS prevalence. Compared to the current prescribing patterns, the more frequent prescription of biologics and systemic treatments may yield better outcomes.

A case series of 20 women with hidradenitis suppurativa treated with spironolactone

Hidradenitis suppurativa (HS) is an uncommon chronic skin condition that can range in severity from a single nodule to extensive disease and can have a profound effect on quality of life. Anti-androgen medication has been suggested as a possible management strategy in female patients with HS and is mentioned in review articles as a treatment option. Despite this, there is limited literature documenting the use of anti-androgens in HS. We present our experience with 20 patients with HS treated with oral spironolactone. We advocate spironolactone as a useful, low-cost first-line treatment for women with HS, with relatively few side-effects.

Recurrence rate and patient satisfaction of CO2 laser evaporation of lesions in patients with hidradenitis suppurativa: a retrospective study

BACKGROUND

Hidradenitis suppurativa (HS) is a debilitating disease and is difficult to treat. Validation of surgical techniques is therefore of great importance in the management of HS. Carbon dioxide (CO2) laser evaporation has been shown effective, but larger-scale studies are scarce.

OBJECTIVE

To determine the recurrence rate, time to recurrence, and factors influencing disease recurrence in skin treated with CO2 laser evaporation, and healing by secondary intention; and patients' satisfaction with treatment.

METHODS

Fifty-eight patients treated with CO2 laser evaporation were interviewed regarding recurrence and satisfaction after a mean of 25.7 months.

RESULTS

Seventeen of 58 (29%) reported recurrence of HS lesions within the borders of the treated areas after a mean of 12.7 months. Obesity was a risk factor for recurrence with a hazard ratio of 4.53. Fifty-five patients (95%) reported some or great improvement, and 91% would recommend the CO2 laser surgery to other HS patients.

CONCLUSION

This study supports the claim that CO2 laser treatment is an effective modality for recurrent HS lesions in a majority of patients. The authors identified obesity as a risk factor for recurrence. Self-reported satisfaction is high, and only 3 of 58 report no change in the condition. None reported a worsening.