Endocrinologic Aspects of Hidradenitis Suppurativa

Treatment Strategies in Neutrophilic Dermatoses: A Comprehensive Review

Neutrophilic dermatoses (NDs) are a group of noninfectious disorders characterized by the presence of a sterile neutrophilic infiltrate without vasculitis histopathology. Their physiopathology is not fully understood. The association between neutrophilic dermatoses and autoinflammatory diseases has led some authors to propose that both are part of the same spectrum of diseases. The classification of NDs depends on clinical and histopathological features. This review focuses on the recent developments of treatments in these pathologies.

Hidradenitis Suppurativa: An Interdisciplinary Problem in Dermatology, Gynecology, and Surgery-Pathogenesis, Comorbidities, and Current Treatments

Hidradenitis suppurativa (HS), also known as acne inversa, is a chronic inflammatory disease that manifests as painful nodules, abscesses, draining dermal tunnels, and scarring in intertriginous areas such as the axillae, groin, and breasts. The nature of the disease and its chronicity have a destructive impact on mental health and quality of life. HS has an estimated global prevalence of 0.00033-4.1% and it disproportionately affects females compared to males. HS involving the female anogenital regions is reported rarely in the gynecological literature, and it can often be mistaken for other vulvar diseases. The distinct phenotypes and HS rarity cause delayed diagnosis and the implementation of effective treatment. Acne inversa is associated with several comorbidities, including metabolic disease, diabetes mellitus, inflammatory bowel diseases, and spondyloarthropathies. Although HS etiology and pathogenesis remain unclear, studies have shown that lifestyle, immunological processes, genetics, and hormonal predispositions may promote follicular hyperkeratosis, dilatation, and rupture, leading to the development of chronic tissue inflammation. This article provides updated information on HS pathogenesis, comorbidities, and treatment methods. Furthermore, we share our experience in the surgical treatment of the disease, which often proves most effective, and highlight that an interdisciplinary management approach ensures optimal outcomes.

How to Define Mild to Severe Hidradenitis Suppurativa? A Simple New Tool Based on Latent Class Analysis of EPIVER Data Study

Purpose

Hidradenitis suppurativa (HS) is an inflammatory skin disease characterized by recurrent or chronic painful and suppurating lesions in the apocrine gland-bearing regions. The lack of knowledge about HS and its extremely heterogeneous clinical presentation, in terms of both lesion appearance and sites of involvement, frequently delay its diagnosis for several years. Objectives: in this study, using the latent class analysis, it was demonstrated that severity of HS could be evaluated not only with clinical or surgical characteristics but also with gender specificities.

Patients and Methods

Clinical and sociodemographic data of HS patients were retrospectively analysed with the latent class method in order to create a classification tool of disease severity.

Results

From the study of 1428 HS patients (544 men and 884 women), two classification models, depending on gender, were developed. Each classification model was composed of three distinct latent classes clearly identified and defined from mild-to-severe cases of HS. These classification models of HS severity were not distorted by patient ages and were coherent with Hurley stages but were more clinically precise.

Conclusion

In this study, a convenient classification tool, useful for facilitating decision support in routine practice, has been developed. This tool could be used to define clinical subgroups within a study population.

Antiandrogen therapy in hidradenitis suppurativa: finasteride for females

BACKGROUND

Given its widely accepted efficacy, androgen blockade therapy for hidradenitis suppurativa (HS) has become a standard of care. Although much less frequently used than spironolactone, a small number of HS studies have reported finasteride as an alternative treatment for women. In this study, we describe the response to and perception of finasteride therapy in a diverse cohort of women with HS.

AIM

To describe finasteride therapy in a diverse cohort of female patients with HS.

METHODS

We conducted an institutional review board-approved retrospective chart review and telephone survey of 20 female patients aged ≥ 18 years with a diagnosis of HS. Finasteride was prescribed by a single provider at a specialized HS centre.

RESULTS

The mean age of the patients was 34.3 ± 13.5 years. Finasteride was initiated predominantly because of one or more contraindications or poor responsiveness to spironolactone. Most patients interviewed (90%; n = 18) were willing to take finasteride again or continue with therapy if indicated. Of the 20 patients, 10 (50%) reported overall satisfaction with finasteride, while 7 (35%) were neutral and 3 (15%) were dissatisfied. No patient reported worsening disease activity while on finasteride and only one (5%) reported decreased quality of life. When asked about adverse effects of finasteride, 80% (n = 16) reported none, while 20% (n = 4) experienced ≥ 1 of the following: headache, nausea, menstrual irregularities, breast tenderness or reduced libido/sexual function.

CONCLUSIONS

Our study suggests that androgen blockade therapy with finasteride is a safe and effective alternative for female patients with HS who have contraindication(s) or intolerance to spironolactone.

[Pathogenesis of hidradenitis suppurativa/acne inversa]

Hidradenitis suppurativa/acne inversa (HS) has a multifactorial pathogenesis. In addition to a sporadic form, a familial form is reported in around 40% of patients, for whom an autosomal dominant (AD) inheritance with reduced gene penetrance is assumed. The phenotype of the disease with inflammatory nodules, abscesses and secreting sinus tracts suggests an infectious origin, but the exact role of the bacteria detected in HS pathogenesis remains unclear. Smoking and metabolic syndrome are regarded as important trigger factors in HS, with obesity and hormonal changes playing a pathogenic role in the latter. Ultimately, Toll-like receptors, antimicrobial peptides, immune cells and key cytokines are involved in the excessive inflammatory reaction of HS and are also the targets of future therapies.

[Epidemiology, patient quality of life, and treatment costs of hidradenitis suppurativa/acne inversa]

Hidradenitis suppurativa/acne inversa (HS) is associated with numerous and relevant restrictions on the quality of life for those affected and their relatives. The exact prevalence of HS varies significantly across studies, but it is likely to be higher than suggested in previous publications. HS care is associated with high costs for the healthcare system and for those affected. The introduction of biologic therapy has led to additional costs, but also to considerable additional benefits in terms of care. In view of the complexity of diagnostics and therapy, there is a particular need for optimized care concepts in order to reduce the burden on those affected, their relatives and the healthcare system.

Anti-COVID-19 measurements for hidradenitis suppurativa patients

The reported incidence of COVID‐19 among cohorts of patients with inflammatory bowel and skin diseases under treatment with biologicals is low. Treatment may further modify disease severity as some biological modifiers, such as anakinra, are also proposed for the management of COVID‐19 patients potentially providing HS patients with an advantage.

The above preliminary evidence suggests that hidradenitis suppurativa (HS) does probably not provide an increased susceptibility for COVID‐19 and that any susceptibility is unlikely to be modified negatively by treatment with biologicals.

On the occasion of its 10th International Conference, experts of the European Hidradenitis Suppurativa Foundation e.V. have prepared a consensus statement regarding anti‐COVID‐19 measurements for HS patients. Based on the available knowledge, patients with HS may be vaccinated against SARS‐CoV2 and patients affected by metabolic syndrome constitute a high‐risk group for COVID‐19 and should be vaccinated at the earliest convenient point in time. HS patients on treatment with adalimumab can be vaccinated with non‐living virus anti‐SARS‐CoV2 vaccines. A possible suboptimal effect of the vaccine may be suspected but might not be expected universally. The management of the biological treatment in HS patients is at the discretion of the dermatologist / responsible physician.

Potential predictive biomarkers of adalimumab response in patients with hidradenitis suppurativa

BACKGROUND

Adalimumab provides significant efficacy for patients with hidradenitis suppurativa (HS), which was demonstrated by at least 50% of patients achieving a clinical response by week 12 that was maintained through to week 168 in the PIONEER trials.

OBJECTIVES

To identify whether there are biomarkers that could predict adalimumab response, as well as markers that differentially respond to adalimumab in patients with HS.

METHODS

Baseline and week-12 plasma samples from the PIONEER studies were used to assess the levels of circulating proteins by multiplex and enzyme-linked immunosorbent assays.

RESULTS

Analyses revealed significantly higher high-sensitivity C-reactive protein (hs-CRP) and chemokine (C-C motif) ligand (CCL) 16 (HCC-4) levels in nonresponders at baseline and identified a multivariate response signature of calprotectin, fractalkine and HCC-4, reaching an 86% predictive accuracy rate for adalimumab response. Additionally, post-treatment reduction of plasma C-X-C motif chemokine ligand (CXCL)9, CXCL8 (interleukin-8) and CCL19 (macrophage inflammatory protein 3β) were greater in adalimumab super-responders than in nonresponders (P = 0·026, P = 0·044 and P = 0·026, respectively). These cytokines are involved in the recruitment of innate and adaptive inflammatory cells, and/or stimulation of certain inflammatory responses, suggesting that these pathways could be disease drivers in adalimumab nonresponders.

CONCLUSIONS

These initial results suggest HCC-4, calprotectin and fractalkine could be potential predictive biomarkers of adalimumab response in HS and identified possible tumour necrosis factor-independent disease pathways.

Skin and metabolic syndrome: A review of the possible associations

Metabolic syndrome (MeTS) is a well-known health-related problem with several end-organ damages and the resulted side effects such as rising in the blood glucose and lipid and blood pressure. Although MeTS might show several skin symptoms such as acanthosis nigricans, skin tags, acne, and androgenic alopecia, it could also be implicated in the pathophysiology of numerous dermatologic disorders. Furthermore, some dermatologic drugs might be implicated in the incidence or exacerbation of MeTS. Consequently, MeTS and skin problem could interfere closely with each other and each one could predispose the patient to the other one and vice versa. Remembering these close relationships help us to have better therapeutic choices regarding each inflammatory skin conditions. Moreover, some of the skin symptoms should be followed cautiously to define the underlying MeTS.

[Psychiatric comorbidities in hidradenitis suppurativa/acne inversa]

BACKGROUND

The findings of most studies suggest that depression and anxiety disorders are the most common psychiatric comorbidities in patients with hidradenitis suppurativa/acne inversa (HS/AI).

METHODS

In a prospective study, 51 patients with HS/AI were further examined for psychiatric comorbidity using a standardized interview and questionnaires.

RESULTS

In psychiatric examination, 29.4% of HS/AI patients had additional mental symptoms, mainly manifested as depressive disorder. The HS/AI patients were rather young and female, and they showed a high incidence of nicotine and alcohol use, and a positive family history of paternal alcohol dependence. In addition, HS/AI patients experienced more severe psychosocial impairments in the form of lack of partnership and lower school attainment.

CONCLUSIONS

Acne inversa is a severe chronic inflammatory skin disease that, like other inflammatory dermatoses, is associated with mental comorbidity and psychosocial impairments. Since especially young patients are affected, a psychiatric-psychotherapeutic cotreatment should be considered already at an early stage.

Acne keloidalis nuchae and thyroid diseases: a population-based cohort study

BACKGROUND

The association between acne keloidalis nuchae (AKN) and thyroid diseases is yet to be investigated.

OBJECTIVE

To evaluate the risk of developing hypothyroidism and hyperthyroidism among patients with AKN and to characterize the patients who have AKN and thyroid comorbidities.

METHODS

A population-based cohort study was conducted comparing AKN patients (n = 2,677) with age-, gender-, and ethnicity-matched control subjects (n = 13,190) with regard to incident cases of hypothyroidism and hyperthyroidism. Adjusted hazard ratios (HRs) were estimated by Cox regression analysis.

RESULTS

The incidence rates of hypothyroidism among patients with AKN and controls were estimated at 2.15 (95% CI, 1.49-2.99) and 0.82 (95% CI, 0.66-1.00) cases/1000 person-years, respectively. The crude risk of developing incident hypothyroidism was 1.85-fold greater in patients with AKN (HR, 1.85; 95% CI, 1.24-2.78; P = 0.003). The elevated risk persisted following the adjustment for putative confounders (adjusted HR, 1.72; 95% CI, 1.03-2.89; P = 0.040). The risk of hyperthyroidism was comparable in patients with AKN and controls both in the crude (HR, 1.55; 95% CI, 0.57-4.22) and adjusted (adjusted HR, 1.92; 95% CI, 0.59-6.21) analyses. Patients with coexistent AKN and thyroid diseases were significantly older at the onset of AKN, had more prominent female preponderance, and had a higher burden of comorbidity.

CONCLUSIONS

Patients with AKN are at an increased risk of hypothyroidism. Screening for hypothyroidism should be considered in AKN patients with a compatible clinical picture.

Emerging medical treatments for hidradenitis suppurativa

Hidradenitis suppurativa (HS) is a chronic inflammatory disease affecting intertriginous skin areas, and it is characterized by recurrent painful episodes of inflammatory drainage. Although the pathophysiology of HS is not fully understood, recent research points to an imbalance of cytokines as a contributing factor to the associated symptoms of purulent drainage and sinus tract formation. HS lesions are often characterized by a superimposed pathogenic/commensal bacterial infection that can improve with targeted antibiotic therapy. New medical treatments have emerged in recent years, many of which specifically work against a variety of proinflammatory mediators associated with HS. These newer, specified treatment options, in conjunction with surgery and lasers, are thought to provide positive outcomes and an overall improvement in quality of life in patients with HS.

Is There a Role for Antiandrogen Therapy for Hidradenitis Suppurativa? A Systematic Review of Published Data

BACKGROUND

Hidradenitis suppurativa/acne inversa is a disease with deep-seated chronic painful nodules, abscesses, and draining sinus tracts, which manifests on the apocrine gland-rich skin areas of the body. Observational findings demonstrate that the disease usually appears after puberty, exhibits pre-menstrual flares in women, improves in pregnancy, and worsens post-partum, which indicates a role of hormones and particularly of androgens in its pathophysiology. Because increased androgen levels in serum have not been widely reported, an end-organ androgen hypersensitivity has been postulated.

OBJECTIVE

The aim of this systematic review was to identify and present evidence for antiandrogen therapeutic options for the treatment of hidradenitis suppurativa/acne inversa.

METHODS

A literature search was conducted in different medical electronic databases using the keywords "hidradenitis", "suppurativa", "acne inversa", and "antiandrogen" on 1 December, 2018. The main therapeutic options were subsequently used as separate keywords with the disease terms in a separate search.

RESULTS

The main therapeutic options yielded were cyproterone acetate, spironolactone, finasteride, and metformin. One randomized controlled crossover trial and seven case series were identified following use of a standard extraction form for eligibility.

CONCLUSION

The existing studies do not allow a robust evidence-based recommendation for the use of antiandrogens in the treatment of hidradenitis suppurativa/acne inversa. Further randomized controlled trials are needed to define the role of hormonal treatment as an alternative or concomitant therapy together with antibiotics or biologics.

Topical, systemic and biologic therapies in hidradenitis suppurativa: pathogenic insights by examining therapeutic mechanisms

Hidradenitis suppurativa (HS) is a chronic inflammatory disease of the skin, manifesting in chronic, recurrent painful pustules, nodules, boils and purulent draining abscesses. Our current understanding of the pathogenesis of the disease is incomplete. This review aims to identify available treatment options in HS and discuss the pharmacological mechanisms through which such agents function. Identifying common pathways may inform our understanding of the pathogenesis of HS as well as identify future therapeutic targets. The pharmacological mechanisms implicated in topical therapies, antibiotic, hormonal, systemic immunomodulatory and biologic therapies for HS are discussed. Significant differences exist between agents and implicated pathways in therapy for mild and severe disease. This is an expression of the possible dichotomy in inflammatory pathways (and treatment responses) in HS. Studies involving monoclonal antibodies provide the greatest insight into what these specific mechanisms may be. Their variable levels of clinical efficacy compared with placebo bolsters the suggestion that differential inflammatory pathways may be involved in different presentations and severity of disease. Nuclear factor kappa B (NF-κB), tumor necrosis factor (TNF)-α and other innate immune mechanisms are strongly represented in treatments which are effective in mild to moderate disease in the absence of scarring or draining fistulae, however complex feed-forward mechanisms in severe disease respond to interleukin (IL)-1 inhibition but are less likely to respond to innate immune inhibition (through NF-κB or TNF-α) alone. It is unclear whether IL-17 inhibition will parallel TNF-α or IL-1 inhibition in effect, however it is plausible that small molecule targets (Janus kinase1 and phosphodiesterase 4) may provide effective new strategies for treatment of HS.

Hidradenitis suppurativa and diabetes mellitus: updated systematic review and adjusted meta-analysis

BACKGROUND

Hidradenitis suppurativa (HS) is a debilitating and distressing chronic inflammatory skin disease. There is also evolving evidence supporting the association between HS and cardiovascular risk factors, including smoking, obesity, hyperlipidaemia and metabolic syndrome. Notably, these are clinical features and risk factors that are closely associated with type 2 diabetes mellitus (DM).

AIMS

We performed a pooled adjusted meta-analysis of comparative studies to investigate the relationship between HS and DM.

METHODS

A systematic review and meta-analysis was performed according to recommended Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. OR was used as the summary effect size.

RESULTS

From pooled analysis of unadjusted data from 12 studies, we found a significantly higher proportion of DM in HS cases compared with non-HS healthy controls (16.1% vs. 15.7%; OR = 2.17; 95% CI 1.85-2.55; P < 0.001). Adjusted effect sizes from five studies were also pooled. A significantly higher proportion of DM was found for HS compared with healthy controls, although the effect size was attenuated compared with unadjusted analyses (OR 1.69; 95% CI 1.50-1.91; P < 0.001).

CONCLUSIONS

To our knowledge, our systematic review and meta-analysis is the first to pool adjusted effect sizes. We found that HS was associated with a 1.69-fold increased odds of diabetes; however, the absolute risk difference was small (16.1% vs. 15.7%) and is probably not clinically relevant. Treating clinicians should be aware of this association, but there may not be an urgent need to perform screening for impaired glucose tolerance or diabetes.

Dissecting folliculitis (dissecting cellulitis) of the scalp: a 66-patient case series and proposal of classification

BACKGROUND AND OBJECTIVES

Dissecting folliculitis (DF) or dissecting cellulitis of the scalp is regarded as a rare disease with disfiguring scarring alopecia. This study aimed to analyze the features of DF and to propose a classification to define its severity.

PATIENTS AND METHODS

A hospital-based retrospective study was conducted. Patients with a histopathological diagnosis or clinical features leading to diagnosis of DF were included and classified into three stages.

RESULTS

Among the 66 patients recruited (63 men / 3 women, mean age 24.9 years), multiple interconnected alopecic nodules involving the vertex scalp were the main feature. Histopathology showed an extensive inflamed granulation abscess forming a dissection plane in the lower dermis/subcutis in the acute stage. Lymphocytic infiltration was predominant in seven of 21 histology specimens. Overweight and obesity were noted in 29 of 45 patients examined. No association with smoking was found. There was comorbidity with acne conglobata in 15 of 66 patients, two of whom had acne inversa. Longer disease duration and greater number of nodules were associated with higher severity of DF (p < 0.05). A complete remission rate of 25 % was achieved by any treatment, and a rate of 37.5 % was achieved with oral isotretinoin alone.

CONCLUSIONS

DF is not uncommon in Taiwan. An association with obesity needs to be clarified.

Antiandrogen therapy with spironolactone for the treatment of hidradenitis suppurativa

BACKGROUND

Hormonal therapy is a potential treatment for hidradenitis suppurativa (HS). However, few data exist describing the efficacy of spironolactone in treatment of HS.

OBJECTIVE

To assess whether spironolactone treatment improves HS disease severity and patient-reported pain.

METHODS

We performed a single-center chart review of female patients with HS who were treated with spironolactone between 2000 and 2017. Primary outcome measurements included the HS Physician's Global Assessment (HS-PGA), Hurley staging, inflammatory lesion count, fistula count, and a numeric rating scale for pain.

RESULTS

On average, subjects were exposed to 75 mg of spironolactone daily over a 7.1-month follow-up period. Patients achieved significant disease improvement with regard to pain (Δ-1.5 [P = .01]), inflammatory lesions (Δ-1.3 [P = .02]), and HS-PGA score (Δ-0.6 [P < .001]). As expected, no change was found for Hurley stage (Δ0 [P = .32]) or fistulas (Δ0 [P = .73]). There was no difference in improvement between subjects who received less than 75 mg of spironolactone daily (n = 25; average dose, 45 mg/d) and those who received more than 100 mg daily (n = 21; average dose, 112 mg/d).

LIMITATIONS

Retrospective nature, limited sample size, and variations in severity measures documented were limiting factors.

CONCLUSIONS

Management of HS with spironolactone reduces lesion count, HS-PGA score, and pain. Lower doses appear to be effective and may be an appropriate option for patients with tolerability concerns.

Metabolic syndrome and the skin: a more than superficial association. Reviewing the association between skin diseases and metabolic syndrome and a clinical decision algorithm for high risk patients

There is ongoing scientific interest regarding comorbidities associated with the metabolic syndrome (MeTS). MeTS comprises a combination of parameters that predispose individuals to the development of type 2 diabetes and cardiovascular disease (CVD). Three or more of the following criteria are necessary: fasting glucose > 110 mg/dl (5.6 mmol/l), hypertriglyceridemia > 150 mg/dl (1.7 mmol/l), HDL levels < 40 mg/dl (men)/< 50 mg/dl (women), blood pressure > 130/85 mmHg, waist circumference (values for Mediterranean populations > 94 cm (men)/> 89 cm (women). In this review we attempted to summarize relevant data by searching dermatological literature regarding associations between various skin conditions and MeTS. A multitude of studies was retrieved and a further goal of the present article is to present plausible mechanistic connections. The severity of skin conditions like psoriasis has been linked with MeTS. Parameters of MeTS like insulin resistance are present in patients with early onset androgenic alopecia, hidradenitis suppurativa acne and rosacea. Since MeTS can lead to CVD and type 2 diabetes early detection of patients would be very important. Also therapeutic intervention on MeTS could lead to improvement on the severity of skin conditions. This reciprocal relationship between skin diseases and MeTS in our opinion holds great interest for further investigation.

The critical role of macrophages in the pathogenesis of hidradenitis suppurativa

INTRODUCTION

Hidradenitis suppurativa (HS) is a painful chronic inflammatory disease with a prevalence between 1 and 4% of general population. The pathogenesis of HS long eluded scientists, but growing evidence suggests that it is a consequence of inflammatory dysregulation.

FINDINGS

Recent studies suggest that dysregulated immune response to skin flora and overexpression of inflammatory cytokines leads to chronic skin inflammation seen in HS. Macrophages are the most numerous inflammatory cells found in HS infiltrates and release numerous pro-inflammatory cytokines such as IL-23, and IL-1β and TNF-α, exacerbating the inflammation and contributing to the pathogenesis of HS. Furthermore, in HS, there is dysregulated function of other immune players closely associated with macrophage function including: matrix metalloproteases (MMP) 2 and 9 overexpression, toll-like receptor upregulation, impaired Notch signalling, NLRP3 inflammasome upregulation, and dysregulated keratinocyte function. Lifestyle factors including obesity and smoking also contribute to macrophage dysfunction and correlate with HS incidence.

CONCLUSIONS

The overexpression of pro-inflammatory cytokines and subsequent efficacy of anti-cytokine biologic therapies highlights the importance of managing macrophage dysfunction. Future therapies should target key molecular drivers of macrophage dysfunction such as TLR2 and NLRP3 overexpression.

Diabetes mellitus and the skin

Diabetes is a debilitating, life-threatening disease accounting in 2015 for the death of 5 million people worldwide. According to new estimations, 415 million adults currently suffer from the disease, and this number is expected to rise to 642 million by 2040. High glucose blood levels also affect the skin among systemic organs, and skin disorders can often predict the onset of this metabolic disorder. In this review, we address the pathomechanistic effects of diabetes on the skin and give an overview on the most common skin diseases associated with diabetes.