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Krueger JG, Frew J, Jemec GBE, Kimball AB, Kirby B, Bechara FG, Navrazhina K, Prens E, Reich K, Cullen E, Wolk K. Hidradenitis suppurativa: new insights into disease mechanisms and an evolving treatment landscape. Br J Dermatol 2024; 190:149-162. [PMID: 37715694 DOI: 10.1093/bjd/ljad345] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 09/08/2023] [Accepted: 09/11/2023] [Indexed: 09/18/2023]
Abstract
Hidradenitis suppurativa (HS), also known as acne inversa, is a chronic disabling and debilitating inflammatory disease with a high unmet medical need. The prevalence of HS reported in most studies is 1-2%, although it is likely to be under-reported and estimates vary globally owing to variance in data collection methods, ethnicity, geographical location and under-diagnosis. HS is characterized by persistent, painful cutaneous nodules, abscesses and draining tunnels commonly affecting the axillary, anogenital, inguinal and perianal/gluteal areas. Over time, chronic uncontrolled inflammation results in irreversible tissue destruction and scarring. Although the pathophysiology of HS has not been fully elucidated, the tumour necrosis factor (TNF)-α and interleukin (IL)-17 pathways have an important role, involving multiple cytokines. Currently, treatment options include topical medications; systemic therapies, including repeated and/or rotational courses of systemic antibiotics, retinoids and hormonal therapies; and various surgical procedures. The anti-TNF-α antibody adalimumab is currently the only biologic approved by both the US Food and Drug Administration and the European Medicines Agency for HS; however, its efficacy varies, with a clinical response reported in approximately 50% of patients in phase III trials. HS is a rapidly evolving field of discovery, with a diverse range of agents with distinct mechanisms of action currently being explored in clinical trials. Several other promising therapeutic targets have recently emerged, and agents targeting the IL-17 and Janus kinase (JAK)/signal transducer and activator of transcription (STAT) pathways are the most advanced in ongoing or completed phase III clinical trials. Alongside limited therapeutic options, significant challenges remain in terms of diagnosis and disease management, with a need for better treatment outcomes. Other unmet needs include significant diagnostic delays, thus missing the therapeutic 'window of opportunity'; the lack of standardized outcome measures in clinical trials; and the lack of established, well-defined disease phenotypes and biomarkers.
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Affiliation(s)
- James G Krueger
- Laboratory of Investigative Dermatology, The Rockefeller University, New York, NY, USA
| | - John Frew
- Laboratory of Translational Cutaneous Medicine, Ingham Institute for Applied Medical Research, Sydney, Australia
- Department of Dermatology, Liverpool Hospital, Sydney, Australia
- University of New South Wales, Sydney, Australia
| | - Gregor B E Jemec
- Department of Dermatology, Zealand University Hospital, Roskilde, Denmark
- Health Sciences Faculty, University of Copenhagen, Copenhagen, Denmark
| | - Alexa B Kimball
- Department of Dermatology, Harvard Medical School, Boston, MA, USA
- Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Brian Kirby
- Charles Department of Dermatology, St Vincent's University Hospital, Dublin, Ireland
- Charles Institute of Dermatology, University College Dublin, Dublin, Ireland
| | - Falk G Bechara
- Department of Dermatology, Venereology and Allergology, Ruhr-University Bochum, Bochum, Germany
| | - Kristina Navrazhina
- Laboratory of Investigative Dermatology, The Rockefeller University, New York, NY, USA
- Weill Cornell/Rockefeller/Sloan Kettering Tri-Institutional MD-PhD Program, New York, NY, USA
| | - Errol Prens
- Department of Dermatology, Erasmus University Medical Center, Rotterdam, TheNetherlands
| | - Kristian Reich
- Translational Research in Inflammatory Skin Diseases, Institute for Health Care Research in Dermatology and Nursing, University Medical Center Hamburg-Eppendorf, Germany
- MoonLake Immunotherapeutics AG, Zug, Switzerland
| | - Eva Cullen
- MoonLake Immunotherapeutics AG, Zug, Switzerland
| | - Kerstin Wolk
- Psoriasis Research and Treatment Centre, Department of Dermatology, Venereology and Allergology and Institute of Medical Immunology, Charité - Universitätsmedizin Berlin, Berlin, Germany
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Hidradenitis Suppurativa: Where We Are and Where We Are Going. Cells 2021; 10:cells10082094. [PMID: 34440863 PMCID: PMC8392140 DOI: 10.3390/cells10082094] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 08/11/2021] [Accepted: 08/13/2021] [Indexed: 12/19/2022] Open
Abstract
Hidradenitis suppurativa (HS) is a chronic inflammatory skin disease primarily affecting apocrine gland-rich areas of the body. It is a multifactorial disease in which genetic and environmental factors play a key role. The primary defect in HS pathophysiology involves follicular occlusion of the folliculopilosebaceous unit, followed by follicular rupture and immune responses. Innate pro-inflammatory cytokines (e.g., IL-1β, and TNF-α); mediators of activated T helper (Th)1 and Th17 cells (e.g., IFN-γ, and IL-17); and effector mechanisms of neutrophilic granulocytes, macrophages, and plasma cells are involved. On the other hand, HS lesions contain anti-inflammatory mediators (e.g., IL-10) and show limited activity of Th22 cells. The inflammatory vicious circle finally results in pain, purulence, tissue destruction, and scarring. HS pathogenesis is still enigmatic, and a valid animal model for HS is currently not available. All these aspects represent a challenge for the development of therapeutic approaches, which are urgently needed for this debilitating disease. Available treatments are limited, mostly off-label, and surgical interventions are often required to achieve remission. In this paper, we provide an overview of the current knowledge surrounding HS, including the diagnosis, pathogenesis, treatments, and existing translational studies.
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Navrazhina K, Frew JW, Gilleaudeau P, Sullivan-Whalen M, Garcet S, Krueger JG. Epithelialized tunnels are a source of inflammation in hidradenitis suppurativa. J Allergy Clin Immunol 2021; 147:2213-2224. [PMID: 33548397 PMCID: PMC8184580 DOI: 10.1016/j.jaci.2020.12.651] [Citation(s) in RCA: 59] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 10/28/2020] [Accepted: 12/11/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Hidradenitis suppurativa (HS), also known as acne inversa, is a chronic, painful, and burdensome inflammatory disease manifesting in nodules and abscesses, with progression to chronically draining tunnels in later-stage disease. OBJECTIVE We sought to determine whether HS tunnels are immunologically active participants in disease activity. METHODS Skin biopsy specimens were obtained by using ultrasound guidance in untreated patients with HS and those enrolled in an open-label study of brodalumab (ClinicalTrials.gov identifier NCT03960268) for patients with moderate-to-severe HS. RESULTS Immunohistochemistry of HS biopsy specimens demonstrated that the epithelialized HS tunnels recapitulate the psoriasiform epidermal hyperplasia morphology of the overlying epidermis, displaying molecular inflammation, including S100A7 (psoriasin) positivity, as well as features of epidermal skin, including loricrin, filaggrin, lipocalin-2, and Melan-A positive cells. Tunnels were associated with increased infiltration of T cells, dendritic cells, and neutrophils; formation of neutrophil extracellular traps, and increased expression of psoriasiform proinflammatory cytokines. Unsupervised hierarchical clustering demonstrated a separation of HS samples based on the presence or absence of tunnels. Tunnels isolated by microdissection had higher levels of epithelium-derived inflammatory cytokines compared with the overlying epidermis and healthy controls. Clinically, the size and draining of the tunnels were decreased with treatment with the IL-17RA antagonist brodalumab. CONCLUSION These data suggest that tunnels are a source of inflammation in HS.
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Affiliation(s)
- Kristina Navrazhina
- Laboratory of Investigative Dermatology, The Rockefeller University, New York, NY, USA
- Weill Cornell/Rockefeller/Sloan Kettering Tri-Institutional MD-PhD program, New York, NY
| | - John W. Frew
- Laboratory of Investigative Dermatology, The Rockefeller University, New York, NY, USA
| | - Patricia Gilleaudeau
- Laboratory of Investigative Dermatology, The Rockefeller University, New York, NY, USA
| | - Mary Sullivan-Whalen
- Laboratory of Investigative Dermatology, The Rockefeller University, New York, NY, USA
| | - Sandra Garcet
- Laboratory of Investigative Dermatology, The Rockefeller University, New York, NY, USA
| | - James G. Krueger
- Laboratory of Investigative Dermatology, The Rockefeller University, New York, NY, USA
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Zouboulis CC, Benhadou F, Byrd AS, Chandran NS, Giamarellos‐Bourboulis EJ, Fabbrocini G, Frew JW, Fujita H, González‐López MA, Guillem P, Gulliver WPF, Hamzavi I, Hayran Y, Hórvath B, Hüe S, Hunger RE, Ingram JR, Jemec GB, Ju Q, Kimball AB, Kirby JS, Konstantinou MP, Lowes MA, MacLeod AS, Martorell A, Marzano AV, Matusiak Ł, Nassif A, Nikiphorou E, Nikolakis G, Nogueira da Costa A, Okun MM, Orenstein LA, Pascual JC, Paus R, Perin B, Prens EP, Röhn TA, Szegedi A, Szepietowski JC, Tzellos T, Wang B, van der Zee HH. What causes hidradenitis suppurativa ?—15 years after. Exp Dermatol 2020; 29:1154-1170. [DOI: 10.1111/exd.14214] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 10/05/2020] [Indexed: 02/06/2023]
Affiliation(s)
- Christos C. Zouboulis
- European Hidradenitis Suppurativa Foundation e.V. Dessau Germany
- Departments of Dermatology, Venereology, Allergology and Immunology Dessau Medical Center Brandenburg Medical School Theodor Fontane and Faculty of Health Sciences Brandenburg Dessau Germany
| | - Farida Benhadou
- European Hidradenitis Suppurativa Foundation e.V. Dessau Germany
- Department of Dermatology Hôpital Erasme Universite Libre de Bruxelles Bruxelles Belgium
| | - Angel S. Byrd
- Department of Dermatology Howard University College of Medicine Washington DC USA
| | - Nisha S. Chandran
- European Hidradenitis Suppurativa Foundation e.V. Dessau Germany
- Division of Dermatology Department of Medicine National University Hospital Singapore
| | - Evangelos J. Giamarellos‐Bourboulis
- European Hidradenitis Suppurativa Foundation e.V. Dessau Germany
- 4th Department of Internal Medicine National and Kapodistrian University of Athens Medical School Athens Greece
| | - Gabriella Fabbrocini
- European Hidradenitis Suppurativa Foundation e.V. Dessau Germany
- Section of Dermatology Department of Clinical Medicine and Surgery University of Naples Federico II Naples Italy
| | | | - Hideki Fujita
- Division of Cutaneous Science Department of Dermatology Nihon University School of Medicine Tokyo Japan
| | - Marcos A. González‐López
- European Hidradenitis Suppurativa Foundation e.V. Dessau Germany
- Division of Dermatology Hospital Universitario Marqués de Valdecilla University of Cantabria IDIVAL Santander Spain
| | - Philippe Guillem
- European Hidradenitis Suppurativa Foundation e.V. Dessau Germany
- Department of Surgery Clinique du Val d’Ouest (Lyon), ResoVerneuil (Paris) and Groupe de Recherche en Proctologie de la Société Nationale Française de ColoProctologie Paris France
| | - Wayne P. F. Gulliver
- European Hidradenitis Suppurativa Foundation e.V. Dessau Germany
- Faculty of Medicine Memorial University of Newfoundland, and NewLab Clinical Research Inc St. John's Canada
| | - Iltefat Hamzavi
- Department of Dermatology Henry Ford Hospital Wayne State University Detroit MI USA
| | - Yildiz Hayran
- Department of Dermatology Ankara Numune Training and Research Hospital Ankara Turkey
| | - Barbara Hórvath
- European Hidradenitis Suppurativa Foundation e.V. Dessau Germany
- Department of Dermatology University Medical Centre Groningen University of Groningen Groningen The Netherlands
| | | | - Robert E. Hunger
- European Hidradenitis Suppurativa Foundation e.V. Dessau Germany
- Department of Dermatology, Inselspital Bern University Hospital Bern Switzerland
| | - John R. Ingram
- European Hidradenitis Suppurativa Foundation e.V. Dessau Germany
- Department of Dermatology & Academic Wound Healing Division of Infection and Immunity Cardiff University Cardiff UK
| | - Gregor B.E. Jemec
- European Hidradenitis Suppurativa Foundation e.V. Dessau Germany
- Department of Dermatology Zealand University Hospital Roskilde Denmark
| | - Qiang Ju
- European Hidradenitis Suppurativa Foundation e.V. Dessau Germany
- Department of Dermatology RenJi Hospital School of Medicine Shanghai Jiaotong University Shanghai China
| | - Alexa B. Kimball
- Department of Dermatology Beth Israel Deaconess Medical Center and Harvard Medical School Boston MA USA
| | - Joslyn S. Kirby
- Department of Dermatology Penn State Milton S. Hershey Medical Center Hershey PA USA
| | - Maria P. Konstantinou
- Dermatology Department Paul Sabatier University University Hospital of Toulouse Toulouse France
| | | | - Amanda S. MacLeod
- Department of Dermatology Department of Immunology Department of Molecular Genetics and Microbiology Duke University Durham NC USA
| | - Antonio Martorell
- European Hidradenitis Suppurativa Foundation e.V. Dessau Germany
- Department of Dermatology Hospital of Manises Valencia Spain
| | - Angelo V. Marzano
- European Hidradenitis Suppurativa Foundation e.V. Dessau Germany
- Dermatology Unit Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico Milan Italy
- Department of Pathophysiology and Transplantation Università degli Studi di Milano Milan Italy
| | - Łukasz Matusiak
- European Hidradenitis Suppurativa Foundation e.V. Dessau Germany
- Department of Dermatology, Venereology and Allergology Wrocław Medical University Wrocław Poland
| | - Aude Nassif
- European Hidradenitis Suppurativa Foundation e.V. Dessau Germany
- Institut Pasteur Paris France
| | - Elena Nikiphorou
- Centre for Rheumatic Diseases King’s College London, and Department of Rheumatology King’s College Hospital London UK
| | - Georgios Nikolakis
- European Hidradenitis Suppurativa Foundation e.V. Dessau Germany
- Departments of Dermatology, Venereology, Allergology and Immunology Dessau Medical Center Brandenburg Medical School Theodor Fontane and Faculty of Health Sciences Brandenburg Dessau Germany
| | - André Nogueira da Costa
- European Hidradenitis Suppurativa Foundation e.V. Dessau Germany
- Translational Science and Experimental Medicine Early Respiratory and Immunology Biopharmaceuticals R&D AstraZeneca Gothenburg Sweden
| | | | | | - José Carlos Pascual
- European Hidradenitis Suppurativa Foundation e.V. Dessau Germany
- Alicante University General Hospital Alicante Institute for Health and Biomedical Research (ISABIAL‐FISABIO Foundation) Alicante Spain
| | - Ralf Paus
- European Hidradenitis Suppurativa Foundation e.V. Dessau Germany
- Dr. Phillip Frost Department of Dermatology & Cutaneous Surgery University of Miami Miller School of Medicine Miami FL USA
| | - Benjamin Perin
- Division of Dermatology University of Washington Seattle WA USA
| | - Errol P. Prens
- European Hidradenitis Suppurativa Foundation e.V. Dessau Germany
- Department of Dermatology Erasmus University Medical Center Rotterdam The Netherlands
| | - Till A. Röhn
- Autoimmunity, Transplantation and Inflammation Novartis Institutes for BioMedical Research Novartis Pharma AG Basel Switzerland
| | - Andrea Szegedi
- Division of Dermatological Allergology Department of Dermatology Faculty of Medicine University of Debrecen Debrecen Hungary
| | - Jacek C. Szepietowski
- European Hidradenitis Suppurativa Foundation e.V. Dessau Germany
- Department of Dermatology, Venereology and Allergology Wrocław Medical University Wrocław Poland
| | - Thrasyvoulos Tzellos
- European Hidradenitis Suppurativa Foundation e.V. Dessau Germany
- Department of Dermatology Nordland Hospital Trust Bodø Norway
| | - Baoxi Wang
- European Hidradenitis Suppurativa Foundation e.V. Dessau Germany
- Department of Dermatology Plastic Surgery Hospital Chinese Academy of Medical Sciences and Peking Union Medical College Beijing China
| | - Hessel H. van der Zee
- European Hidradenitis Suppurativa Foundation e.V. Dessau Germany
- Department of Dermatology Erasmus University Medical Center Rotterdam The Netherlands
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