Paradoxical hidradenitis suppurativa to biologic agents: a case series and literature review

Paradoxical Hidradenitis Suppurativa during Biologic Therapy, an Emerging Challenge: A Systematic Review

Hidradenitis suppurativa (HS) is a chronic, inflammatory skin disease usually occurring after puberty with painful, deep-seated, inflammatory lesions in the apocrine gland-bearing areas of the body. Although HS pathogenesis is still unproven, recent major research advantages have increased our knowledge of the mechanisms behind HS lesions. Particularly, follicular occlusion followed by follicular rupture has been shown to be crucial to HS development, leading to immune response activation, and resulting in typical clinical HS lesions. Moreover, an increased and imbalanced cytokine production, such as interleukin (IL) 17 and tumor necrosis factor (TNF) α, may play a role in HS. In recent years, paradoxical adverse events have been described during treatment. Since the recent increased use of biologic treatments in HS, an increased number of paradoxical HS occurrences have been reported. In this review, we analyzed all current data on paradoxical HS triggered by biological drugs.

Paradoxical hidradenitis suppurativa in Crohn's disease patients receiving infliximab: a case report and review of literature

The introduction of TNF blockers in the therapeutic armamentarium of inflammatory bowel diseases (IBD) has largely advanced the way by which clinicians manage these disorders. However, some patients develop de novo immune-mediated diseases during the treatment. We here present the case of paradoxical hidradenitis suppurativa, a chronic inflammatory skin disease characterized by the development of recurrent nodules and abscesses in intertriginous areas, in a 20-year-old, nonsmoker, normal-weight women, with no family history of hidradenitis suppurativa or IBD, diagnosed with nonstricturing nonpenetrating ileocolonic Crohn's disease in 2013, during treatment with infliximab. Infliximab discontinuation was followed by a significant improvement of skin lesions. We also discuss 22 additional cases of paradoxical hidradenitis suppurativa in IBD patients on TNF antagonists reported in the literature with the aim to identify potential risk factors for the development of such a complication. All the patients had Crohn's disease, and the majority of them were women (19/23; 82.6%). All cases occurred during therapy with anti-TNF agents [14/23 (61%) patients were treated with adalimumab and 9/23 (39%) patients were treated with infliximab]. The therapeutic approach directed at maintaining/holding the undergoing biologic therapy is still uncertain. Further studies are needed to determine the most appropriate treatment choice toward ongoing biologic therapy.

Metabolic, pharmacokinetic, and toxicological issues of biologic therapies currently used in the treatment of hidradenitis suppurativa

INTRODUCTION

Hidradenitis suppurativa is a chronic, relapsing, debilitating inflammatory dermatologic disease of the terminal hair follicles at intertriginous sites clinically characterized by painful inflammatory nodules, abscesses, draining sinus tracts, and dermal fibrosis. The management of hidradenitis suppurativa is a challenge and usually consists of both medical and surgical approaches, which must often be combined for best outcome. The introduction of biological therapies, specifically TNFα-inhibitors such as adalimumab, has profoundly changed the therapeutic armamentarium of the disease.

AREAS COVERED

The PubMed database was searched using combinations of the following keywords: hidradentis suppurativa, biologic therapy, TNF-α inhibitors, adalimumab, etanercept, infliximab, certolizumab pegol, golimumab, adverse effects, pharmacodynamics, pharmacology, adverse events, pharmacokinetics, drug interaction. This article reviews and updates the chemistry, pharmacokinetics, mechanism of action, adverse effects, drug interactions of on-label and off-label use of TNF-α inhibitors in HS.

EXPERT OPINION

Biologic agents, particularly adalimumab, exhibit clinical efficacy in patients with hidradenitis suppurativa. Careful patient selection and close monitoring during treatment are mandatory to provide safe and effective use of the TNF-α inhibitor. Familiarity with biologic agents is crucial because these agents could become a consolidated treatment option in the clinician's therapeutic approaches.

A case paradoxical hidradenitis suppurativa with janus kinase inhibitor, literature review and pooled analysis of biological agent-induced HS

Hidradenitis suppurativa (HS) is a debilitating chronic inflammatory skin disease. Biological therapy has revolutionized it's the treatment. Paradoxical HS occur with various biological and targeted agents. We report a patient with juvenile rheumatoid arthritis who developed HS after 6 months of tofacitinib therapy. A comprehensive literature review identified 43 cases of paradoxical HS among patients on biological and targeted agents. Pooled analysis of the cases showed Crohn's disease 18(41.8%) and RA 9(20.9%) as commonest indications for biological therapy. Adalimumab 20(46.5%) followed by infliximab 9(20.9%) were the commonest offending agents. Duration of biological treatment prior to HS manifestation was 12(1-120) months. Smoking 21(48.8%) and overweight or obese 20(46.5%) were most frequent HS risk factors. Fourteen (32.6%) patients had a second paradoxical event, 11(25.6%) developed psoriasis and 4(9.3%) Crohn's disease. Presence of ≥1 risk factor for HS, continuation of the implicated biological agent and occurrence of more than one paradoxical event were factors associated with poor paradoxical HS outcome.

Immunomodulatory drugs alone and adjuvant to surgery for hidradenitis suppurativa/acne inversa-A narrative review

Hidradenitis suppurativa/acne inversa (HS/AI) is one of the most debilitating dermatoses with a strong negative impact on every dimension of quality of life. Treatment is dependent on the severity of clinical manifestations and comorbidities. While anti-inflammatory and antimicrobial approaches are recommended for mild and moderate stages, immunomodulatory drugs have gained increasing interest in all stages of HS/AI. We reviewed the available data on this subject in a narrative review and included not only substances with published final outcome but those where either the ongoing trials or experience from case report. Furthermore, we investigated combined surgical therapy and immunomodulatory drugs and raised specific questions to be answered in controlled settings. This aspect seems to be underrepresented. The first approved medical treatment for HS/AI is adalimumab. Other cytokine, interleukin, Janus kinase and C5a inhibitors and antagonists are under investigation. IL-1 inhibitors and antagonists may become an option for mild to moderate HS/AI, while most of the other medical compounds target moderate to severe HS/AI. Despite medical efforts with immunomodulatory agents, surgery remains a cornerstone of efficient HS/AI therapy. Better outcome in advanced disease might be achieved by combining drug therapy and surgery, but more systematic clinical trials are necessary for the optimal combination.

Paradoxical Hidradenitis Suppurativa in Patients Receiving TNF-α Inhibitors: Case Series, Systematic Review, and Case Meta-Analysis

BACKGROUND/AIMS

TNF-α inhibitors represent the most advanced approved therapeutic option for moderate and severe forms of hidradenitis suppurativa (HS). However, in recent years, cases of paradoxical HS secondary to the use of these biological drugs have been described, with very few cases reported in the literature. The aims of this study are (1) to present 2 new cases of paradoxical HS and (2) to perform a systematic review of scientific evidence regarding paradoxical HS with TNF-α inhibitors.

MATERIAL AND METHODS

This is a retrospective study in which we searched all the cases of paradoxical HS secondary to the use of TNF-α inhibitors published in the literature and included two additional cases observed in our clinical practice.

RESULTS

A total of 34 patients under TNF-α inhibitor treatment were included (adalimumab = 21; infliximab = 9; etanercept = 4). The median delay from exposure to TNF-α inhibitor and the development of paradoxical HS was 12 months (range 1-72). The majority of patients were Hurley stage II (58.8%). Clinical improvement and complete remission were more frequent when the TNF-α inhibitor was stopped or switched to another biological agent with a different therapeutic target rather than maintenance or change to another TNF-α inhibitor.

CONCLUSIONS

Paradoxical HS is an unusual adverse effect of TNF-α inhibitors. When this adverse effect appears, interruption or substitution of treatment is associated with a better clinical outcome.