Subjects:
20 women treated with spironolactone
Synopsis:
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.
Full Research Link:
Absence of efficacy of oral isotretinoin
Absence of efficacy of oral isotretinoin in hidradenitis suppurativa: a retrospective study based on patients’ outcome assessment
Synopsis:
Background: In analogy to acne, oral isotretinoin has been considered in the treatment of hidradenitis suppurativa (HS).
Objectives: To assess the efficacy of oral isotretinoin according to patients.
Methods: From 1999 to 2006, 358 consecutive HS patients were interviewed and examined. A standardized record of the data was performed for each patient during the first consultation. Patients were questioned regarding the effect of previous treatment with oral isotretinoin: patients had to grade the effect as either ‘improved’, ‘no effect’ or ‘worse’.
Results: Fourteen patients (16.1%) declared an improvement, 67 patients (77%) no effect and 6 patients (6.9%) worsening of HS.
Conclusion: According to our patients, oral isotretinoin is not effective in the treatment of HS.
Abstract: https://www.karger.com/Article/Abstract/182261
Link to Research: https://pubmed.ncbi.nlm.nih.gov/19060466/
Adalimumab Dose Intensification in Recalcitrant HS
Synopsis:
Background: Adalimumab is the only approved compound for the treatment of adult patients with moderate-to-severe hidradenitis suppurativa (HS) who did not respond to a systemic classical treatment. Despite its significant short- and long-term efficacy, a percentage of patients do not respond sufficiently. Moreover, some primary responders experience a response loss with time.
Objective: To analyse the effectiveness of adalimumab dose intensification in HS patients.
Methods: A case series of adalimumab 80 mg/week subcutaneously (s.c.) compassionate use in patients with HS, who did not respond sufficiently or in primary responders with progressive response loss to the registered adalimumab dose of 40 mg/week s.c. Patients were collected and evaluated retrospectively. Patients’ data were extracted from medical records.
Results: The 14 patients collected were Caucasian with HS of Hurley stage II-III and moderate or severe International HS Severity Score System (IHS4) stage. Adalimumab dose intensification significantly improved IHS4 score, Pain Index, HS-Physician Global Assessment, pain, and Cardiff Dermatology Life Quality Index. Two young female patients with HS and Crohn’s disease developed psoriatic lesions during the treatment with adalimumab 80 mg/week s.c.
Conclusion: An enhanced level of effectiveness was assessed in the majority of the HS patients treated with adalimumab dose intensification (80 mg/week s.c.). Larger studies are required to evaluate this observation.
Full Research Link:
Apremilast (Otezla): no significant change in lesional skin inflammatory biomarkers
Synopsis:
Background: Treatment with apremilast has recently demonstrated clinically meaningful improvement in moderate hidradenitis suppurativa (HS).
Objective: To evaluate the change in expression of inflammatory markers in lesional skin of HS patients receiving apremilast 30 mg twice daily (n = 15) for 16 weeks compared with placebo (n = 5).
Methods: At baseline, 5-mm punch biopsies were obtained from an index lesion (HSL) and non-lesional (HSN) skin in the same anatomical area. Subsequent HSL samples were taken as close as possible to the previously biopsied site at week 4 and week 16. After sampling, biopsies were split; one half was processed for in vivo mRNA analysis using real-time quantitative PCR; the other half was cultured for ex vivo protein analysis using a proximity extension assay (Olink). Linear mixed effects models were calculated to compare the levels of inflammatory markers in HSL skin between apremilast and placebo over time.
Results: At baseline, 17 proteins with a fold change >2 in HSL vs. HSN skin were identified in 20 patients. The top five were IL-17A (5), S100A12, CST5, IL-12/23p40, CD6 (1) with fold changes ranging from 6.6 to 1638, respectively (FDR <0.044). Linear mixed effects models for 75 assays were calculated. Protein levels of S100A12 decreased during treatment in the apremilast group compared with the placebo group (p = 0.014, FDR = 0.186). None of the 14 genes exhibited significant changes in expression over time. However, an evident downward trend in relative mRNA expression of IL-17A and IL-17F was demonstrated in patients receiving apremilast.
Conclusion: We did not detect statistically significant changes in inflammatory markers in HSL skin of HS patients receiving apremilast compared with placebo, despite clinical improvement in the apremilast group. Nonetheless, S100A12 and IL-17A were significantly elevated in HSL skin and showed a decrease in response to apremilast. The translational model in clinical trials involving HS clearly needs further improvement.
Synopsis version of study
https://www.ncbi.nlm.nih.gov/pubmed/30451329
Full version of study
Bermekimab Shows Resolution of Inflammatory Lesions and Pain
Synopsis:
The objective of this study was to evaluate the safety and efficacy of bermekimab, an IL-1α inhibitor, in the treatment of hidradenitis suppurativa (HS). This study was a phase II, multicenter, open-label study of two dose cohorts of bermekimab in patients with moderate-to-severe HS who are naïve to or have failed prior anti-TNF therapy. Patients with HS (n = 42) were divided into groups A and B based on whether or not they had previously failed an anti-TNF therapy. In group A (n = 24), bermekimab was administered subcutaneously at a dose of 400 mg weekly (13 doses) in patients who had previously failed anti-TNF therapy; in group B (n = 18), bermekimab was administered subcutaneously at a dose of 400 mg weekly (13 doses) in patients who were anti-TNF naïve. Bermekimab, previously found to be effective in treating HS, was evaluated using a subcutaneous formulation in patients with HS naïve to or having failed anti-TNF therapy. There were no bermekimab-related adverse events with the exception of injection site reactions. Bermekimab was effective despite treatment history, with 61% and 63% of patients naïve to and having failed anti-TNF therapy, respectively, achieving HS clinical response after 12 weeks of treatment. A significant reduction in abscesses and inflammatory nodules of 60% (P < 0.004) and 46% (P < 0.001) was seen in anti-TNF naïve and anti-TNF failure groups, respectively. Clinically and statistically significant reduction was seen in patients experiencing pain, with the Visual Analogue Scale pain score reducing by 64% (P < 0.001) and 54% (P < 0.001) in the anti-TNF naïve and anti-TNF failure groups, respectively. IL-1α is emerging as an important clinical target for skin disease, and bermekimab may represent a new therapeutic option for treating moderate-to-severe HS..
Full Research Link:
https://www.jidonline.org/article/S0022-202X(20)30071-3/fulltext
Botulinum Toxin Off-Label Use in Dermatology
Botulinum Toxin Off-Label Use in Dermatology: A Review
*hidradenitis suppurativa cited in this research.
Synopsis:
Botulinum toxin is a neurotoxin produced by the bacterium Clostridium botulinum which causes a flaccid muscle paralysis. It is currently used for aesthetic treatments and in the focal hyperhidrosis. Recently, botulinum toxin has also been used experimentally in many other dermatological conditions with good results.
Objective: To review and analyze the possible botulinum toxin off-label applications published.
Methods: A retrospective review of the published data was conducted.
Conclusions: This potent drug can lead to several off-label indications of interest for dermatologists. Further clinical trials are still needed to better understand the real efficacy and safety of these applications and to standardize injection and dose protocols.
Link to Review:
Botulinum toxin type a therapy
Two cases of Hidradenitis suppurativa and botulinum toxin type a therapy: A novel approach for a pathology that is still difficult to manage
Synopsis:
Hidradenitis suppurativa is a chronic skin disease with an intense inflammatory activation. It typically affects the intertriginous areas with cysts, fistulae, and scarring extremely painful. Patients suffer from severe psychological impact. HS still results in a high unmet medical need with several underdiagnosed cases, probably due to the incomplete knowledge of the pathogenesis of HS. The use of botulinum toxin a has recently been proposed as an effective therapy for HS.
Full Research Link:
Clinical characteristics and determinants of treatment efficacy
Synopsis:
Hidradenitis suppurativa (HS) is a chronic inflammatory skin disorder that causes a significant decline in quality of life. There are numerous treatment options; however, real-life data on the efficacy of these treatments is limited. This study was performed in two centers to describe clinical characteristics and assess treatment outcome in a cohort of 139 patients with HS. Data on demographic and clinical characteristics, Hurley stage and comorbidities were collected from patient charts and evaluated retrospectively. Treatment response was measured with HS clinical response index (HISCR). Mean body mass index was 27.8±4.88. Inflammatory comorbidities were present in 23%. Among first-line drugs systemic doxycycline resulted in 60% HISCR followed by rifampicin–clindamycin combination (46.4%). Isotretinoin had the lowest HISCR (30.7%) in this group. For second-line therapies, all acitretin treated patients achieved response and patients treated with tumor necrosis factor alpha (TNF-α) inhibitors had the highest HISCR. Currently recommended first-line therapies have moderate efficacy in HS. Acitretin appears to be a reasonable alternative for the highly effective TNF-α inhibitors in patients with severe and resistant HS. Overall, these results support that excessive inflammatory response play an important role in pathogenesis of HS.
Full Research Link:
Complementary & Alternative Medicine
Synopsis:
Hidradenitis suppurativa (HS) is a debilitating disease characterized by recurrent painful nodules, abscesses, and sinus tracts in intertriginous areas. Available treatments have variable and limited efficacy. Complementary and alternative medicine (CAM) is widely used in other chronic dermatoses; however, there is a dearth of investigations into CAM in HS. The goal of this study is to explore patterns of conventional and CAM therapies used by patients with HS.
Link to Research:
https://jamanetwork.com/journals/jamadermatology/fullarticle/2759748
Could Accutane Flare HS?
Could isotretinoin (accutane) flare hidradenitis suppurativa? A case series.
We report eight cases of patients with severe acne who were treated with isotretinoin and developed painful nodules in the axillae and groin, consistent with hidradenitis suppurativa (HS). The pathogenesis of HS is still not completely understood; recent research from a study in 2011 of biopsies from HS lesions showed a reduction or absence of sebaceous glands compared with normal skin in patients with HS, with the report suggesting that this contributes to the pathogenesis of the disease. Interestingly, the main effect of isotretinoin is to decrease the size and action of sebaceous glands, so hypothetically, as isotretinoin acts by reducing the sebaceous glands further it could potentially aggravate HS. Our experience has instilled caution in our prescribing of isotretinoin, and we question patients, particularly those with acne conglobata, about symptoms of HS prior to and during treatment.
Full Research Link:
Cryoinsufflation for Hurley Stage II
A woman in her 30s presented with hidradenitis suppurativa (HS), Hurley stage II. She was treated with oral contraceptives (drospirenone/ethinyl estradiol), spironolactone (50 mg/d), topical clindamycin, and monthly intralesional corticosteroids (triamcinolone acetonide, 10 mg/mL). Previously, she had received rifampicin (600 mg/d), first with minocycline (100 mg/d), then with clindamycin (300 mg/d), and finally with moxifloxacin (400 mg/d). After these treatments failed, she received isotretinoin (0.5 mg/kg/d) for 2 more years to achieve remission, but without success.
Because she had decided to become pregnant, she was searching for an alternative treatment, devoid of teratogenic effects, to safely replace oral contraceptives. Effective therapy was paramount because the HS seriously interfered with sexual intercourse and indirectly with her planned pregnancy. Surgical treatment was offered (local incision and drainage, deroofing, limited local or wide excision), which she declined.
Therapeutic Challenge
Both neonatal outcome and maternal health are important in this case; fetal exposure can occur prior to knowledge of pregnancy, and during the first trimester, the fetus is most susceptible to teratogenic damage. Because the patient decided to discontinue taking oral contraceptives to become pregnant, acitretin, which is more effective than isotretinoin,1 is contraindicated. Both treatments are highly teratogenic, and pregnancy should be avoided for at least 3 years following discontinuation of acitretin treatment.
Although antibiotics are widely used to treat HS, few are safe in pregnant women. Physicians are usually reluctant to prescribe a prolonged course of systemic antibiotics for women with HS who are trying to conceive. The teratogenicity of the treatment is often deemed to impart greater risk than the disease itself HS which is not thought to increase fetal morbidity, compared with hypertension or diabetes.
Finally, manufacturers of anti–tumor necrosis factor (TNF) advise discontinuation of treatment with these agents prior to a planned pregnancy, although anti-TNF therapies (infliximab, etanercept, adalimumab) are in fact pregnancy category B drugs. And even if systemic medications had been considered completely safe, our patient perceived them to be harmful, which ruled them out and restricted the treatment choices to surgical procedures, intralesional corticosteroids, and less effective treatments such as cryotherapy2 and topical agents. The patient refused both minor (local incision and drainage, deroofing) and major surgical treatment (limited local or wide excision). While intralesional corticosteroids are safe, they are rarely effective when used as monotherapy (and are considered to be Category C agents by the US Food and Drug Administration, posing the potential risk of orofacial cleft development in utero).
Solution
To control the HS symptoms for our patient and discontinue her systemic medical therapy, we proposed cryoinsufflation (CI), a modified spray cryotherapy performed by injecting liquid nitrogen (LN) through an ordinary needle directly into HS tracts.
After the patient provided written informed consent, she underwent local anesthesia with lidocaine hydrochloride, 1%. Abscesses and sinus tracts in the HS-affected areas were filled with LN using a 21-gauge needle mounted on a cryosurgical unit (CRY-AC; Brymill Cryogenic Systems Ltd) equipped with the CRY-AC Malleable Extension and Luerlok Adaptor for CRY-AC. The ossa of the sinocutaneous fistulas were cannulated, and LN was sprayed into the fistula track.
As the LN enters infected sinuses, it boils and vaporizes. Because of the large expansion ratio of liquid to gas, it quickly disperses into all communicating pockets and is expressed like a geyser. Pulsing each spray to avoid an overexpansion of the treatment site helps to prevent excessive pain and the formation of iceballs, recognized by the appearance of a white rim around the insertion point of the needle. We suggest a 5-second pulse followed by a 1-second pause, repeated 3 times for each lesion. Monthly treatment sessions allow for focused scarring to replace sinuses and cause minimal damage to the skin surface.
We treated the patient with 3 monthly treatment sessions. No recurrence was observed after 6 months. Of note, neither hypopigmentation nor scarring was observed and the patient was very satisfied with the results (Figure).
Current Understanding of Pathogenic Mechanisms and Suggestion for Treatment Algorithm
Synopsis:
Hidradenitis suppurativa is one of the most distressing dermatological conditions and has a significant negative impact on patients’ quality of life. However, the exact pathogenic mechanisms remain incompletely understood and—therefore—efficient therapies are still lacking. The current manuscript focuses on new findings on its pathogenic mechanisms and aims to provide practical therapy recommendations.
Full Research Link:
https://www.frontiersin.org/articles/10.3389/fmed.2020.00068/full
Dapsone therapy for hidradenitis suppurativa: a series of 24 patients
Synopsis:
Background: Hidradenitis suppurativa (HS) is an inflammatory skin disease with a chronic intermittent course. HS is difficult to treat, and the evidence for the effect of most treatments consists of smaller open studies. The use of dapsone in the treatment of HS is based on a few published cases successfully treated.
Objective: To evaluate the potential of dapsone treatment for HS in an open case series.
Methods: An exploratory and retrospective review of case notes from HS patients treated with dapsone was performed. Patients were included irrespective of treatment outcome. Prior to the treatment the level of glucose-6-phosphate dehydrogenase in the blood was tested for all patients.
Results: A total of 24 HS patients were included and treated with dapsone. Improvement was seen in 9 out of 24 (38%) treated patients, whereas 15 out of 24 (62%) did not experience any improvement. None of the 4 cases with severe disease experienced improvement. Side effects leading to discontinuation of the treatment occurred in 2 of 24 patients (8%). Recurrence of disease at the cessation of treatment was described as rapid.
Limitations: The study is limited by lacking a control group.
Conclusion: Therapy with dapsone for patients with HS is possible, particularly in milder cases. The effect may be due to either antibacterial or anti-inflammatory effects of the drug, or both. Rapid recurrence after stopping treatment however suggests that anti-inflammatory effects may predominate. The effect appears to be smaller than that reported with combination therapy using clindamycin and rifampicin. To clarify the true effect of dapsone future randomized controlled trials are necessary.
Link to Study:
Infliximab every 4 weeks may be beneficial in treatment
Synopsis:
Infliximab maintenance therapy could reduce pain and disease activity in hidradenitis suppurativa, according to a study published in Journal of the American Academy of Dermatology.
“Physicians should be using infliximab as the standard for treating hidradenitis suppurativa,” study co-author Steven R. Cohen, MD, MPH, told Healio. “A large percentage of patients with HS have obesity as a comorbidity. When you are dealing with that, you really need a drug that is weight-based.”
The prospective analysis included 42 patients who received an induction dose of infliximab 7.5 mg/kg at weeks 0, 2 and 6, with a maintenance dose of 7.5 mg/kg every 4 weeks thereafter. In a second cohort, 16 patients who did not experience sufficient disease control after the induction dose received a dose escalation of infliximab 10 mg/kg.
Full Research Link:
Full Research Circulation Link:
Intralesional corticosteroid injection for the treatment of HS
Synopsis:
Background and objectives: Hidradenitis suppurativa (HS) is a chronic inflammatory disease of the follicular unit characterized by recurrent, painful, skin lesions including inflammatory nodules, abscesses, tunnels, and mutilating scarring. Intralesional corticosteroids injection (ICI) for HS has received little attention in the scientific literature. We evaluate the clinical response of ICI in acute and chronic HS lesions and aim to identify new applications of ultrasound-assisted procedures in HS management.
Patients and methods: An observational, retrospective, multicenter study of HS patients treated with ICI was conducted from January 1 to August 1, 2015. We collected 98 HS patients. A total of 135 individual lesions were infiltrated, including non-inflammatory nodules, inflammatory nodules abscesses and fistulous tracts.
Results: Complete response was reached in 95 lesions (70.37%), 34 showed partial response (25.19%) and 6 (4.44%) were non-response. A total of 105 individual lesions underwent sonographic scan before ICI.
Conclusion: Clinical experience supported the use of ICI for individual lesions. Our results showed that ICI is a useful treatment to control in acute and recalcitrant HS lesions. Response rates improve significantly if lesions are previously evaluated with HFUS.
Link to Study:
Laser and Light-Based Treatment Modalities
Laser and Light-Based Treatment Modalities for the Management of Hidradenitis Suppurativa
Conclusions:
Laser and light-based treatment modalities have been used alone and in combination with other treatment modalities for the treatment of HS with varying rates of success. Most of the information in support or against their use has come from small clinical trials or case series. Thus, larger randomized controlled trials are needed to elucidate their role and determine optimal treatment settings. There is promising evidence for Nd:YAG, ablative CO2, diode, alexandrite laser, IPL, PDT, radiofrequency, and external beam radiation for HS, while microwave technology has not proven effective. In addition, fractionated CO2 can be used to help aid in wound healing and improve HS scars. Because there are no standardized HS outcome measures for comparison between trials, comparisons between treatment modalities is challenging. Similarly, there are no standardized treatment protocols using these devices, and settings vary between machines. Further studies to elucidate optimal outcome measures, formulate treatment protocols, and investigate the role of the treatments in pregnant/lactating women and in children are also needed. In the end, an individualized patient-centered multimodal approach using a combination of topical, medical, systemic, laser, light-based, and surgical options for the management of HS should be utilized.
Latent TB Infection Screening in Patients with HS may be Unnecessary
Synopsis:
Latent tuberculosis infection screening in patients with hidradenitis suppurativa who are treated with TNF alpha inhibitors may be unnecessary, according to a letter published in the Journal of the American Academy of Dermatology.
Research article link:
Long-Term Safety of Adalimumab
Long-Term Safety of Adalimumab in 29,967 Adult Patients From Global Clinical Trials Across Multiple Indications: An Updated Analysis
Synopsis:
Introduction: The safety profile of adalimumab was previously reported in 23,458 patients across multiple indications. Here we report the long-term safety of adalimumab in adults with plaque psoriasis (Ps), hidradenitis suppurativa (HS), rheumatoid arthritis (RA), ankylosing spondylitis, psoriatic arthritis, non-radiographic axial spondyloarthritis, peripheral spondyloarthritis, Crohn’s disease (CD), ulcerative colitis (UC), and non-infectious uveitis (UV).
Methods: Safety data from 77 clinical trials were pooled. Safety assessments included adverse events (AEs) and serious AEs (SAEs) that occurred after the first study dose and within 70 days (5 half-lives) after the last study dose.
Results: A total of 29,967 patients were included, representing 56,916 patient-years (PY) of exposure. The most frequently reported SAE of interest was infection (3.7/100 PY) with highest incidences in CD, RA, UV, and UC (3.5/100 PY-6.9/100 PY); serious infections in Ps (1.8/100 PY) and HS (2.8/100 PY) were lower. The observed number of deaths was below what would be expected in an age- and sex-adjusted population for most adalimumab-treated patients (including Ps). Lack of real-life data and limited long-term data (> 5 years) for most patients are limitations of this analysis.
Conclusion: The safety profile of adalimumab was consistent with previous findings and no new safety signals were observed.
Full Research Link:
https://www.ncbi.nlm.nih.gov/m/pubmed/31748904/?i=2&from=hidradenitis%20global%20population
Medical & Surgical Treatment Review
Synopsis:
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.).
Link to Research:
New Minimally Invasive Treatment for Pediatric Patients with HS
Pediatric Endoscopic Hidradenitis Treatment: A New Minimally Invasive Treatment for Pediatric Patients with HS
Note: Pediatric HS is not ‘infrequent,’ just incredibly misdiagnosed and under-reported.
https://www.ncbi.nlm.nih.gov/m/pubmed/32017645/?i=2&from=hidradenitis
Paradoxical reactions under TNF-α blocking agents and other biological agents
Synopsis:
Paradoxical adverse events (PAEs) have been reported during biological treatment for chronic immune-mediated diseases. PAEs are defined as the occurrence during biological agent therapy of a pathological condition that usually responds to this class of drug. A wide range of PAEs have been reported including dermatological, intestinal and ophthalmic conditions, mainly with antitumour necrosis factor α (TNF-α) agents. True PAEs include psoriasis, Crohn’s disease and hidradenitis suppurativa. Other PAEs may be qualified as borderline and include uveitis, scleritis, sarcoidosis and other granulomatous diseases (granuloma annulare, interstitial granulomatous dermatitis), vasculitis, vitiligo and alopecia areata. Proposed hypotheses to explain these PAEs include an imbalance in cytokine production, the differential immunological properties between the monoclonal antibodies and TNF-α soluble receptor, an unopposed type I interferon production and a shift towards a Th1/Th2 profile. Data from registries suggest that the risk for paradoxical psoriasis is low and non-significant. We discuss management of these PAEs, which depends on the type and severity of the adverse events, pre-existing treated conditions and the possibility of alternative therapeutic options for the underlying disease. Paradoxical adverse events are not restricted to anti-TNF-α agents and close surveillance of new available biological drugs (anti-interleukin-17/23, anti-integrin) is warranted in order to detect the occurrence of new or as yet undescribed events.
Full Research Link:
Psychiatric Events with Isotrentinoin/Accutane
“The risk of psychiatric adverse events in patients taking isotretinoin must be considered in the context of a known increased risk of suicidal ideation in patients with acne independent of isotretinoin therapy,” Priyank Sharma, MD, of the department of dermatology at Brigham and Women’s Hospital, Harvard Medical School, and colleagues wrote.
Link to article:
Psychiatric Events with Isotretinoin/Accutane
Psychiatric Events with Isotretinoin/Accutane
“The risk of psychiatric adverse events in patients taking isotretinoin must be considered in the context of a known increased risk of suicidal ideation in patients with acne independent of isotretinoin therapy,” Priyank Sharma, MD, of the department of dermatology at Brigham and Women’s Hospital, Harvard Medical School, and colleagues wrote.
Reduced risk of suicidal behaviors with tumor necrosis factor (TNF) alpha antagonists
Synopsis:
Background: Hidradenitis suppurativa (HS) is a chronic, recurrent condition that presents as painful, suppurating lesions in the apocrine gland-bearing skin regions. HS has been associated with increased suicidal behaviours (SB), independent of any treatment. TNF-alpha antagonists are used to treat moderate-to-severe HS and have also been associated with SB, a factor that could confound the decision to use the TNF-α antagonists in the moderately to severely affected HS patients, who may already be experiencing increased SB risk.
Objectives: To determine presence or absence of a safety signal for SB when HS is treated with TNF-α antagonists.
Methods: We calculated the reporting odds ratios (ROR) with 95% CI of SB associated with treatment for HS with TNF-α antagonists vs. the reference group of all other treatments for HS in the US Food and Drug Administration pharmacovigilance database from 1 January 2004 to 31 March 2019. A second analysis excluded isotretinoin (which has been used to treat HS and has also been associated with SB) from the reference group.
Results: There was a signal for decreased risk of SB with TNF-α antagonists (ROR = 0.1959, 95% CI 0.1247-0.3079; z = 7.071, P < 0.0001] vs. all other HS treatments; the ROR did not change significantly after isotretinoin was excluded from the reference group.
Full Research Link:
https://www.ncbi.nlm.nih.gov/m/pubmed/31981260/?i=12&from=hidradenitis%20suppurativa
STEEP Surgical Treatment Option
Skin-Tissue-sparing Excision with Electrosurgical Peeling (STEEP): a surgical treatment option for severe hidradenitis suppurativa Hurley stage II/III
Synopsis:
Background: Surgery is the only curative treatment for removal of the persistent sinus tracts in the skin that are characteristic of severe hidradenitis suppurativa (HS). Complete resection of the affected tissue by wide excision is currently regarded as the preferred surgical technique in these cases. However, relatively large amounts of healthy tissue are removed with this method and suitable skin-tissue-saving techniques aiming at creating less-extensive surgical defects are therefore needed in severe HS.
Method: We describe a skin-tissue-saving surgical technique for HS Hurley stage II-III disease: the Skin-Tissue-sparing Excision with Electrosurgical Peeling (STEEP) procedure.
Discussion: In contrast to wide excisions that generally reach into the deep subcutaneous fat, the fat is maximally spared with the STEEP procedure by performing successive tangential excisions of lesional tissue until the epithelialized bottom of the sinus tracts has been reached. From here, secondary intention healing can occur. In addition, fibrotic tissue is completely removed in the same manner as this also serves as a source of recurrence. This tissue-sparing technique results in low recurrence rates, high patient satisfaction with relatively short healing times and favourable cosmetic outcomes without contractures.
Link to Research:
Studies Related to Zinc Supplements
Initial data support zinc supplementation for acne vulgaris, hidradenitis suppurativa
Synopsis:
“Zinc appears to have several lines of anti-inflammatory action that involve both adaptive and innate immunity and has been shown to decrease neutrophil chemotaxis, inhibit T helper-17 cell activity and downregulate the expression of Toll-like receptor-2 from keratinocytes,” Raja K. Sivamani, MD, MS, CAT, of the department of dermatology at University of California-Davis, and colleagues wrote.
Link to Article:
Effects of Zinc Supplementation on Inflammatory Skin Diseases: A Systematic Review of the Clinical Evidence
Synopsis:
Some preliminary evidence supports the use of zinc in the treatment of acne vulgaris and hidradenitis suppurativa; however, more research is needed with similar methodologies and larger sample sizes in these diseases. Further, zinc may be of some benefit in the treatment plan for atopic dermatitis and diaper dermatitis; however, additional studies should be conducted to further evaluate these potentially positive associations. To date, no evidence is available to suggest that zinc may be of benefit in rosacea and psoriasis; however, limited data are available evaluating the use of zinc in these conditions.
Link to Article:
https://link.springer.com/article/10.1007/s40257-019-00484-0
Suggested Treatment Algorithm
Synopsis:
Hidradenitis suppurativa is one of the most distressing dermatological conditions and has a significant negative impact on patients’ quality of life. However, the exact pathogenic mechanisms remain incompletely understood and—therefore—efficient therapies are still lacking. The current manuscript focuses on new findings on its pathogenic mechanisms and aims to provide practical therapy recommendations.
Link to Research:
https://www.frontiersin.org/articles/10.3389/fmed.2020.00068/full
Topical, systemic and biologic therapies in HS
Topical, systemic and biologic therapies in hidradenitis suppurativa:
pathogenic insights by examining therapeutic mechanisms
Synopsis:
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.
Link to Study:
Trends in Oral Antibiotic Prescription in Dermatology, 2008 to 2016
Synopsis:
Continuing to develop alternatives to oral antibiotics for noninfectious conditions, such as acne, can improve antibiotic stewardship and decrease complications from antibiotic use. In addition, the rising use of postoperative antibiotics after surgical visits is concerning and may put patients at unnecessary risk of adverse events. Future studies are needed to identify the value of this practice and the risk of adverse events.
Full Research Link:
https://jamanetwork.com/journals/jamadermatology/fullarticle/2720317