Therapies for hidradenitis suppurativa
Biologics added to the list of potential options for treating this challenging disease
Other biologic options
Besides infliximab, there are two other investigational biologics for HS, but with different mechanisms of action. Ustekinumab (Stelara, Janssen), used for psoriasis and inflammatory bowel disease (IBD, is an anti-interleukin-12/23 (anti-IL-12/23) inhibitor, whereas anakinra (Kineret, Sobi), for rheumatoid arthritis (RA) and rare autoinflammatory conditions, is an anti-IL-1 inhibitor.
Both of these agents have been evaluated in small studies,” Dr. Micheletti says.
Like adalimumab, both ustekinumab and anakinra are subcutaneous injections “that are potential options for people who have failed the two TNF inhibitors,” Dr. Micheletti says.
All four biologics “tend to be fairly well tolerated,” Dr. Micheletti says. However, there are infection risks; for example, with the TNF inhibitors, “there is a risk of reactivation of tuberculosis.”
Like the evolving development of medical therapy for psoriasis, “it is a good sign that we now have a couple of HS drugs that seem to help, and maybe there will be more in the future,” Dr. Micheletti says. “With the passing of time, as with psoriasis, we hope to have more and more options that benefit patients who do not respond to one or another drug, especially in the most severe forms of HS.”
For less severe disease, there are topical antibiotics and topical antibacterial washes, as well as oral antibiotics like doxycycline, or combination clindamycin and rifampin. “This combination can work reasonably well for people with moderate or even severe disease, without resorting to a biologic,” Dr. Micheletti notes.
Hormonal treatments such as spironolactone may also help, especially for female patients who present with polycystic ovarian syndrome (PCOS).
Oral retinoids (isotretinoin, acitretin) also sometimes have benefit.
“But from an evidence-based perspective, we have evidence for topical clindamycin, some of the antibacterial washes and clindamycin/rifampin,” Dr. Micheletti says. “While there is no evidence for doxycycline, it is often effective in those with mild hidradenitis and is still recommended by experts.”
Certain types of laser therapy, minor bedside surgical procedures, and injecting inflamed lesions with steroids can be useful in combination with other therapies. Together, these combinations “constitute an effective overall treatment plan,” Dr. Micheletti says.
Dr. Micheletti reports no relevant financial disclosures.