WASHINGTON – Hidradenitis suppurativa (HS) management should be individualized in patients, with consideration of their comorbidities, and therapies should be layered and rotated to improve efficacy, Ginette Okoye, MD, said at the annual meeting of the American Academy of Dermatology.
Jeff Craven/MDedge News
Dr. Ginette Okoye
, spironolactone, and oral contraceptives, said Dr. Okoye, professor and chair of dermatology at Howard University, Washington. A patient’s comorbidities can help tailor which treatments to use, so if a patient with HS also has androgenetic alopecia, finasteride can be considered, while spironolactone, with or without an OC, can be considered for a patient with acne – and metformin can be considered for a patient with diabetes or prediabetes, or polycystic ovary syndrome (PCOS), she commented.
The main goal behind hormonal and metabolic therapies in patients with HS is to decrease androgens. Metformin, the oral hypoglycemic drug, reduces ovarian androgen production, and increases insulin-receptor sensitivity, and is an option for patients with HS, and can also treat comorbid conditions these patients tend to have, such as obesity, insulin resistance, and PCOS, she noted. Metformin dosing is 1,500 to 2,000 mg a day, starting at 500 mg per day with an evening meal, titrating up 500 mg every 2-4 weeks based on how patients tolerate side effects such as diarrhea, nausea, vomiting, and flatulence. Lactic acidosis is a less common side effect, but the risk increases for patients with renal and hepatic impairment or excessive alcohol intake, and for those who are undergoing a radiological procedure with contrast or who are over 65 years of age. While metformin alone, in her experience, does not make a big difference, it can be helpful when combined with other treatments such as antibiotics and biologics, and in patients with these comorbidities, she said.
Pregnant women with HS can benefit from treatment with metformin, but dermatologists should consult with the patient’s obstetrician-gynecologist as the medication is classified as pregnancy category B. In addition, metformin should not be given to patients with a glomerular filtration rate (GFR) less than 45 mL/min, and long-term use is associated with low vitamin B12 levels, she said.
“I often layer this with the antibiotic therapy, so my patient may be on clindamycin, rifampin, and metformin,” said Dr. Okoye. “If they are, you can give them a much lower dose of metformin since rifampin increases the plasma concentration of metformin.”
Patients with HS may also respond well to finasteride at doses between 1 mg and 5 mg once daily, an off-label use for this medication. Finasteride, which targets type 2 5-alpha-reductase, reduces the levels of dihydrotestosterone within hair follicles, which can improve HS symptoms, she said. However, she discusses potential side effects of finasteride use with patients, which include reduced libido, abnormal ejaculation, breast tenderness, prostate cancer, and depression. She also referred to postmarketing data suggesting that finasteride can lead to post-finasteride syndrome, characterized by symptoms that include depression and anhedonia, even long after stopping treatment, she said.
“I still think that it’s worth a try,” Dr. Okoye commented. “Many of our HS patients already are dealing with depression because of their disease. ... In 3 months, we talk about their symptoms, [and] make sure that they’re feeling okay before continuing.”
While finasteride is not appropriate for women of childbearing potential (pregnancy category X), it can be an option for women with HS who are of childbearing age but are not at risk for becoming pregnant, Dr. Okoye added, which can be determined by discussing a patient’s family planning goals. For example, she said, “if you have a woman of childbearing age but she’s in a same-sex relationship and has no intention of having children, then maybe finasteride is an option for her.”
The mineralocorticoid- and aldosterone-receptor antagonist spironolactone, used off label for acne treatment, also has antiandrogenic properties and is an option for patients with HS “at the higher end of the dosing spectrum” with 100-200 mg daily. However, Dr. Okoye referred to a recently published single-center retrospective study that showed a low daily dose of 75 mg was effective for HS (J Am Acad Dermatol. 2019 Jan;80[1]:114-9).
While spironolactone increases the risk of hyperkalemia, in patients with no preexisting renal disease under 50 years of age, monitoring is not necessary because there is little to no risk of clinical hyperkalemia in these patients, she said. Combining spironolactone or finasteride with OCs may increase antiandrogenic activity, she noted.
The data on effectiveness of hormonal contraceptives are mixed with regard to treatment of HS, with some studies showing benefit or worsening of the disease with OC use. “I think one of the reasons the data is so ‘dirty’ is because OCs range widely in terms of their ingredients and in terms of how androgenic their progesterones are,” Dr. Okoye commented.
OCs increase the risk of venous thromboembolism (VTE), but Dr. Okoye noted the risk is less than a patient would experience during pregnancy. “When you talk to dermatologists, there are two camps: some dermatologists who are very comfortable prescribing OCs, and dermatologists who prefer not to, given the risk of VTEs,” she said. However, risk should also be applied to patient population and location, she noted.
“If you are in an area [where] you serve a patient population that has fewer options for access to care, and if you don’t prescribe the OCs, those patients have to wait several months before getting on therapy, said Dr. Okoye. “Maybe that’s a case where you might want to start the OC [with] one or two refills while they find an OB, but it’s really up to you and your risk aversion.”
Dietary factors may also contribute to HS, but more studies are needed to analyze how sugar and carbohydrates contribute to the condition. Instead of taking for granted that a patient will understand what reducing dietary carbohydrate and sugar intake means, Dr. Okoye said, “I like to get very specific; ask them what they’re drinking on a daily basis.”
With regard to weight loss, there is little to link significant weight loss and symptom improvement. However, weight loss could help with comorbid conditions in patients with HS, like metabolic syndrome, and subsequent skin reduction may reduce friction of intertriginous areas, she pointed out.
Dr. Okoye reports receiving grants and/or research funding from Eli Lilly.