Clinical practice guidelines have been developed to assist health care practitioners in the medical management of hidradenitis suppurativa (HS) in special patient populations, which have been published in the Journal of the American Academy of Dermatology.
The guidelines include 118 expert consensus recommendations for HS in 7 patient populations in North America, including pregnancy, breastfeeding, pediatrics, malignancy, tuberculosis (TB) infection, hepatitis B or C infection, and HIV infection.
The recommendations were developed with the use of the Grading of Recommendations Assessment, Development, and Evaluation approach by a panel of experts. Each recommendation was rated as conditional (a suggestion) or strong (a recommendation).
Pregnancy
Guidelines on the use of topical antibiotics or antiseptic washes in pregnant patients with HS are generally similar to guidance for the general population with HS. The guidelines suggest avoiding the use of resorcinol because research on its safety is lacking as well as avoiding the use of triclosan owing to a risk for endocrine-disrupting effects. For patients with HS who require antiseptic washes, the guidelines suggest using chlorhexidine, bleach baths, and zinc pyrithione.
A strong recommendation was made for using zinc supplements for pregnant patients seeking natural therapies, as moderate quality evidence supports its safe use in pregnancy. Intralesional steroids may be used for acute, localized flares.
These guidelines address the unique needs of diverse groups typically underrepresented in clinical trials, and highlight the importance of a multidisciplinary approach.
For pregnant patients with HS who need treatment with systemic antibiotics, oral cephalexin, oral azithromycin, and oral clindamycin may be used, as moderate quality evidence supports their use. A combination of oral rifampin and clindamycin can be used in some patients with severe disease. The guidelines suggest avoiding oral metronidazole, oral co-trimoxazole, and oral dapsone in this population due an increased risk for adverse fetal and maternal events.
A strong recommendation was provided for avoiding oral doxycycline owing to the risk for congenital anomalies, binding of the medication in fetal bones, and tooth discoloration. A strong recommendation also was made for avoiding oral erythromycin because of an increased risk for adverse outcomes such as elevated liver enzyme levels. Metformin is strongly recommended in pregnant patients with HS who require anti-androgens, with moderate quality evidence that it is safe during pregnancy.
The guidelines suggest prednisone use for acute, widespread flares only and limiting cyclosporine use for treatment-refractory cases among pregnant patients with HS who require systemic immunomodulators. For patients with HS who are considering pregnancy while on biologic therapies, providing counseling on the use of biologics during pregnancy is strongly recommended. In those who are planning pregnancy and who are well-controlled on biologic therapies, continuing biologic therapy throughout pregnancy is strongly recommended.
The guidelines include a strong recommendation for consulting with a pediatrician on the timing of live vaccine administration for neonates with in-utero biologic exposure from maternal HS management. Adalimumab is strongly recommended in pregnant patients with HS who require biologics. Infliximab and secukinumab may be used in those who need biologics. Some patients with HS who are planning pregnancy and require biologics may use certolizumab as an alternative biologic.
Breastfeeding
Among breastfeeding patients with HS who need systemic antibiotics, the guidelines suggest use of oral rifampin and caution when prescribing oral clindamycin owing to an increased risk for gastrointestinal adverse effects in the infant. Oral amoxicillin/clavulanic acid, oral erythromycin, oral azithromycin, and oral metronidazole may also be used in breastfeeding patients with HS who require systemic antibiotics. A strong recommendation was made for limiting the use of oral doxycycline in these patients. For cases in which no alternative antibiotic is available, the guidelines recommend that oral doxycycline be limited to less than 3 weeks duration and without repeating courses.
In breastfeeding patients who require anti-androgens, metformin and estrogen-containing oral contraceptives may be used. For those who need systemic immunomodulators, prednisone at a dose of less than 20 mg daily is suggested for acute, widespread flares. Patients are advised to wait 4 hours or longer before breastfeeding when doses of 20 mg or greater daily are required. Cyclosporine should be limited to select treatment-refractory cases.
Biologics are likely safe to use during breastfeeding. A strong recommendation was made for the use of adalimumab in breastfeeding patients with HS who require biologics. Infliximab may be used, and continuing use of certolizumab in those who benefitted from its use during pregnancy is suggested only in select cases. The guidelines also suggest using caution with anti-interleukin-17 agents and ustekinumab.
Pediatrics
Recommendations for pediatric patients with HS are frequently based on adult data and expert opinion, guideline authors noted. For pediatric patients with HS who require topical antibiotics, the guidelines suggest the use of concomitant antiseptic washes to reduce bacterial resistance. Both antiseptic washes and topical antibiotics are suggested to be used in a similar approach to other HS patient populations. Topical retinoids and resorcinol can be used in select patients who require topical keratolytics. Intralesional steroids are suggested for acute, localized flares, depending on the patient’s age and tolerance.
The guidelines gave a strong recommendation for oral doxycycline in patients aged 8 years and older among those who require systemic antibiotics. Oral minocycline is suggested for patients aged 8 years and older with doxycycline intolerance. Combination therapy with oral rifampin and clindamycin may also be used.
In adolescent girls with HS who require anti-androgens, spironolactone and combined oral contraceptives are suggested. Finasteride may be used in select cases, especially among boys, and metformin may be used, particularly in patients with insulin resistance. Other suggestions in pediatric patients include using prednisone for acute, widespread flares; limiting cyclosporine use to up to 1 year for select treatment-refractory cases; and using oral isotretinoin only in patients who have concomitant moderate to severe acne.
Adalimumab is strongly recommended for patients aged 12 years and older in those who require biologics. Also, the guidelines suggest using adalimumab for patients aged 2 to 11 years. Infliximab, secukinumab, and ustekinumab are suggested for use in patients aged 6 years and older.
Malignancy
Among patients with HS and a history of malignancy, intralesional steroids are suggested for acute, localized flares. For patients with malignancy who require systemic antibiotics for HS, oral doxycycline is strongly recommended with evidence to support its safety. In this population, oral tetracycline, oral minocycline, oral moxifloxacin, oral clindamycin, and oral dapsone may be used, as well as intravenous ertapenem for severe, recalcitrant cases. For those receiving moxifloxacin and clindamycin, patients should be monitored for QT prolongation or severe diarrhea and Clostridium difficile colitis, respectively.
A strong recommendation was provided for the use of metformin in patients with a history of malignancy who require anti-androgens for HS owing to evidence of safety and potential survival benefit with certain malignancies. Spironolactone, oral contraceptives, and finasteride may be used as evidence of their safety have been observed.
In cases in which immunosuppressive medications or biologics are considered for patients with HS and malignancy, the guidelines strongly recommend consultation with the patient’s oncologist and that physicians review HS activity, the patient’s age, previous cancer characteristics, time since completion of cancer treatment, and the carcinogenic effects of immunosuppressants. A shared therapeutic decision-making approach should be used with respect for the patient’s preferences.
For patients with malignancy who require systemic immunomodulators for HS, the guidelines suggest using prednisone for acute, widespread flares and methotrexate as an adjunct treatment for preventing anti-tumor necrosis factor (TNF) antibody formation. Oral retinoids may also be used in this patient population in a manner similar to other patient populations.
For patients who have been in remission for longer than 5 years who require biologics for HS, anti-TNFs may be used, especially in patients with malignancies that are not high risk. In those with a history of malignancy in the previous 5 years who need biologics, secukinumab and ustekinumab may be considered.
Tuberculosis
For patients with HS who need treatment for latent TB, the guidelines strongly recommend oral rifampin for 4 months. In those with a high risk for active TB and require anti-androgens for HS, metformin is strongly recommended.
The guidelines also issued a strong recommendation for annual screening for latent TB when a dose exceeds prednisone equivalent 15 mg daily for 4 weeks or longer among patients who require glucocorticoids. In patients who require biologics, screening for TB before initiation is strongly recommended.
Non-anti-TNF biologic classes may be considered for patients with a high risk for active TB who require biologics, with caution needed when using anti-TNFs. For those with latent TB who are not at high risk for active TB and require anti-TNFs, prophylactic antibiotics are suggested to be initiated at least 1 month before biologic initiation. Completion of prophylactic antibiotics before biologic initiation is suggested in patients with latent TB at high risk for active TB and/or among those that are from endemic areas and require anti-TNFs for HS.
Further, the completion of TB treatment before biologic re-initiation is suggested among those with active TB. Latent TB may be treated concomitantly with anti-interleukin-17s or anti-interleukin-12/23s.
Hepatitis B and C
Oral ciprofloxacin is suggested among patients with HS and chronic hepatitis B or C who need systemic antibiotics, especially in those with evidence of cirrhosis, because it appears to be safe and may be associated with improved survival and a lower risk for spontaneous bacterial peritonitis. Similarly, oral cotrimoxazole (trimethoprim/sulfamethoxazole) may be used, especially in patients with cirrhosis. Oral doxycycline can also be used. Caution is suggested when using oral rifampin owing to the potential risk for hepatotoxicity.
For patients with chronic hepatitis B or C without cirrhosis who need anti-androgens, a strong recommendation was provided for using these agents in a similar manner to other patient populations with HS regardless of hepatitis B or C status. The use of caution is suggested when prescribing metformin in patients with cirrhosis who require anti-androgens for HS because of the risk for metabolic acidosis and ascites.
Screening for hepatitis B and C before treatment initiation is strongly recommended for patients with HS who need immunosuppressants or biologics. Coordinating care with a hepatologist is strongly recommended for patients who need these therapies for HS and are positive for hepatitis B surface antigen (HBsAg-positive). A strong recommendation was made for monitoring alanine aminotransferase, HBsAg, and hepatitis B virus (HBV) DNA every 3 to 6 months and beginning anti-HBV treatment if reactivation occurs in HBcAb-positive or HBsAg-negative patients who require immunosuppressants or biologics for HS.
The guidelines strongly recommend referring to a hepatology specialist for treatment consideration before beginning immunosuppressant or biologic therapy in patients with hepatitis C infection who require these therapies. A strong recommendation was made for anti-HBV prophylaxis before initiation of prednisone therapy in HBsAg-positive patients who require high dose prednisone (>20 mg) for HS. For patients with a history of hepatitis B or C infection who need systemic immunomodulators for HS, the guidelines strongly recommend avoiding methotrexate when there is evidence of hepatic impairment regardless of serologic status.
HIV
For patients with HS who are HIV-positive and who need systemic antibiotics, oral doxycycline may be used because of its prophylactic benefit against bacterial sexually transmitted infections. A strong recommendation was provided for using caution with oral rifampin, owing to the risk for drug interactions with certain HIV therapies in these patients. Oral dapsone and co-trimoxazole (trimethoprim/sulfamethoxazole) may also be used in these patients. Among patients with HS and HIV positivity who require anti-androgens, non-metformin anti-androgens may be considered, as well as metformin in patients with overweight and/or with metabolic syndrome.
A strong recommendation was provided for HIV screening before treatment initiation in patients with HS who require immunosuppressives or biologics. Additionally, coordinating care with an infectious disease specialist is strongly recommended for these patients, along with addressing factors such as HIV control and potential drug interactions.
In patients with HS and HIV positivity who require systemic immunomodulators, prednisone may be used cautiously for acute, widespread flares.
In those who need biologics, adalimumab and infliximab may be used cautiously owing to limited evidence. Anti-interleukin-17s and ustekinumab can be used if the HIV infection is well controlled among patients with HS and HIV positivity who require biologics.
References:
Alhusayen R, Dienes S, Lam M, et al. North American clinical practice guidelines for the medical management of hidradenitis suppurativa in special patient populations.J Am Acad Dermatol. Published online December 24, 2024. doi:10.1016/j.jaad.2024.11.071
