Amyloidosis secondary to hidradenitis suppurativa. Exceptional response to infliximab

Biologics for hidradenitis suppurativa: an update

Hidradenitis suppurativa (HS) is a chronic, inflammatory dermatosis characterized by an occurrence of nodules, abscesses, sinus tracks and scarring. Its pathogenesis is multifactorial and still not fully understood, therefore, current systemic therapies still remain a serious challenge. Increased levels of several proinflammatory cytokines have been reported in patients suffering from HS, therefore biologics appear as a new approach to therapy for this condition. Adalimumab is the only one internationally registered agent and should be considered first after the conventional therapies appear insufficient. The efficacy and safety profile of some preparations, like infliximab and etanercept was confirmed so far in randomized trials, but there are some new biologics which are still being evaluated and require more rigorous examination.

Systematic review of immunomodulatory therapies for hidradenitis suppurativa

Background: Greater understanding of the roles of tumor necrosis factor-α, IL-1β, IL-10, and the IL-23/T-helper (Th) 17 and IL-12/Th1 pathways in immune dysregulation in moderate/severe hidradenitis suppurativa (HS) has helped in developing new regimens. We aim to review the use of different immunomodulatory therapies used to manage HS.

Methods: A comprehensive literature search was conducted on the PubMed and Clinicaltrials.gov databases from 1 January 1947 to 31 December 2018. Only clinical trials, case reports, case series and retrospective analyses published in the English language were included.

Results: Our search yielded 107 articles and 35 clinical trials, of which 15 are still ongoing. The tumor necrosis factor-α inhibitors adalimumab and infliximab were the most comprehensively studied agents. Published data from clinical trials support the efficacy of adalimumab, infliximab, anakinra, ustekinumab, bermekimab and apremilast but not etanercept and MEDI8968. Clinical trials for CJM112 have been completed, with results awaiting publication. Trials are underway for secukinumab, IFX-1, INCB054707 and bimekizumab. Biologics used in smaller cohorts include canakinumab, golimumab and rituximab. Most agents are well tolerated and demonstrate a good safety profile, with the most commonly reported adverse event being infections.

Discussion and conclusions: To date, adalimumab is the only biologic which has been approved by the United States Food and Drug Administration for HS. However, other agents also show promise, with further trials underway to evaluate their efficacy, tolerability and safety profiles. Different clinical measurement scores and endpoints used to make direct comparison difficult. Longitudinal surveillance and pooled registry data are paramount to evaluate the long-term safety profile and efficacy of therapy.

Association of pyrin mutations and autoinflammation with complex phenotype hidradenitis suppurativa: a case-control study

BACKGROUND

Hidradenitis suppurativa (HS) is a rare, debilitating neutrophilic dermatosis characterized by chronic inflammation of hair follicles. Many inflammatory conditions may accompany HS.

OBJECTIVES

To investigate the association of variants of the MEFV gene with a complex HS phenotype.

METHODS

Firstly, we identified the clinical characteristics of 119 patients with HS with a complex phenotype (Hurley stage III disease and/or additional inflammatory symptoms). Then, we searched for MEFV variants among these patients. The odds ratios (ORs) for pathogenic MEFV mutations were calculated using data from these patients with HS and 191 healthy controls.

RESULTS

The male/female ratio was higher, and the mean age of onset was earlier, in our complex HS group compared with patients with HS in general. Five of the patients with HS (4·2%) had a diagnosis of familial Mediterranean fever (FMF) with a standardized morbidity ratio of 45 [95% confidence interval (CI) 16·50-99·84, P < 0·001] when compared with the frequency of FMF in the general Turkish population. Of the patients with complex HS, 38% were positive for pathogenic variants of MEFV. The OR for carrying a pathogenic MEFV allele was 2·80 (95% CI 1·31-5·97, P < 0·001).

CONCLUSIONS

The frequency of MEFV mutations in the group of patients with complex HS was higher than that in healthy controls, suggesting that MEFV mutations may contribute to the pathogenesis of HS. Understanding the role of autoinflammation in HS is of fundamental importance for the development of novel therapies.

Adalimumab in treatment-resistant hidradenitis suppurativa following recurrence after extensive affected area excision: a review of biologics therapy

BACKGROUND

Hidradenitis suppurativa (HS) is characterized by chronic, suppurative abscesses, sinus tracts, and fistulas affecting the axilla, groin, and perianal region resulting from hyperkeratosis and occlusion of the terminal hair follicle.

OBJECTIVE

This report highlights the use of biologic agents for the treatment of recalcitrant HS.

METHOD

We report on a 48-year-old male with a 15-year history of refractory perianal-inguinal-buttock HS who, despite receiving numerous surgical drainages and traditional medical treatment for HS, still had severe pain. After trialing etanercept and infliximab with methotrexate, the patient had marked improvement with adalimumab. A literature review of biologics therapy was also performed.

RESULTS

After trialing many traditional therapies, we found that adalimumab appears to be the most effective treatment modality for our patient. A literature search revealed 53 articles on biologics therapy in HS. These articles are summarized.

DISCUSSION

Biologic agents have been shown to have variable results in the treatment of refractory HS. Enough low-grade evidence has been accumulated to make the use of these agents suitable in HS. Until more clinical trials are performed on this topic, physicians should use clinical judgment when treating HS with biologic agents and be cautious by watching for significant adverse effects.

The off-label treatment of severe hidradenitis suppurativa with TNF-α inhibitors: a systematic review

To provide an overview of the current evidence regarding off-label treatment of hidradenitis suppurativa (HS) with TNF-α inhibitors, a systematic search was performed in MEDLINE, EMBASE and CENTRAL. Any type of original article concerning HS patients treated with infliximab, etanercept and/or adalimumab was included. No language restriction was applied. After full-text screening 65 studies involving 459 patients met the inclusion criteria and were subjected to data extraction. Four randomized controlled trials (RCTs) were available, and the remainders were case series or reports. Only RTCs were subjected to methodological quality assessment. Based on efficacy data extracted from the case reports, a moderate to good response was seen in 82% of the patients treated with infliximab, 76% of the patients treated with adalimumab, and 68% of the patients treated with etanercept. Due to the moderate level of evidence only a weak recommendation can be provided. If conventional treatment options fail, the use of TNF-α inhibitors can be a useful supplement for the treatment of recurrent severe HS. Infliximab should be preferred based on the most encouraging results regarding efficacy and expenses. Also adalimumab seems promising when administered in higher doses. The use of etanercept should be discouraged.