Dr. Steve Daveluy discusses treating hidradenitis suppurativa concomitant with chronic infections or malignancy and provides tips for therapy selection in HS patients with health issues that complicate treatment.
Steve Daveluy, MD, Associate Professor and Program Director, Wayne State Dermatology, Detroit, Michigan, and President, Michigan Dermatological Society.
“I covered chronic infections, including tuberculosis, hepatitis, and HIV, as well as patients with active or history of malignancy and how you might want to adjust your therapies to take care of their hidradenitis suppurativa (HS),” said Steve Daveluy, MD, who presented “Treating HS in the setting of malignancy and chronic infections” during the “Hidradenitis Suppurativa: Case-based Clinical Pearls” session at the 2023 AAD Innovation Academy in Tampa, Florida.
Starting with Tuberculosis
In the setting of HS and tuberculosis (TB), rifampin is a great choice for treating latent TB because it is a proven therapy for latent TB and has evidence that it can improve HS, said Dr. Daveluy.
“Metformin has been shown to lower people’s risk of getting tuberculosis, so it’s a great choice if someone has increased risk of exposure for contracting tuberculosis. It might help their HS and help to lower their TB risk.”
According to Dr. Daveluy, chronic steroid treatment increases the risk for tuberculosis. Dermatologists with patients on long-term steroids should be screening for TB, just like they would with a biologic or Janus kinase (JAK) inhibitor, he said.
“Other treatments including acitretin, apremilast, and interleukin (IL)-17 inhibitors don’t have any [reported] cases of TB reactivation and have some evidence that they can help HS, so they can be great choices.”
Tumor necrosis factor (TNF) inhibitors have a risk of reactivating latent TB, said Dr. Daveluy.
“But it has been proven in other disease states, outside of HS, that after one month of treatment for TB it’s safe to start a TNF inhibitor. I should mention we don’t have this data yet for HS, so we’re looking at the rheumatoid arthritis and inflammatory bowel disease literature and extrapolating these recommendations.”
HS Patients with Hepatitis
Dermatologists should avoid systemic steroids when treating patients with hepatitis for HS because the steroids have been linked to poorer outcomes, said Dr. Daveluy.
“Both metformin and oral contraceptives have been shown to be safe to use in patients with hepatitis, with no increased risk of hepatocellular carcinoma.”
When starting a biologic, dermatologists should also start treatment for hepatitis, he said.
“In this case, you don’t necessarily need to delay. You can start [the biologic and hepatitis treatment] at the same time. But you might want to start the hepatitis treatment first just to make sure that they don’t have any issues with insurance coverage or picking it up.”
There is a risk of reactivation of hepatitis, which is greatest with TNF inhibitors, followed by IL-12/23 inhibitors, and lastly the IL-17 inhibitors, said Dr. Daveluy.
“If you want to decrease that risk, you can go with something like an IL-17 inhibitor, and we should have a couple of those approved for HS very soon.”
HS and HIV
Using clindamycin without rifampin is advised for treating HS in the setting of HIV, said Dr. Daveluy.
“There is evidence from HS patients that clindamycin monotherapy is just as effective and safe as the combination of clindamycin and rifampin, which we used for a long time because it had randomized controlled trials. I’ve shifted my practice a little to use more clindamycin alone. Specific to HIV, rifampin can have increased risk of side effects when given with anti-retrovirals. That’s why with HIV it’s particularly important to leave that out.”
According to Dr. Daveluy, both cotrimoxazole and dapsone are used in HIV for pneumocystis jirovecii pneumonia (PJP) prophylaxis and there’s evidence that they help with HS. As a result, they can be great choices in patients with uncontrolled HIV, he said.
“Metformin is safe in HIV and has been shown in patients with HIV to reduce some of the other risk factors, like cardiovascular disease.”
TNF inhibitors are safe to use in patients once their HIV has been controlled, said Dr. Daveluy.
“Those biologics aren’t off the table. You just want to get the HIV under control and preferably undetectable, first.”
Acitretin, again, is a good choice because it doesn’t affect the immune system. The main problem with acitretin is that the data in HS isn’t robust and it doesn’t help a lot of patients, he said.
“It has been shown that short courses or low doses of steroids are safe to give in patients with HIV. So as a backup that could be a good treatment if a patient is flaring and you’re struggling to get them under control.”
Malignancy
HS clinical trial investigators typically exclude patients who have a history of solid organ malignancy in the last five years. As a result, there is limited data, said Dr. Daveluy.
“But we are getting more real-world data from other disease states like rheumatoid arthritis and irritable bowel syndrome.”
Dermatologists should avoid using methotrexate, azathioprine, or cyclosporin because of the risks associated with those medications, and while acitretin is safe, it may not be effective, said Dr. Daveluy.
“Antibiotics are safe to use. You just want to make sure that you talk with the patient’s oncologist to make sure there aren’t any interactions with their cancer treatment regimen or any other issues that they’re worried about,” he said.
TNF inhibitors appear safe in patients with a history of malignancy. They haven’t been shown to increase recurrence, with the exception of melanoma, said Dr. Daveluy.
“So, if your patient has a history of melanoma, you are going to want to avoid TNF inhibitors.”
Metformin has been shown to be safe with improved outcomes in various cancers, so it’s a good option, he said.
“Spironolactone and oral contraceptives have actually been shown to be safe to use in patients with breast cancer, even active breast cancer. And finasteride is an option, especially in patients with prostate cancer, as it can improve prostate cancer outcomes.”
IL-17 inhibitors are good choices for patients with a history of cancer, said Dr. Daveluy.
“IL-17 is involved in tumorigenesis and angiogenesis. Studies in mice show that if you treat cancer with a PD-1 inhibitor immunotherapy and add an IL-17 blocker, response improves because cancer cells utilize IL-17 for their growth and evading the immune system. We just don’t have human studies yet but I’m sure they’re coming in the future.”
Disclosure: Dr. Daveluy is a researcher, speaker and consultant for Abbvie and UCB; speaker and consultant for Novartis; and researcher for Pfizer.