Researchers have developed the first comprehensive clinical practice guidelines for managing hidradenitis suppurativa in special patient populations, addressing a significant gap in the literature.
The guidelines, published in the Journal of the American Academy of Dermatology, provide 118 expert consensus statements covering seven specific patient populations often excluded from clinical trials.
The recommendations were developed by a large group of experts co-chaired by Raed Alhusayen, MBBS, MSc, and Haley B. Naik, MD, MHSc, using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system to ascertain levels of evidence, with final recommendations selected through a modified Delphi consensus process.
"Managing [hidradenitis suppurativa (HS)] is challenging due to limited high-quality evidence and scarce guidance for special patient populations often excluded from clinical trials," the guideline authors stated.
The guidelines specifically cover management approaches in patients with HS who are:
- Pregnant
- Breastfeeding
- Pediatric
- Affected by malignancy
- Infected with tuberculosis (TB)
- Infected with hepatitis B or C
- Diagnosed with human immunodeficiency (HIV) virus.
Among pregnant patients, the guidelines suggest that topical antibiotics can be used with an approach similar to other HS populations, while resorcinol should be avoided because of its potential risks to fetal neurodevelopment. Regarding systemic antibiotics, cephalexin, azithromycin, and clindamycin are considered safe during pregnancy, while doxycycline should be avoided as a result of its potential risks of congenital anomalies and tooth discoloration.
The guidelines strongly recommend metformin as the antiandrogen of choice in pregnant patients with HS, supported by numerous randomized controlled trials and cohort studies in pregnant patients with type 2 diabetes, gestational diabetes, or polycystic ovary syndrome.
For biologics, the guidelines state: "In patients with HS who are planning pregnancy while well-controlled on biologics, we recommend continuing biologic therapy throughout the pregnancy." Adalimumab specifically receives a strong recommendation for use during pregnancy.
The guidelines provide conditional recommendations for various antibiotics during breastfeeding, including rifampin, clindamycin (with caution because of its potential gastrointestinal effects in infants), amoxicillin/clavulanic acid, erythromycin, azithromycin, and metronidazole. For doxycycline, "[w]e recommend limiting the use of oral doxycycline; if no suitable alternative antibiotic is available, oral doxycycline use should be limited to < 3 weeks and without repeating courses," the guideline authors indicate.
Regarding biologics during breastfeeding, the guidelines suggest that "biologics are likely safe to use during breastfeeding based on pharmacokinetics, as these are large proteins not well-absorbed by the [gastrointestinal] tract, with very little medication passing into breast milk." Adalimumab receives a strong recommendation in patients who are breastfeeding.
Among pediatric patients, the guidelines recommend oral doxycycline for those 8 years and older, and suggest combination therapy with oral rifampin and clindamycin. Adalimumab is strongly recommended in patients 12 years and older.
"In pediatric patients with HS who require biologics, we recommend using adalimumab for patients 12 y[ears] and older," the guidelines authors state. Among patients aged 2 to 11 years, adalimumab receives a conditional recommendation.
The guidelines provide detailed recommendations for managing HS in patients with comorbid conditions. Among those with a history of malignancy, the guidelines emphasize a multidisciplinary approach: "When considering immunosuppressive medications or biologics for patients [with HS] in the setting of malignancy, we recommend the physician consult with the patient's oncologist and take into account activity of HS, patient's age, characteristics of the previous cancer (organ, stage, histologic type, and prognosis), the time since completion of cancer treatment, and the individual carcinogenic effects of immunosuppressants."
For patients with TB concerns, screening recommendations are provided for those requiring biologics, with preference for Interferon-Gamma Release Assay (IGRA) testing in regions with high Bacille Calmette-Guérin (BCG) vaccination rates. The guidelines state: "In patients with HS who require biologics, we recommend screening for TB prior to initiation. Screening can be performed with [a tuberculin skin test] and/or IGRA, but in endemic regions with high percentages of BCG vaccination, IGRA may improve sensitivity and specificity."
For hepatitis B and C management, the guidelines strongly recommend screening for these conditions prior to initiating immunosuppressive therapy. They also emphasize that "in HBsAg-positive patients who require immunosuppressants or biologics for HS, we recommend coordinating care with a hepatologist."
Among patients with HIV, the guidelines specifically recommend coordinating care with infectious disease specialists: "In patients with HS and HIV positivity who require systemic immunomodulators or biologics, we recommend coordinating care with an ID specialist and taking into account factors such as HIV control (viral load, CD4 count) and potential for drug interactions."
These guidelines represent a significant advancement in the management of HS in special populations, providing evidence-based guidance for clinicians treating these complex patients. They highlight the importance of multidisciplinary care and tailored approaches based on individual patient circumstances.
"These guidelines address the unique needs of diverse groups typically underrepresented in clinical trials, and highlight the importance of a multidisciplinary approach," the guideline authors conclude.
An extended version of these guidelines, as well as detailed methodology, is available via data.mendeley.com.
Full disclosures can be found in the published guidelines.