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Anais Brasileiros de Dermatologia

Print version ISSN 0365-0596

An. Bras. Dermatol. vol.84 no.6 Rio de Janeiro Nov./Dec. 2009

http://dx.doi.org/10.1590/S0365-05962009000600022 

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Hidradenitis suppurativa treated with infliximab*

 

 

Daniel Lago ObadiaI; Egon Luiz Rodrigues DaxbacherII; Thiago JeunonIII; Alexandre Carlos GrippIV

ISpecialist in Dermatology, Sociedade Brasileira de Dermatologia (SBD), Graduate studies in Dermatology, Universidade do Estado do Rio de Janeiro (UERJ), Deputy Professor, Service of Dermatology, Universidade do Estado do Rio de Janeiro (UERJ) – Rio de Janeiro (RJ), Brazil
IISpecialist in Dermatology, Sociedade Brasileira de Dermatologia (SBD), Graduate studies in Dermatology, Universidade do Estado do Rio de Janeiro (UERJ), Deputy Professor, Service of Dermatology, Universidade do Estado do Rio de Janeiro (UERJ) – Rio de Janeiro (RJ), Brazil
IIISpecialist in Dermatology, Sociedade Brasileira de Dermatologia (SBD), Residence Program in Dermatology, Universidade do Estado do Rio de Janeiro (UERJ), Physician/preceptor of the Service of Dermatology, Hospital Geral de Bonsucesso - Rio de Janeiro (RJ), Brazil
IVSpecialist in Dermatology, Sociedade Brasileira de Dermatologia (SBD), Residence Program in Dermatology, Universidade Federal Fluminense (UFF), Master in Dermatology, Universidade Federal Fluminense (UFF), Assistant Professor of Dermatology, Universidade do Estado do Rio de Janeiro (UERJ) - Rio de Janeiro (RJ), Brazil

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ABSTRACT

Hidradenitis suppurativa is an inflammatory disease with difficult treatment. Currently, the anti-TNF alfa therapy, with monoclonal antibodies ("biological therapy"), has been shown as a new alternative. However, clinical trials assessing the efficacy of these drugs to treat hidradenitis suppurativa have not yet been published. A case in which the use of infliximab did not result in significant clinical improvement is described.

Keywords:ANTIBODIES, MONOCLONAL; TUMOR NECROSIS FACTOR-ALPHA; HIDRADENITIS


 

 

Hidradenitis suppurativa (HS) is a chronic inflammatory disease with predilection for areas such in apocrine glands, such as axillar, inguinal, perineal and intergluteal areas 1. Prevalence ranges between 0.33 and 4 cases per 1,000 inhabitants 2 and its etiology has not been completely understood yet 3. HS comprises, together with acne conglobata, folliculitis and perifolliculitis capitis abscedens et suffodiens and pilonidal cyst, a group of clinically different diseases that have similar histopathological findings, known as follicular occlusion tetrad. At first, there is suppurative infundibulitis and follicular rupture, followed by superficial and deep mixed inflammatory infiltration caused by neutrophils, lymphocytes, plasmocytes and formation of suppurative granulomas. Granulation tissue and dermal hair stems are observed at variable amounts. Later, fibrosis and fistulae become prominent 4. Inflammation of apocrine glands, considered to be the main pathological process in the past, is a secondary event to follicular impairment.

HS has chronic course in most cases, with periods of exacerbation and improvement, despite the many therapeutic options frequently used. Among them, we can include topical and systemic antibiotics, intralesion and oral corticoids, oral isotretinoin, surgery, cryotherapy, hormonal therapy, among others. Recently, the use of infliximab has been suggested as an effective alternative.

We present the case of a male 49-year-old Caucasian patient who reported onset of erythematous and painful nodules under the armpits and inguinal region since the age of 15 years, when he was diagnosed as having HS. Since then, he had presented periods of improvement and worsening, with partial response to different treatment approaches, but never achieving complete remission of the lesion. He had taken oral tetracycline, erythromycin, cefalexine, ciprofloxacin and isotretinoin. Fifteen years before, he underwent surgical glandular dissection in the axilla, and nine years later, he took oral prednisone to treat pyoderma gangrenosum of the legs. On the visit day, he was taking ciprofloxacin 500 mg/ day and prednisone 20 mg/ day with poor control of the disease.

Dermatological examination showed 1 cm erythematous nodules, with yellow-greenish discharge in the axillas, in addition to scars and skin fistulae in the inguinal regions. In the sacral region, he had an ulcer measuring 7 cm long by 4 cm deep, with erythematous margins and yellowish discharge (Figure 1). The possibility of association with Crohn's disease was excluded by proctologic assessment. The patient was submitted to active or previous tuberculosis infection investigation and the results were negative. Infliximab at 300 mg dose (4.6 mg/kg) per infusion was administered, comprising four infusions (weeks 0, 2, 6 and 10). There were no infusion-related reactions.

 

 

As of the second infusion, there was decrease in discharge from the lesion. However, the sacral ulcer did not reduce its diameter or depth. During infliximab use, prednisone dose was reduced to 10 mg/day, but there was no significant improvement at the end of four applications. The patient was then referred for hyperbaric therapy, but it did not improve significantly his status either (Figure 2).

 

 

Reports and case series have suggested that infliximab may be an efficient medication to treat HS, even though it has not been approved to that purpose 5,6,7,8. Fadet et al reported very good response in five out of seven patients on week 6 of treatment, even though three had presented severe adverse effects 5. Fernández-Vozmediano et al had improvement in six patients studied after the 1st infusion, with mild infusion-related reactions only 7. The suggested dose is 5 mg/Kg application in intravenous infusions on weeks 0, 2 and 6. If necessary, an additional infusion may be given on week 10, as used to treat Crohn's disease and rheumatoid arthritis 9,10. However, the literature does not present controlled clinical trials to quantify and confirm the efficacy of the drug. Considering that therapeutic successes are more appealing to be published than therapeutic failures, it is likely that the efficacy of infliximab in managing HS is overestimated. The present case illustrates that the use of infliximab to treat HS is not an assurance of success. Undoubtedly, the performance of controlled studies with larger samples will contribute for better selection of patients and rational choice of infliximab use in cases in which the medication proves to be the best therapeutic option.

 

REFERENCES

1.  Kurzen H, Kurokawa I, Jemec GB, Emtestam L, Sellheyer K, Giamarellos-Bourboulis EJ, et al. What causes hidradenitis supurativa? Exp Dermatol. 2008;17:455-472.         [ Links ]

2.  Naldi L. Epidemiology. In: Jemec G, Revuz J. Leyden J, eds. Hidradenitis suppurativa. vol 1. Germany: Springer 2006. p. 58-64.         [ Links ]

3.  Hay RJ, Adriaans BM. Bacterial infections. In: Rook's textbook of dermatology. Oxford: Blackwell Publishing; 2004. p.27.82-84.         [ Links ]

4.  Ackerman AB, Böer A, Bennin B, Gottlieb GJ. Histologic Diagnosis of Inflammatory Skin Diseases. An Algorithmic Method Based on Pattern Analysis. 3rd ed. New York: Ardor Scribendi; 2005.         [ Links ]

5.  Fardet L, Dupuy A, Kerob D, Levy A, Allez M, Begon E, et al. Infliximab for severe hidradenitis suppurativa:transient clinical efficacy in 7 consecutive patients. J Am Acad Dermatol. 2007;56:624-8.         [ Links ]

6.  Adams DR, Gordon KB, Devenyi AG, Ioffreda MD. Severe hidradenitis suppurativa treated with infliximab infusion. Arch Dermatol. 2003;139:1540-2.         [ Links ]

7.  Fernández-Vozmediano JM, Armario-Hita JC. Infliximab for the treatment of hidradenitis suppurativa. Dermatology. 2007; 215:41-4.         [ Links ]

8.  Thielen AM, Barde C, Saurat JH. Long-term infliximab for severe hidradenitis suppurativa. Br J Dermatol. 2006;155:1105-6.         [ Links ]

9.  Sullivan TP, Welsh E, Kerdel FA, Burdick AE, Kirsner RS. Infliximab for hidradenitis suppurativa. Br J Dermatol. 2003;149:1046-9.         [ Links ]

10.  Lebwohl B, Sapadin AN. Infliximab for the treatment of hidradenitis suppurativa. J Am Acad Dermatol. 2003;49(5 Suppl):S275-6.         [ Links ]

 

 

Mailing Address:
Daniel Lago Obadia
Rua Nossa Senhora de Lourdes, 83-102. Grajaú
20540 370 Rio de Janeiro, RJ
Tel.:/Fax: 21 2577 8753; 2587 6622
e-mail: danielobadia@hotmail.com

Funding: None
Conflict of interest: None

 

 

* Study carried out at Universidade do Estado do Rio de Janeiro (UERJ) – Rio de Janeiro (RJ), Brazil.