And Other Corticosteroids

18.3.2 Ciclosporin

Early studies of adrenocorticotrophic hormone (ACTH) and corticosteroids suggested that general immunosuppression was beneficial to the well-being of HS patients [4]. These studies however do not conform to current requirements for evidence as they are anecdotal rather than randomized and controlled. Relief is however regularly offered to patients with flares of HS by treating with prednisolone, either as monotherapy or in combination with other therapies. In this manner systemic corticoste-roids may be used in a manner analogous to their use in acne fulminans. Usually doses of 0.5-0.7 mg/kg are sufficient to achieve control of the inflammation. Initial doses can then be tapered over weeks to control the disease. However, in some cases tapering is not possible due to rapid flares and alternative therapies must therefore be instituted. The patients reported by Rose et al. [5] are examples of such cases. Systemic corticosteroids are therefore often used in conjunction with other therapies such as antibiotics [6, 7].

Careful swabbing and biochemical control are necessary to identify ongoing clinically significant infections when prednisolone therapy is instituted. Similarly patients must be informed of possible side-effects of the treatment.

Intralesional steroids are also an important tool for HS management, although their use is again unsupported by formal studies. Intrale-sional steroids are most often used to treat recalcitrant nodules in HS (see Chap. 21). Triamcinolone (10 mg/ml) is the most commonly used drug, but other drugs may be as efficient. The effect of the injection occurs after a few days, either as the disappearance of the lesion, or spontaneous rupture. Pain is generally reduced significantly in a short space of time. The long-term effect of using intralesional corticosteroids is not known. In our experience complications, with for example superinfection, are rare, and can be monitored through more aggressive microbiological sampling with regular swabs from lesions that do not react in the described manner but persist or develop in spite of treatment.

Single cases have been presented showing the beneficial effects of ciclosporin (CsA) in the management of HS [8, 9]. CsA has been used successfully where patients' responses to systemic corticosteroids were found to be unsatisfactory because of rapid relapses [5]. One case found that a 4-month remission was induced by CsA therapy, and that subsequent flares were milder, but CsA has also been used as a low-dose, long-term suppressive therapy.

A beneficial effect of CsA would be in accordance with the described early changes of HS, where a perifollicular lymphocytic infiltrate has been found [10]. In other diseases the use of CsA has furthermore been characterized by a rapid onset of effect, which may be of particular interest to HS patients because of the associated pain reduction. No long-term results (years) or larger case series have been reported.

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