Isotretinoin Therapy in Patients with Acne and Coexistent HS

It is well known that acne and HS can occur in the same person. In addition to the coexistence of acne and HS, there are the so-called acne triad (acne conglobata, HS and perifolliculitis capitis abscedens et suffodiens) and acne tetrad (original acne triad and pilonidal sinus) conditions [16]. This clinical overlap of acne and HS has led to the inclusion of inhomogeneous patients in the treatment groups. It concerns two possible different types of HS; firstly the disease that only affects the inguinal folds and the axil

Table 17.1. Reported results of isotretinoin therapy for hidradenitis suppurativa (HS)

0

«

ID

tn

S 'm

Duration of HS (years)

f o ity

No. of patients with an (almost) clear score

<

0 1

tients

D

e

0 S.

^ S

S SS

At the end of treatment

At the end of follow-up

Jones et al. [7]

3

1.0

4

-

20-30

Severe

0 (0%)

-

Dicken et al. [8]

8

0.71-1.2

4

2-6

5-35

Severe

4 (50%)

1 (12.5%)

Norris and Cunliffe [9]

6

1.0

4

2

many years

Severe

0 (0%)

-

Brown et al. [10]

1

1.0

4

4

3

Severe

1 (100%)

1 (100%)

Mengesha et al. [11]

1

1.0

8

12

1

Severe

0 (0%)

-

Boer and van Gemert [12]

68

0.5-0.81

4-6

6-107

1-30

Mild to severe

16 (23.5%)

11 (16.2%)

Table 17.2. Reported results of isotretinoin treatment of patients with acne and coexisting HS

Author (s)

No. of patients

Dose (mg/kg per day)

Duration of treatment (months)

Improvement of HS

Recurrence

Jones et al. [18]

1

0.1-1.0

4

No change

-

Plewig et al. [19]

Unspecified

1.0-2.0

3

To a certain extent

-

Peck et al. [20]

2

High, no precise data

No data

Improvement

-

Shalita et al. [13]

Unspecified

0.5-1.0

4-5

Only suppressed furunculoid lesions. No change in sinus tracts

-

Harms [21]

2

0.5-1.0

6

Improvement

-

Harms [2]

5

No data

No data

Considerable improvement in 4 out of 5 patients

No

Libow and Friar [22]

1

0.2-1.0

9

Quiescent

No

lae ("Verneuil's disease"), and secondly inguinal and axillary involvement in patients with acne affecting the face and back [2, 13, 17]. The last disease has also been called acne ectopica and acne tetrad.

It has been suggested that patients of these two categories would respond to isotretinoin in different ways [2, 13, 14, 17]. The data are summarized in Table 17.2.

Harms [2] treated eight patients suffering from HS, of whom five had concurrent acne of the face and three did not. Four out of five patients with the combination of acne and HS improved considerably under treatment with isotretinoin and did not suffer any recurrence. The three patients who had only inguinal involvement did not improve (data about the doses, duration of isotretinoin course and follow-up were not mentioned). It was concluded that patients with lesions only in inverse areas (axil-17 lae, groin) should not be treated with isotreti-noin and that there may be patients with HS who respond very well to isotretinoin, namely those with a combination of acne and additional HS [2, 17].

Other authors [13, 14] found that patients with sinus tracts in the areas of acne with coexisting HS of the axillae and groin were often isotretinoin "failures," in that isotretinoin ther apy did not always totally suppress this type of lesion. The conclusion of the authors was that sinus tracts require surgical removal [13, 14].

In several initial trials of isotretinoin in acne, the investigators often included some patients with HS in addition to their severe acne. Jones, Blanc, and Cunliffe reported one case who failed to respond after a 4-month course on an unspecified dose of between 0.1 and 1.0 mg/kg per day [18]. Plewig and colleagues treated an unspecified number of patients with acne tetrad who responded to a certain extent [19]. Peck et al. included two patients with HS in the groin and axilla in addition to their cystic acne, who showed improvement of the HS after the cystic acne had begun to improve and when the dosage had been further increased above the level required to improve their acne (the actual doses used were high but not specified) [20]. Harms described in a case series of 56 patients with nodulocystic acne including two patients with ano-inguinal lesions which only improved on isotretinoin at a dosage of 0.5-1.0 mg/kg per day for 6 months [21]. Libow and Friar reported effective treatment of a patient with arthropathy with associated acne triad condition with isotretinoin [22]. A patient has been described with arthropathy associated with cystic acne, HS (in this case papulo-pustules and cysts in volving the genital and inguinal areas, no sinus tracts), and perifolliculitis capitis abscedens et suffodiens who showed a dramatic response to isotretinoin (1.0 mg/kg per day) for 6 months, followed by isotretinoin (0.5 mg/kg per day every other day) for another 3 months before being discontinued. At the completion of 6 months of therapy, his cutaneous disease was quiescent and there was no recurrence of either joint or cutaneous disease (a follow-up period was not mentioned).

So, the results of these case reports [2, 13, 18-22] are at best equivocal compared to the excellent results in acne treatment. In the same patients the acne seemed to clear completely or was much improved, while in most case reports the HS lesions obviously remained and showed only a limited response. A follow-up period was never mentioned. A (partial) response of HS lesions to isotretinoin was also more slow to develop than the response to acne. Moreover, isotretinoin has a very poor effect on sinus tracts, whether located in the same area as the acne or in the axillae and groin [13, 14, 16, 23].

The use of oral isotretinoin has been recommended by Plewig and co-workers during the weeks or months before surgery and even post-operatively [16, 24]. The drug has anti-inflammatory activity and may drastically reduce suppuration and edema [24]. It also reduces the volume of the sebaceous glands and alternates the pattern of keratinization within the follicle [25]. It has been suggested that in this way the area involved by HS lesions can be significantly reduced [25, 26], although isotretinoin by itself is insufficient to stop the disease [16, 24].

In various German trials, patients were treated with an unspecified dose of between 0.2 and 2.0 mg/kg per day for the 2-4 months before surgical intervention until some days postoper-atively and, if indicated, in combination with glucocorticosteroids for 2-3 weeks at a dose of 0.2-1.0 mg/kg per day and systemic antibiotics [24-26]. Lentner, Rubben and Wienert then reported on 28 patients with HS who responded only poorly to oral antibiotics and isotretinoin (dose were not mentioned) [27]. The authors did not observe preoperative "conditioning" of the HS regions and in their case series they did not recognize any minimalization of the areas involved by the HS lesions. No controlled trials are available to assess the claims of the usefulness of this pre- and postoperative treatment with oral isotretinoin.

Acne Myths Uncovered

Acne Myths Uncovered

What is acne? Certainly, most of us know what it is, simply because we have had to experience it at one time or another in our lives. But, in case a definition is needed, here is a short one.

Get My Free Ebook


Post a comment