Practical Use of Immunosuppressive Therapy

Immunosuppressive therapy can be used at all stages of the disease for the benefit of the patient. Essentially it may be directed at two different aspects of the disease: disease progression and flares.

When used to treat disease progression it is a long-term therapy aimed at controlling the inflammation-induced fibrosis of the tissue, and helping the patient to take more control of their disease. The treatment should be continued for at least 3 months with monitoring of the effect as well as possible side-effects specific to the drug chosen. Very often patients have experienced a relentless progression of their disease and are therefore highly encouraged by the alleviation provided by these drugs. The clinical impression is therefore generally favorable, al though proper randomized controlled trials are lacking. By viewing HS as any other inflammatory skin disease, parallel conclusions may however be drawn about the benefits of such a therapeutic strategy. It may be speculated that long-term immunosuppression and a subsequent reduction of the inflammatory processes may stop or delay the subsequent fibrosis which forms a major factor in the perpetuation of this disease.

In contrast, treatment of flares is a short-term treatment, in which the immunosuppression is aimed at easing the patients' problems, but most often it is used in conjunction with other therapies that may be perceived as being more curative. Particularly in the early stages of the disease immunosuppression may help gain sufficient control of a lesion to allow more curative surgery, as this is made easier if the tissue is not highly inflamed at the time of the operation. Intralesional therapy may be used to achieve this (see Chap. 21). Similarly, immunosuppres-sion at later stages may be combined with, for example, antibiotics to treat the combined effects of long-standing HS and superinfection more effectively.

Just as for most other forms of therapy, the data on which these treatments are used are very limited. Publication of additional, larger case series is therefore strongly encouraged, particularly if the observations are structured so as to provide information about possible dose-effects relationships, which may help determine the optimum dosage of a given drug for use in a subsequent randomized controlled trial.

In general, immunosuppressive therapy is often perceived to be in conflict with the clinical presentation of HS. This is however a view with a limited understanding of the disease process, which involves considerable, sterile inflammation. Therefore, as with many other dermato-logical conditions it may often be treated with anti-inflammatory or immunosuppressive therapies. In addition, these therapies offer the advantage of alleviating patient suffering effectively, if not permanently.

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