I. Introduction

There is no “one size fits all” treatment for HS so there are a number of medications that dermatologists recommend. This chapter explains non-antibiotic medical approaches to empower you to make informed decisions about your care alongside your healthcare provider. It is possible that one of these treatments, or a combination of treatments, may be helpful for you.

II. Hormonal Regulators

Hormones are molecules that act as messengers in the body. Androgens are a hormone type that affect growth and reproduction. Androgens can cause skin cells to overgrow and block the hair pore. This can spark early HS stages. Androgens can further trigger hyperactive immune response, worsening HS symptoms.

Oral Contraceptive Pills. Oral contraceptive pills (OCPs) contain two sex hormones: estrogen and progesterone. They stop pregnancy by blocking egg maturity. OCPs can help with HS symptoms by decreasing active androgens, lessening hair pore blockage and hyperactive immune response. OCPs may also treat HS by stabilizing hormones. Hormonal changes during menstrual cycles (“periods”) and pregnancy may also affect HS patients. Please see Chapter 8 for more information.

The research on the effect of OCPs on patients with HS is mixed. If you are a patient whose HS symptoms fluctuate with hormonal changes (examples: menstrual cycles, pregnancy), you and your healthcare provider can discuss OCPs as a treatment option.

Recommended dosage of estrogen content for OCPs is less than 50 micrograms per day. It may be combined with other treatment methods, including antibiotics and non-biologic immunosuppressants. Side effects include vaginal bleeding/discharge, nausea, headaches, abdominal cramping, and breast tenderness. Do not take OCPs if you are pregnant, smoke, or if you suffer from high blood pressure, valvular heart disease, or migraines.

Spironolactone. Spironolactone has been typically used a diuretic. Diuretics treat heart failure and high blood pressure. However, spironolactone also has the added benefit of decreasing androgen production as well as androgen effects. It is taken by mouth and recommended dosage starts at 25-50 milligrams (mg) per day (can increase up to 50-200 mg/day) based on response. Spironolactone may be combined with other therapeutics like OCPs.

Female HS patients may benefit from spironolactone therapy. Male patients cannot take spironolactone due to the breast enlargement side effect in men. Other side effects include liver toxicity and electrolyte abnormalities. Do not take spironolactone if you are pregnant, already take certain diuretic medications for high blood pressure or heart failure, have irregular periods, or suffer from Addison’s disease.

Finasteride. Finasteride is a 5-alpha reductase inhibitor. 5-alpha reductase converts weak androgens into stronger androgens. This medication
type is typically used for patients suffering from benign prostate hyperplasia and male pattern baldness. Strong androgens interact with the skin to produce HS symptoms (hair pore blockage). Finasteride blocks 5-alpha reductase, decreasing the amount of strong androgens in the skin.

Both men and women can take finasteride. It is notably good for those with other hormonal conditions like polycystic ovary syndrome (PCOS), metabolic syndrome, and precocious puberty. Patients with PCOS experience irregular periods, excess facial and body hair, severe acne, and cystic ovaries. Metabolic syndrome is a cluster of conditions that occur together (high blood pressure, high blood sugar, high cholesterol, and excess body fat around the waist). Precocious puberty is when a child’s body goes through puberty too early (before age eight in girls and before age nine in boys).

Finasteride is taken by mouth and the recommended dosage ranges from 2.5-10 mg per day. Side effects include erectile dysfunction and low blood pressure while standing. You should not take finasteride if you are pregnant, breast-feeding, or planning to become pregnant.

III. Retinoids

Retinoids are vitamin A derivatives that are known to treat acne. Retinoids decrease skin inflammation and hair prevent hyperactive immune responses, which normally incite HS symptoms. They include a variety of medications such as isotretinoin and acitretin.

Besides antibiotics, pain medication, and topical steroids, retinoids are the most prescribed medication for HS. Some studies suggest that isotretinoin is better for milder HS, or for patients with both acne and milder HS. Severe, difficult-to-treat HS may respond well to acitretin. It is taken by mouth and the daily recommended dosage is 0.5-0.6 mg per kilogram (kg) of body weight. Studies suggest therapeutic benefit in combining isotretinoin with other HS treatments, such as antibiotics and surgery. However, more studies are needed.

Common side effects of retinoid medication include skin dryness and eye dryness. Blood work needs to be checked closely, as it can affect liver function as well as increase fat levels in the blood. Retinoids are harmful to fetuses, and should not be taken if you are pregnant or breast-feeding. Women of child-bearing potential are required to either commit to abstaining from sexual inter course or use two forms of contraception such as condoms and birth control pills

IV. Non-biologic Immunosuppressant

Hyperactive immune response can lead to HS symptoms. Two different medication classes are used to fight this hyperactive immune response: immunomodulators and immunosuppressants. Biologic immunomodulators target specific parts of our immune systems. Immunosuppressants decrease the body’s overall immune response. In rare cases, biologic immunomodulators may trigger immediate side effects (examples: allergies, infusion reaction, serum sickness). “Biologic” medications are derived from natural sources.

The rest of this chapter focuses on different non-biologic immunosuppressants. Each immunosuppressant has risks and benefits. Overall, immunosuppressants do decrease immune function, which includes the ability to fight infection. Appropriate use and routine monitoring by your doctor is the key.

Colchicine. Colchicine is an immunosuppressant which disrupts the movement and development of immune system cells called neutrophils. Without colchicine, these cells are part of the hyperactive immune response that assists in HS lesion development. Colchicine may be best for mild-moderate HS.

Colchicine is taken by mouth at a recommended dose of 0.5 milligrams twice per day. Combining colchicine with tetracycline antibiotics (examples: tetracycline, doxycycline, minocycline) may boost HS symptom relief. Potential side effects include nausea and diarrhea. You should not take colchicine if you are pregnant, or suffer from liver or kidney disease.

Methotrexate. Methotrexate is an immunosuppressant which inhibits immune cell activity. It is taken on a weekly basis by mouth or injection. Patients may experience stomach upset when taken by mouth. Methotrexate depletes the body’s folic acid storages, so patients taking methotrexate must also take folic acid supplements.

Methotrexate is combined with other immunosuppressants to increase effectiveness and prevent treatment tolerance, which is when the medication at your current dose has stopped working as effectively as it once did. Potential side effects include liver toxicity, nausea, and decreased bone marrow activity. You should not take methotrexate if you are pregnant. Methotrexate may slightly increase the risk of developing lymphoma.

Dapsone. Dapsone is both an antibiotic and anti-inflammatory agent. It blocks immune cell movement (neutrophil migration). Dapsone may be beneficial for patients with mild-moderate HS. It is taken by mouth at an initial daily dose of 25 mg twice per day (can increase up to 100 mg twice per day). Dapsone has been combined with other HS therapies in small studies, but more research is needed. A major side effect of dapsone therapy is decreased white and red blood cell counts, as well as shortness of breath. For this reason, frequent lab tests and symptom monitoring are required.

Prednisone. Prednisone is a steroid medicine used in many health conditions to decrease immune hyperreactivity. It is taken orally at varying doses. Side effects include mood/sleep disturbance and high blood sugar.

It should be noted that long-term treatment with prednisone alone is not recommended, given the side effects of long-term steroid use (osteoporosis, weight gain, skin thinning). However, it may be helpful as a short-term treatment for HS flares, and can be combined with other treatments.

Cyclosporine. Cyclosporine is an immunosuppressant that blocks immune cell development and inflammatory response pathways. While there are a few reports of successful treatment with cyclosporine, more studies are needed. Patients with severe HS may find cyclosporine helpful. It is taken by mouth and the daily recommended dosage range from 1-6 mg/kg. Side effects include enlargement of gums, high blood pressure, and kidney damage. Lab monitoring is required for this reason. Cyclosporine may also increase the risk of developing cancer, especially lymphoma.