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Systemic Immunosuppressant Treatments

Select Treatments:
  • What is it and how does it work?
  • Who is this for?
  • Who is this not for?
  • How well does it work?
  • What are the possible side effects?
  • Will it inconvenience me?

Systemic Immunosuppressant Treatments

What is it and how does it work?

Cyclosporine

Cyclosporine reduces production of proteins involved in immune responses and inflammation (Zouboulis, et al., 2015).

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Cyclosporine targets a class of white blood cells involved in immune responses called T-lymphocytes, and inhibits their production of inflammatory proteins, TNF- α and IL-2.

A combination of colchicine and minocycline

Colchicine reduces inflammation (WebMD).

Minocycline is a tetracycline antibiotic with anti-inflammatory properties (van Straalen, Schneider-Burrus, & Prens, Current and future treatment of hidradenitis suppurativa, 2018).

Systemic steroids

Systemic steroids, also called glucocorticoids, are hormones that reduce inflammation and immune responses, and inhibit cell growth (Zouboulis, et al., 2015).

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Oral prednisone, a commonly prescribed corticosteroid for HS, reduces inflammation, promotes healing, and prevents the formation of new lesions (WebMD, 2018).

Among 13 moderate to severe HS patients who received oral prednisone with their existing treatment, 6 partially responded while 5 responded well after 4-12 weeks (Wong, Walsh, & Alhusayen, 2016).

Methotrexate

Methotrexate is used to treat inflammation (National Cancer Institute at the National Institutes of Health). It should be avoided in a number of different cases, including:

  • Pregnant and nursing women or those at risk of pregnancy due to serious fetal risks (Murase, Heller, & Butler, 2014; Perng, Zampella, & Okoye, 2017);
  • Those with liver or kidney disease, immune deficiency or blood disorders (Lexicomp).

Azathioprine

This medication suppresses the immune system and can be used either by itself or with other medications. No evidence of fetal risks to suggest its contraindication in pregnant women, and acceptable in nursing women (Perng, Zampella, & Okoye, 2017).

Who is this for?

Cyclosporine

Those with moderate to severe HS who were unresponsive to or cannot take standard therapies (Zouboulis, et al., 2015).

A combination of colchicine and minocycline

It may be effective for those with mild to moderate HS.

Systemic steroids

Patients that need rapid, short-term relief for acute flares or while awaiting transition to other long-term medication or surgery (Zouboulis C. C., et al., 2015).

Prolonged use with low doses when combined with another primary treatment in severe HS following inadequate response to standard treatment (Zouboulis C. C., et al., 2015).

Who is this not for?

Cyclosporine

Those with allergies to cyclosporine; with high blood pressure, kidney problems, cancers, or infections (Lexicomp).

Caution should be taken in those receiving ultraviolet light or radiation therapy; immunosuppressive drugs or coal tar (Lexicomp).

A combination of colchicine and minocycline

Colchicine

  • Those with allergies to colchicine; with liver or kidney problems who are taking certain drugs that can interact negatively.
  • Those with serious gastrointestinal, liver, kidney, or heart problems (Lexicomp).

Minocycline

  • Those with allergies to minocycline or other tetracyclines; with serious liver or kidney problems, or muscle weakness/fatigue (Lexicomp);
  • Children younger than 8 years, as permanent teeth discolouration may occur (Lexicomp).

Systemic steroids

Those with allergies to steroids; with systemic infections (Zouboulis, et al., 2015).

Caution should be taken in those with diseases that may be worsened by steroids (Zouboulis, et al., 2015), such as diabetes, osteoporosis, severe depression, bipolar disorder, or glaucoma.

How well does it work?

Cyclosporine

Level of Evidence: Level III

Strength of recommendation: C

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In two separate cases, both involving HS patients unresponsive to previous treatments, cyclosporine A was administered.

Improvement was noted in one patient after 2 months (Bianchi, Hansel, & Stingeni, 2012) and after 4 months in the other (Buckley & Rogers, 1995).

A combination of colchicine and minocycline

Level of Evidence: Level III

Strength of recommendation: C

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8 moderate to severe HS patients were treated with colchicine. After 1 month, 2 of them slightly improved. Among the 6 patients treated for 2 months, 3 slightly improved. Of the 2 patients treated for 4 months, one slightly improved while the other deteriorated (van der Zee & Prens, 2011).

A combination of colchicine and minocycline for 6 months followed by only colchicine for 3 months may be effective (Armyra, Kouris, Markantoni, Katsambas, & Kontochristopoulos, 2017). Data does not support the use of colchicine alone.

Systemic steroids

Level of Evidence: Level III

Strength of recommendation: C

Methotrexate

Level of Evidence: Level III

Strength of recommendation: Not recommended

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The administration of methotrexate for 6-24 weeks to 3 HS patients who did not respond to previous treatments had no effect on lesions or the frequency of flare-ups (Jemec, 2002).

Azathioprine

Level of Evidence: Level III

Strength of recommendation: Not recommended

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9 moderate to severe HS patients who were unresponsive to previous treatments received azathioprine for 1-7.5 months. A slight improvement was seen in 5 patients and no change in 5 (Nazary, Prens, & Boer, 2016).

What are the possible side effects?

Cyclosporine

Serious: Life threatening allergic reactions or infections, kidney or liver problems, cancers (Lexicomp).

Other: High blood pressure, nausea, diarrhea, shaking, excessive growth of facial/ body hair, overgrowth of gum tissue (Lexicomp).

Pregnancy risk according to the U.S FDA:

  • Category C
  • No evidence of fetal risks (Perng, Zampella, & Okoye, 2017); however, may cause maternal high blood pressure during pregnancy (Murase, Heller, & Butler, 2014).

A combination of colchicine and minocycline

Serious: Life threatening allergic reactions, liver damage, blood disorders (Lexicomp; Lexicomp).

Other: Gastrointestinal problems, fatigue, headaches (Lexicomp; Lexicomp).

Pregnancy risk according to the U.S. FDA:

  • Colchicine
    • Category C
    • Pregnant and nursing women should avoid using it due to possible fetal risks (Murase, Heller, & Butler, 2014).
  • Minocycline
    • Category D
    • Pregnant women should avoid using it due to fetal risks. Nursing women may use it for a short time period but should avoid its long-term use due to possible fetal risks (Lexicomp).

Systemic steroids

Serious: Life threatening allergic reactions, infections, bone and joint damage (Lexicomp).

Other: Gastrointestinal problems, increased appetite, weight gain, high blood pressure, mood changes, elevated blood sugar levels in diabetics (Lexicomp).

Pregnancy risk according to the U.S. FDA:

  • Category C
  • Caution should be taken in pregnant and nursing women due to possible fetal risks and excretion into breast milk, respectively (Zouboulis, et al., 2015; Perng, Zampella, & Okoye, 2017).

Will it inconvenience me?

Cyclosporine

Various blood tests and blood pressure should be monitored (Lexicomp).

Patients should avoid receiving a “live” vaccine while taking cyclosporine, as vaccination may be less effective (Lexicomp).

A combination of colchicine and minocycline

Various blood tests should be monitored in colchicine and minocycline users (Lexicomp; Lexicomp).

Systemic steroids

Blood pressure, weight, blood tests, and possible bone density tests should be monitored (Zouboulis, et al., 2015).