Hormonal anti-androgens, also called androgen receptor blockers, help reduce the effect of androgens at the level of glands that might be important in HS. The same hormones that cause hair-thinning on the scalp in some people or excess hair growth in the beard area of some women can trigger HS for some people, especially around menstrual cycles in some women (Lakshmi, 2013). Blocking the action of these androgens at the level of glands may help control HS symptoms (Clark, Quinonez, Saric, & Sivamani, 2017).
Metformin has anti-androgenic properties responsible for influencing the expression of genes involved in HS, and is an anti-diabetic drug capable of enhancing the body’s sensitivity to insulin (Verdolini, Clayton, Smith, Alwash, & Mannello, 2013).
Anti-androgens may decrease the local concentration of an androgen called dihydrotestosterone (DHT) at the level of hair follicles, and alter the body’s sensitivity to circulating androgens (Clark, Quinonez, Saric, & Sivamani, 2017).
Metformin may prevent the ovaries and adrenal glands from producing androgens, thus reducing androgen levels (Lashen, 2010).
Retinoids are synthetic forms of vitamin A, and can reduce both inflammation and pore blockage (Boer, 2006; Bhuiyan & Chowdhury, 2016; Bubna, 2015).
Isotretinoin decreases the size and secretion of sebaceous glands, thus reducing the amount of oil released into the skin (Boer, 2006).
Acitretin influences the growth of the outer layer of skin cells (Bhuiyan & Chowdhury, 2016).
Alitretinoin is responsible for modifying the immune response, inhibiting cell growth, and establishing programmed cell death (Bubna, 2015).
Tetracyclines are a class of anti-inflammatory antibiotics (van Straalen, Schneider-Burrus, & Prens, 2018). Examples include tetracycline, doxycycline, and minocycline.
Tetracyclines inhibit the production of bacterial proteins by reversibly binding to a component of the bacteria (Zouboulis, et al., 2015).
Clindamycin and rifampin are anti-inflammatory antibiotics that work by modifying the body’s immune response and altering bacteria on the skin (van Straalen, Schneider-Burrus, & Prens, 2018).
Clindamycin and rifampin reversibly bind to different components of the bacteria to inhibit the production of bacterial proteins and bacterial ribonucleic acid, respectively (Zouboulis, et al., 2015).
Refer to the definition of rifampin listed in the systemic + rifampin section.
Moxifloxacin is a fluoroquinolone antibiotic that works by interfering with bacterial enzymes responsible for duplicating or repairing bacterial DNA (Lexicomp).
Metronidazole is an antibiotic that causes cell death by inhibiting the production of bacterial proteins (Lexicomp).
Dapsone is a sulphone drug with anti-inflammatory properties (Yazdanyar, Boer, Ingvarsson, Szepietowski, & Jemec, 2011).
Its antibacterial properties are responsible for inhibiting the production of dihydrofolic acid, a form of folic acid (Zouboulis, et al., 2015).
Its anti-inflammatory properties may be responsible for preventing the recruitment of neutrophils and the production of toxic products (Zouboulis, et al., 2015).
Ertapenem is a beta-lactam antibiotic that treats skin infections by killing bacteria (Join-Lambert, et al., 2016).
It binds to proteins on the bacteria’s outer layer, thus inhibiting the formation of a rigid and protective coat, and leading to bacterial death (Lexicomp).
Some patients may benefit from taking the following antibiotics:
Both male and female HS patients (Clark, Quinonez, Saric, & Sivamani, 2017), particularly female HS patients with menstrual abnormalities or signs of hyperandrogenism (Zouboulis, et al., 2015).
Those with mild to moderate HS, when no other treatment(s) is/are used.
Those with severe HS, when a combination of other treatments are used.
Isotretinoin:
Acitretin:
Alitretinoin: Females HS patients who are unresponsive to standard treatments (Bubna, 2015).
They may be effective in those with mild to moderate HS.
Those with widespread Hurley stage I or II (Zouboulis, et al., 2015).
Those with any stage of inflammatory HS (Zouboulis, et al., 2015). In particular, those with mild to moderate HS as a second-line treatment when no other treatment(s) is/are used or those with severe HS as an initial treatment or adjuvant.
Those who were previously unresponsive or intolerant to oral tetracyclines (Lexicomp).
It may be most effective in those with Hurley stage I who have failed to respond to other treatments. However, it may also be effective in those with Hurley stage II or III (Join-Lambert, et al., 2011).
Those considering a bridge therapy to either surgery or another long-term therapy.
Those with Hurley stage I or II (Zouboulis, et al., 2015).
Those who have failed to respond to first- or second-line treatments (Zouboulis, et al., 2015), or who are intolerant to common antibiotics (van Straalen, Schneider-Burrus, & Prens, 2018).
It may be used as a maintenance therapy for HS (Yazdanyar, Boer, Ingvarsson, Szepietowski, & Jemec, 2011).
It may be effective in those with any Hurley stage, especially those with Hurley stage I or II (Join-Lambert, et al., 2016).
Those wishing to reduce the intensity of HS lesions in preparation for surgery or biologic therapy (Chahine, Nahhas, Braunberger, Rambhatla, & Hamzavi, 2018).
Oral contraceptive pills: Those with heart/liver disease or blood clots, as well as those who smoke (Martin & Barbieri, 2018). They should also be used with caution in older aged women.
Spironolactone: Those with allergies to spironolactone, those with elevated levels of potassium in the blood, Addison’s disease, as well as those using eplerenone or heparin (Lexicomp). Due to high risk of fetal harm, women should avoid pregnancy and refer to pregnancy prevention programs while on spironolactone.
Metformin: Those with allergies to metformin, as well as those with kidney dysfunction or excessive amounts of acid in the body (Lexicomp).
Finasteride: Those with allergies to finasteride, women, and children (Lexicomp).
Those with allergies to retinoids.
Isotretinoin: Those with allergies to or elevated levels of vitamin A, those with liver failure or high levels of fat in the blood, those using tetracyclines, as well as those who are pregnant or attempting conception (Lexicomp).
Acitretin: Those with liver/kidney disease or elevated levels of fat in the blood, those taking methotrexate, tetracyclines, vitamin A, or other retinoids, as well as those who are pregnant or attempting conception (Lexicomp).
Alitretinoin: Those with elevated levels of vitamin A, liver or kidney impairment, or uncontrolled levels of fat in the blood, those taking tetracyclines, as well as those who are pregnant or attempting conception (Lexicomp).
Those with allergies to tetracyclines, those with kidney problems, as well as children younger than 8 years old (Lexicomp).
Caution should be taken in those with a history of gastrointestinal disease (Zouboulis, et al., 2015).
Those with allergies to clindamycin, rifampin, or lincomycin, as well as those taking a combination of saquinavir and ritonavir (Lexicomp; Lexicomp).
Those with allergies to rifampin, moxifloxacin, or metronidazole (Lexicomp; Lexicomp; Lexicomp).
Rifampin:
Metronidazole:
It may not be effective in those with Hurley stage III (Yazdanyar, Boer, Ingvarsson, Szepietowski, & Jemec, 2011).
Those wishing to use a first-line treatment (Yazdanyar, Boer, Ingvarsson, Szepietowski, & Jemec, 2011).
Those with allergies to sulphones, as well as those with glucose-6-phosphate dehydrogenase (G6PD) deficiency, severe anemia, or acute porphyria (Zouboulis, et al., 2015).
Those with allergies to ertapenem, beta-lactams, or local amide anesthetics (Lexicomp).
Those wishing to use a first-or second-line treatment, or a long-term treatment.
Level of Evidence:
Strength of recommendation:
Spironolactone:
Metformin:
Finasteride:
Level of Evidence:
Strength of recommendation:
Isotretinoin:
Acitretin:
Alitretinoin:
Level of Evidence: Level II, III
Strength of recommendation: “C” rating
46 HS patients with Hurley stage I or II randomly received oral tetracycline or applied topical 1% clindamycin solution for a minimum of 3 months. Abscesses were reduced during the first 3 months in all patients, demonstrating no significant differences between the two treatments (Jemec & Wendelboe, 1998).
Level of Evidence: Level II
Strength of recommendation: “B” rating
34 patients were treated with a combination of clindamycin and rifampin for approximately 10 weeks. A partial improvement and complete clearance was observed in 12 and 16 patients, respectively. 6 patients, the majority of which had severe HS, did not improve. However, worsening of HS did not occur in any cases (van der Zee, Boer, Prens, & Jemec, 2009).
Level of Evidence: Level II
Strength of recommendation: “C” rating
A combination of rifampin, moxifloxacin, and metronidazole was administered over a 6-week period to 28 HS patients who were previously unresponsive to treatment. Among the 16 patients who cleared completely, 100%, 80%, and 16.67% had Hurley stage I, II, and III, respectively. Those who relapsed due to stoppage of treatment eventually responded when a second treatment was introduced (Join-Lambert, et al., 2011).
Level of Evidence: Level III
Strength of recommendation: “C” rating
9 of the 24 patients who received dapsone within 2-48 months improved, while 15 did not. Among those with Hurley stage III, none improved (Yazdanyar, Boer, Ingvarsson, Szepietowski, & Jemec, 2011).
Level of Evidence: Level III
Strength of recommendation: “C” rating
Upon intravenous administration of ertapenem for 6 weeks in 30 HS patients, an absence of inflammatory symptoms and an improvement was observed in the majority of Hurley stage I/II lesions and Hurley stage III lesions, respectively (Join-Lambert, et al., 2016).
Serious:
Other:
Pregnancy risk according to the U.S. Food & Drug Administration:
Serious: Severe inflammation of the liver or pancreas, heart problems, or serious allergic reactions that may cause death (Lexicomp; Lexicomp; Lexicomp; Aryal & Upreti , 2017).
Other: Elevated levels of fat in the blood, dry eyes or skin, hair loss, or inflamed lips (Lexicomp; Lexicomp; Lexicomp; Aryal & Upreti , 2017).
Pregnancy risk according to the U.S. Food & Drug Administration:
Serious: Skin discoloration, inflammation of parts of the digestive system, microbial resistance, or life threatening allergic reactions (WebMD).
Other: Teeth discoloration in children under the age of 13, increased sensitivity to sunlight, or gastrointestinal symptoms (WebMD).
Pregnancy risk according to the U.S. Food & Drug Administration:
Serious: Abnormally low platelet levels or life threatening allergic reactions (epocrates; epocrates).
Other: Gastrointestinal symptoms, skin rash, or dizziness (epocrates; epocrates).
Pregnancy risk according to the U.S. Food & Drug Administration:
Serious: Liver inflammation, seizures, decreased white blood cells that may increase infection risk, or life threatening allergic reactions (epocrates; epocrates; epocrates).
Other: Gastrointestinal symptoms, headache, dizziness, or abdominal pain (epocrates; epocrates; epocrates).
Pregnancy risk according to the U.S. Food & Drug Administration:
Serious: Blood disorders, peripheral nerve damage, or liver damage (epocrates).
Other: Nausea, dizziness, tiredness, or headache (epocrates).
Pregnancy risk according to U.S. Food & Drug Administration:
Serious: Antimicrobial resistance or life threatening allergic reactions (epocrates).
Other: Vaginal yeast infection, gastrointestinal symptoms, or headache (epocrates).
Pregnancy risk according to the U.S. Food & Drug Administration:
Oral contraceptive pills:
Spironolactone:
Metformin: Blood and renal function tests must be monitored at least once yearly (Bubna, 2016).
Finasteride: Sexual side effects, such as reduced sexual desire or erectile dysfunction, may persist after treatment is stopped (Khandalavala & Do, 2016).
As these medicines can cause birth defects in unborn children, pregnancy prevention programs must be followed.
Isotretinoin:
Acitretin:
Alitretinoin:
Dairy products may interfere with the body’s absorption of tetracyclines (Lexicomp).
These medications are usually used in combination for a few months at a time (van Straalen, Schneider-Burrus, & Prens, 2018).
Rifampin may interfere with the effectiveness of oral contraceptives (Zouboulis, et al., 2015).
Consider monitoring the following when using rifampin:
These medications are usually used in combination for up to a few months at a time (Join-Lambert, et al., 2011).
Those who stop treatment before being completely cleared may relapse (Join-Lambert, et al., 2011).
Refer to the monitoring parameters for rifampin listed in the systemic clindamycin + rifampin section.
The following should be monitored when using moxifloxacin:
The following should be monitored when using metronidazole:
Complete blood cell counts and liver function test results should be monitored when using dapsone (epocrates).
It must be injected into a muscle or vein.
Continued use of antibiotics is required to prevent relapses, which are common when treatment is stopped (Join-Lambert, et al., 2016).
The following should be monitored when using ertapenem: