Hormonal treatments effective, safe for women with hidradenitis suppurativa

Key takeaways:

• Hormonal therapies are promising treatments for patients with hidradenitis suppurativa.
• Common adverse events include, but are not limited to, nausea, dizziness, gastrointestinal upset and more.

Hormonal treatments for hidradenitis suppurativa — particularly finasteride, spironolactone and metformin — are efficacious and safe for women, but dermatologists should be aware of treatment interactions, according to a review.

HS is a debilitating skin disease that disproportionately affects women more than twice as often as men.

“Given that women of child-bearing age are disproportionately affected by HS, understanding the effects of different hormonal treatments on HS symptoms is critical,” Rahul Masson, BS, of the Keck School of Medicine of University of Southern California, and colleagues wrote. “Herin, we conducted a systematic review to evaluate existing literature on the efficacy and safety of hormonal therapies in HS.”

Researchers reviewed 30 articles published between 1952 and 2022 that discussed hormonal treatments for 634 patients with HS.

Anti-androgen treatments

The researchers found that the most discussed anti-androgen treatments for HS were finasteride in eight studies, spironolactone in seven studies and cyproterone acetate in five studies. Flutamide, leuprolide and buserelin acetate were each discussed in a single study.

Across all studies reporting response rates, 62.8% of patients with HS improved from finasteride, 53.3% from cyproterone acetate monotherapy or combination therapy, and 50.5% with spironolactone.

Spironolactone was the most extensively studied anti-androgen treatment, with 186 patients treated with this drug. Spironolactone improved pain, lesion counts and PGA scores among patients, regardless of dosage amount when comparing 75 mg to 100 mg daily, according to the researchers.

Adverse events of spironolactone included nausea, dizziness, gastrointestinal upset, altered mood, breast tenderness and changes in urination.

The researchers also found finasteride to be widely studied. This drug induced remission for many years, and some patients experienced success in suppressing recurrences with reintroduction of finasteride.

Patient-reported adverse events of finasteride included breast tenderness, nausea, menstrual irregularities, headache, sexual dysfunction, generalized pruritis and rash.

More than half of the patients across the studies exhibited a response to cyproterone acetate. However, in one study referenced by the authors, after 12 months of treatment, 16.6% of patients withdrew from the study due to adverse events and 8.3% dropped out due to deterioration of disease.

Oral contraceptive pills and testosterone treatment

Cyproterone acetate, an anti-androgenic progesterone that is often taken in combination with estrogen as a birth control pill, proved to elicit positive responses in HS. However, the researchers found that other types of contraceptives such as intrauterine devices or pills with high progesterone could possibly exacerbate HS.

In another study referenced by the authors, women taking oral contraceptive pills for their HS who suffered from menstrual HS flares had a greater response compared with those who did not suffer from flares (24.5% vs. 10%).

On the other hand, the authors found two case studies that described worsening HS symptoms for those taking testosterone therapy, specifically transgender men. Both patients experienced resolution of HS flares after decreasing testosterone dosage.

Metabolic treatments

Metabolic treatments were also used to treat HS including metformin in eight studies and liraglutide in two studies.

Forty-six percent of patients treated with metformin saw improvement in their HS. The authors postulated that metformin may “desensitize androgen receptors by decreasing peripheral insulin levels and minimizing de novo production of androgens from ovaries,” thus improving HS.

Adverse events associated with metformin include mood changes and minor gastrointestinal disturbances.

Liraglutide, although only studied in two patients, caused significant weight loss and clinical improvement in HS as well as no adverse events.

Conclusion

“Overall, hormonal therapies are promising treatment options for patients with HS,” the authors wrote. “Large randomized controlled trials are needed to explore the efficacy, safety and optimal dosing of hormonal treatments in HS and identify subpopulations that may benefit the most.”