‘There are options’: Managing hidradenitis suppurativa during pregnancy

Key takeaways:

• Hidradenitis suppurativa disproportionately affects women of reproductive age.
• These patients have pregnancy-class b treatment options including topicals, oral antibiotics, metabolic therapies and biologics.

SAN DIEGO — It is important for both patients and dermatologists to know that there are options for the management of hidradenitis suppurativa during pregnancy, according to a speaker at the American Academy of Dermatology Annual Meeting.

“HS disproportionately affects women of reproductive age and many with the condition may be in phases of their lives where they are actively family planning,” Katrina Lee, MD, FAAD, clinical assistant professor of dermatology at Keck School of Medicine of University of Southern California, told Healio concerning her presentation. “As dermatologists, it’s imperative to closely follow these patients, escalate therapy as needed and work alongside our colleagues in obstetrics to address any modifiable risk factors.”

According to Lee, to effectively treat these patients, it is important to know exactly what the impact of HS, especially uncontrolled HS, is on pregnancy and mothers.

“The impact of uncontrolled HS on pregnancy is not fully known,” Lee admitted, “but the literature suggests that HS may be an independent risk factor for adverse pregnancy and maternal outcomes.”

According to a study referenced by Lee, women with HS had lower odds of having a live birth (adjusted OR = 0.42; 95% CI, 0.37-0.49) and higher rates of elective termination (aOR = 2.51; 95% CI, 2.13-2.96) compared with the general population. In a second study Lee discussed, patients were found to be at a higher risk for gestational diabetes (OR = 1.43; 95% CI, 1.22-1.66) and gestational hypertension (OR = 1.38; 95% CI, 1.11-1.71) vs. controls.

Not only must practitioners know what the impact is of HS on pregnancy but also the inverse: What is the impact of pregnancy on HS?

“As of now, there seems to be a mixed clinical course in regard to HS disease activity during pregnancy,” Lee said. “Studies suggest that most patients experience no relief or even potential exacerbation of their HS during this period.”

According to a systematic review and meta-analysis referenced by Lee, only 24% of women reported improved HS disease severity during their pregnancy, whereas 56% reported no change and 20% reported worsened severity.

“This shows that many patients may require treatment to help control symptoms of their disease,” Lee continued.

There are still many treatment options for pregnant patients with HS; however, physicians need to ensure that the drug lands in FDA pregnancy category B or higher, meaning there is no evidence that the drug poses a risk to human pregnancies, Lee said.

According to Lee, effective class B topical agents for HS include clindamycin 1%, metronidazole 0.75% and erythromycin 2%. Oral antibiotics include clindamycin, cephalexin, cefdinir, amoxicillin-clavulanate or metronidazole. Physicians may also use the metabolic drug, metformin, for these patients, as well as zinc with low-dose copper if the patient wants alternative options.

Lee highlighted the use of biologics as a treatment option for these patients including adalimumab, infliximab or certolizumab. Fetal exposure to adalimumab and infliximab is absent during the first 20 weeks of gestation; however, there is an increased placental transfer in the third trimester, meaning physicians will need to weigh the risks and benefits of fetal drug exposure with severity of disease.

Certolizumab may be a treatment option as well for patients with moderate to severe HS during pregnancy; however, there is a paucity of data in this indication. Secukinumab and ustekinumab have also proved to be potential class b options for these patients if they fail or are not candidates for tumor necrosis factor inhibition, but again, data is lacking.

Above all, Lee emphasized that physicians must avoid treating pregnant patients with HS with tetracyclines, acitretin, isotretinoin, finasteride, spironolactone and methotrexate as these are classified as high-risk medications during pregnancy.

Despite the list of medications to avoid, Lee emphasized that physicians should not be discouraged as there are many options out there for the treatment of pregnant patients with HS.

“It’s important for both patients and dermatologists to know that there are options including topical agents, oral antibiotics, metabolic therapies, biologics and in-office procedures that can be implemented for the management of HS during pregnancy,” Lee told Healio.