PracticeUpdate: Dermatology - Winter 2018

EDITOR’S PICKS 19

Antiandrogen Therapy With Spironolactone for the Treatment of Hidradenitis Suppurativa Journal of the American Academy of Dermatology Take-home message

Abstract BACKGROUND Hormonal therapy is a potential treatment for hidradenitis suppurativa (HS). How- ever, little data exists describing the efficacy of spironolactone in HS treatment. OBJECTIVE To assess whether spironolactone treatment improves HS disease severity and patient reported pain. METHODS We performed a single center chart review of female HS patients treated with spironolactone between 2000 and 2017. Pri- mary outcome measurements included the HS Physician Global Assessment (HSPGA), Hurley Staging, inflammatory lesion count, fistula count, and a numeric rating scale for pain. RESULTS Subjects on average were exposed to 75mg of spironolactone daily over a 7.1-month follow-up period. Patients achieved significant disease improvement with regards to pain (Δ-1.5, P=.01), inflammatory lesions (Δ-1.3, P=.02), and HSPGA (Δ-0.6, P<.001). As expected, no change was found for Hurley stage (Δ0, P=.32) or fis- tulas (Δ0, P=.73). There was no difference in improvement between subjects who received less than 75mg daily (n= 25, average 45mg/day) and those who received greater than 100mg daily (n=21, average 112mg/day). LIMITATIONS Retrospective nature, limited sample size, and variations in severity measures docu- mented were limiting factors. CONCLUSIONS Management of HS with spironol- actone reduces lesion count, HSPGA and pain. Lower doses appear to be effective and may be an appropriate option for patients with tol- erability concerns. Antiandrogen Therapy With Spironolactone for the Treatment of Hidradenitis Suppurativa. J Am Acad Dermatol 2018 Jul 09;[EPub Ahead of Print], NM Golbari, ML Porter, AB Kimball. www.practiceupdate.com/c/70847

• This single-center retrospective study evaluated the efficacy of spironolactone in the treatment of hidradenitis suppurativa (HS). Participants were given spirono- lactone 75 mg daily on average (range, 25–100 mg) over a 7.1-month follow-up period. They achieved significant improvements in pain, inflammatory lesions, and HSPGA. No change was found for Hurley stage or fistulas. There were no significant outcome differences between individuals who received <75 mg daily and those who received >100 mg daily. • Spironolactone may reduce lesion count, HSPGA, and pain in HS individuals at an average dose of 45 mg/day. InYoung Kim MD, PhD

COMMENT By Paul G. Hazen MD H idradenitis suppurativa (HS) is rec- ognized to affect women 3 times more frequently than men. Addi- tionally, the disease has onset with puberty, may improve with menopause, and may worsen with menses and preg- nancy. These features suggest a potential hormonal influence in the condition. Spironolactone is recognized to possess androgen antagonist qualities, and is fre- quently used in the management of acne, as well as empirically in HS. This article details the experience of spironolactone therapy in themanagement of hidradenitis suppurativa. It represents a retrospective, single-center chart review, covering a period of 17 years, and evaluat- ing the clinical effects of spironolactone in young women. Such evaluation appeared to demonstrate statistical benefit with regards to pain, number of inflammatory lesions, and measurement of HS Physi- cian Global Assessment scores. There was no improvement in Hurley scoring, and patients receiving spironolactone doses greater than 100 mg daily did no better than those receiving less than 75 mg per day. The patient population included 67 patients, with 21 lost to follow-up after the first visit. Overall, 17% of patients were thought to have polycystic ovary syn- drome. Treatment was complicated by the fact that 37% of patients also received antibiotics and 30% received hormonal contraceptives. The small patient popu- lation, retrospective/uncontrolled nature of the study, and comingling of therapies

were deficiencies of the study. No asso- ciation was noted regarding whether responders were those with premenstrual or pregnancy flares. These features notwithstanding, the article provides at least a suggestion that such therapy may have a place in the management of this condition.

Dr. Hazen is a Clinical Professor of Dermatology at Case-Western Reserve University School of Medicine, Clinical Associate Professor of Dermatology at Ohio University Heritage College of Osteopathic Medicine, and Director of the Division of Dermatology at Fairview General Hospital in Cleveland, Ohio.

VOL. 2 • NO. 3 • 2018