Study Suggests New Treatment for Hidradenitis Suppurativa
| March 19, 2012
March 19, 2017 (San Diego, California) — Six weeks of compassionate treatment with intravenous (IV) ertapenem resulted in a dramatic improvement in patients with severe hidradenitis suppurativa (HS). The treatment "is hardly seen in the literature for this disease," reported Aude Nassif, MD, here at the American Academy of Dermatology 70th Annual Meeting.
"It is the first time an antibiotic with no recognized anti-inflammatory activity has shown a real efficiency in HS, which raises the question of an infectious participation," said Dr. Nassif, who is from the Institut Pasteur in Paris, France.
Despite the response, this therapy must still be considered an induction treatment. "It needs complementary treatment with oral antibiotics and surgery. It can't prevent this, but it will help to reduce the number and size of excisions," she said.
The study follows one recently published by her group (Dermatology. 2011;222:49-58), which assessed the efficacy of triple therapy (oral rifampin, moxifloxacin, and metronidazole) in HS patients; "however, results for stage 3 patients were unsatisfactory," she explained.
With triple therapy, "we kept seeing lapses in stage 3 patients right when they stopped metronidazole. This suggested that a more prolonged antianaerobic treatment could be necessary to treat these patients. But you can't prolong metronidazole beyond 6 weeks without serious risk of neuropathy. It is not recommended."
The approach with ertapenem was chosen because "it is easy to use (a once-a-day IV injection, which allows home treatment), it has a good tolerance profile," and it covers a wide spectrum of bacteria that are found in the superinfection of HS lesions.
"Unlike what is commonly thought, microbiological culture reveals a rich anaerobic bacterial flora in stage 2 and 3 HS lesions," she said.
The retrospective monocentric study involved 30 consecutive patients with severe HS, defined as stage 3 (n = 12) or resistant stage 2 (n = 18), who were treated for 6 weeks with IV ertapenem 1 g daily as induction treatment.
"We're talking about people who can't sit and can't walk sometimes, and can't use their arms," she explained.
Outcomes of the study included tolerability to both the drug and the central IV catheter, as well as subjective and objective assessment of efficacy, including visual analog scale scores for pain, purulent discharge, daily handicap, and objective physician's assessment based on lesional and global Hurley staging.
Patient assessment showed that mean pain levels dropped from a baseline level of 6 to 0 after 6 weeks of treatment, "which is hardly seen in the literature for this disease," she said. In addition, the mean amount of purulent discharge decreased from 8 to 2, and the daily handicap score decreased from 8 to 3.
Physician assessment showed that two thirds of patients had an improvement in global Hurley score.
Improvement from Hurley stage 3 to 2 meant that normal skin areas appeared between lesions, she said. Improvement from stage 2 to 1 meant fragmentation of hypertrophic scars into nodules. Complete remission was defined as the complete disappearance of inflammatory lesions, meaning no drainage, normal skin color, and skin softening.
"In comparison to oral therapy, the side effects are much milder, but we had 1 lymphangitis and 1 thrombosis with the catheter. We removed the catheter and there was no further complication," she said.
For patients with severe HS, in which symptoms are "unmanageable," with "a very poor quality of life," ertapenem treatment might bring "dramatic improvement," she concluded. "Of course, this should be reserved for severe patients, since it requires the insertion of a central catheter and it's a long treatment."
Asked to comment on the findings, Richard L. Gallo, MD, PhD, professor and chief of dermatology at the University of California at San Diego, and moderator of the session at which the study was presented, explained that "we've known there is a bacterial component to the disease, but we've also been frustrated by many oral antibiotics' ability to benefit these patients."
"What this study suggests is that maybe we haven't tried hard enough with the use of antibiotics in these patients," he told Medscape Medical News.
"I don't think this study suggests that [ertapenem] is the only treatment. She was very specific to say it is induction of suppression of inflammation that may in fact be infection prior to surgery. I was very excited by that. It may be that this is true only for a very small subset of very severe patients. The overuse of antibiotics has to be tempered, but certainly she showed great effect in this small study," Dr. Gallo said.
Dr. Nassif reports that her travel expenses were partially paid by Merck Sharp & Dohme, but the company did not fund the study. Dr. Gallo reports receiving consulting fees from Allergan and Novartis; investigator grants from Colgate-Palmolive, Galderma Laboratories, L.P., Intendis, Johnson & Johnson Consumer Products, and L'Oreal USA; and being a founder and stockholder of Skin Epibiotics.
American Academy of Dermatology (AAD) 70th Annual Meeting: Late-breaking abstracts. Presented March 16, 2012.