HIDRADENITIS ------------------------------------------------- The Brits make a big deal about the role of androgens in hidradenitis suppurativa [1-5]. I do not have any personal experience with this approach. I have a 40 y/o female I am treating with hidradenitis, mainly in the buttocks and groin area who responded incompletely to a four month course of isotretinoin at 1 mg/kg and tolerated it poorly because of severe headaches (no papilledema). IL steroids has helped, but we are looking for a remittive drug that would be a viable alternative to a repeat course of Accutane. She has chronic pain, and has developed substance dependency in the past related to this. Her continual demand for pain medication is pushing me to try and do something. Accutane-related headaches made refusing her pain meds even harder, and I am not looking forward to another round of that. The problem is too diffuse for surgical management and she is within 10-15% of ideal body weight. I believe she has had a hysterectomy, so etretinate is thinkable, but I am worried it will produce severe headaches as Accutane did. Anyone have any experience treating hidradenitis with the antiandrogens available in the U.S. [Casodex (becalutamide), Eulexin (flutamide), Lupron (leuprolide acetate)] which are mainly used to treat prostate cancer? What about older, less potent drugs with antiandrogen properties like Aldactone (spironolactone), Nizoral (ketoconazole)? What about cyclosporin (or anything else)? 1. Ebling FJ: Hidradenitis suppurativa: an androgen-dependent disorder [editorial]. Br J Dermatol 115(3):259-62, 1986. 2. Mortimer PS, Dawber RP, Gales MA, et al.: A double-blind controlled cross-over trial of cyproterone acetate in females with hidradenitis suppurativa. Br J Dermatol 115(3):263-8, 1986. 3. Mortimer PS, Dawber RP, Gales MA, et al.: Mediation of hidradenitis suppurativa by androgens. Br Med J (Clin Res Ed) 292(6515):245-8, 1986. 4. Sawers RS, Randall VA, Ebling FJ: Control of hidradenitis suppurativa in women using combined antiandrogen (cyproterone acetate) and oestrogen therapy. Br J Dermatol 115(3):269-74, 1986. 5. Goldsmith PC, Dowd PM: Successful therapy of the follicular occlusion triad in a young woman with high dose oral antiandrogens and minocycline. J R Soc Med 86(12):729-30, 1993.^A Mark Naylor, M.D. ----------------- I recently filed a good reference on the use of CyA in hidradenitis. Last week I mentioned a woman with acne and hidradenitits who did not respond adequately to Accutane but is doing very well on Biaxin and Naprosyn. I probably try that combination before CyA, unless she's a total mess, in shich case you might knowck it down with CyA then try to keep it down with Biaxin / Naprosyn. Haven't had much success with antiandrogens for hidradenitis. Here in Canada we have acetretin (Soriatane) - this is not nearly as lipid soluble as etretinate and Accutane, so it doesn't cross the blood-brain barrier to a great extent. Soriatane might be worth trying if headaches are a problem. I had a guy who became violent and depressed on etretinate for psoriasis, but did great on Soriatane, probably because Soriatane didn't get into his CNS. KC Smith MD FRCPC ----------------- For hidradenitis I use low dose accutane, 20-40 mg/day to avoid the more problematic sideeffects, and use it for more than 6months. Someone is doing a type of more superficial liposuction in these areas, akin to those being done for hyperhidrosis-I can't remember the reference. I have found Duricef and Ceftin to be excellent antibiotics for this problem as well-why they work I don't know. I am not big on manipulation of androgens systemically in women-or men for that matter-unless they are very intouch with their psyche and can recognize subtle changes. What is the putative mechanism claimed by the British? And have they popped a months worth of these drugs themselves? They may be the same ones who write for hydroxyzine 25mg TID-I'd like to see them take just one and try to function at work. It is hard to imagine that unopposed Estrogen will be healthy, mind or bodywise. Diane Thaler ------------ I don't buy their logic re: androgens and hidradinitis. The process is one of aberrant follicular keratinization/occlusion according to Gerd Plewig, and is thus not under androgenic influence. I wish that I had some magic to offer HS patients. I rely on weight loss, rotating antibiotics, IL kenalog, and surgery. Guy Webster ----------- I have tried Cyclosporin in a patient with very severe citatrizing hidradenitis suppurativa (associated with elbow and shoulder contractures) with no response after a several month course. This patient was also resistent to retinoids. Rhett Drugge ------------ After reading recently that follicular occlusion is the etiology rather than apocrinitis, I have had great success in hidradenitis with the addition of Retin A gel .01% to previously unsuccessful benzoyl peroxide wash/oral Minocin regimens. IL steroids are a great adjunct for big cysts. I have been disappointed with Accutane in hidradenitis. (I have not tried spironolactone but I presume it would work.) Philip Hughes, M.D. ------------------- I second this comment. Topical Retin-A has helped two of my milder hidradenitis patients, both in the axillary and inguinal areas. These patients both had comedones clinically in these areas, in addition to cysts. Gene Sienkiewicz, M. D. ----------------------- Since recalcitrant comedonal acne patients, non Retin A responders, all respond to Accutane, why do hidradenitis patients respond so well to Retin A and apparently not to Accutane (nb, mine do respond to Accutane, not the same experience as the others on the list it seems). Diane Thaler ------------