alitretinoin and Hidradenitis-Suppurativa

Dissecting cellulitis (DC) also referred to as to as perifolliculitis capitis abscedens et suffodiens (Hoffman) manifests with perifollicular pustules, nodules, abscesses and sinuses that evolve into scarring alopecia. In the U.S., it predominantly occurs in African American men between 20-40 years of age. DC also occurs in other races and women more rarely. DC has been reported worldwide. Older therapies reported effective include: low dose oral zinc, isotretinoin, minocycline, sulfa drugs, tetracycline, prednisone, intralesional triamcinolone, incision and drainage, dapsone, antiandrogens (in women), topical clindamycin, topical isotretinoin, X-ray epilation and ablation, ablative C02 lasers, hair removal lasers (800nm and 694nm), and surgical excision. Newer treatments reported include tumor necrosis factor blockers (TNFB), quinolones, macrolide antibiotics, rifampin, alitretinoin, metronidazole, and high dose zinc sulphate (135-220 mg TID). Isotretinoin seems to provide the best chance at remission, but the number of reports is small, dosing schedules variable, and the long term follow up beyond a year is negligible; treatment failures have been reported. TNFB can succeed when isotretinoin fails, either as monotherapy, or as a bridge to aggressive surgical treatment, but long term data is lacking. Non-medical therapies noted in the last decade include: the 1064 nm laser, ALA-PDT, and modern external beam radiation therapy. Studies that span more than 1 year are lacking. Newer pathologic hair findings include: pigmented casts, black dots, and "3D" yellow dots. Newer associations include: keratitis-ichthyosis-deafness syndrome, Crohn disease and pyoderma gangrenosum. Older associations include arthritis and keratitis. DC is likely a reaction pattern, as is shown by its varied therapeutic successes and failures. The etiology of DC remains enigmatic and DC is distinct from hidradenitis suppurativa, which is shown by their varied responses to therapies and their histologic differences. Like HS, DC likely involves both follicular dysfunction and an aberrant cutaneous immune response to commensal bacteria, such as coagulase negative staphylococci. The incidence of DC is likely under-reported. The literature suggests that now most cases of DC can be treated effectively. However, the lack of clinical studies regarding DC prevents full understanding of the disease and limits the ability to define a consensus treatment algorithm.

Topics: Acitretin; Alitretinoin; Anti-Bacterial Agents; Cellulitis; Dermatologic Agents; Diagnosis, Differential; Estrogens; Ethinyl Estradiol; Hidradenitis Suppurativa; History, 20th Century; Humans; Laser Therapy; Lymphotoxin-alpha; Phototherapy; Radiotherapy; Scalp Dermatoses; Skin Diseases, Genetic; Tretinoin; Zinc

Despite a better insight into its pathogenesis, hidradenitis suppurativa (HS) remains very frustrating to treat. Acitretin has been described as one of the agents with the highest effective profile. Acitretin however, due to its teratogenicity and prolonged half-life (up to three years) is not an option in young women of fertile age who, unfortunately, are the target of this disease. Alitretinoin has a similar pharmacology action to acitretin, but much shorter half-life (only four weeks), making it a far much more attractive option compared to acitretin for women of child-bearing age. The aim of this paper was to evaluate the use of alitretinoin in treating recalcitrant cases of HS, which have not been responsive to standard treatments.. Fourteen patients (all female, of child-bearing age), who persistently failed traditional treatments, were treated with alitretinoin 10 mg/day for 24 weeks. The disease trend was evaluated by using both Sartorius and Dermatology Life Quality Index scores at time 0, at week 12 and at week 24.. A significant improvement was recorded in 78.5% of the cases.. Although more studies are necessary, this preliminary study shows that alitretinoin may have a role in the treatment of HS specifically in women of fertile age.

Topics: Adult; Alitretinoin; Dermatologic Agents; Female; Hidradenitis Suppurativa; Humans; Middle Aged; Quality of Life; Treatment Outcome; Tretinoin; Young Adult