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Finasteride for the Treatment of Hidradenitis Suppurativa in Children and Adolescents

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Finasteride for the Treatment of Hidradenitis Suppurativa in Children and Adolescents OBSERVATION Finasteride for the Treatment of Hidradenitis Suppurativa in Children and Adolescents Harkamal Kaur Randhawa, MD; Jill Hamilton, MD; Elena Pope, MD Importance: Hidradenitis suppurativa (HS) is a chronic ity of disease flares with no significant adverse effects. debilitating cutaneous disease for which there is no uni- versally effective treatment. Patients typically present at Conclusions and Relevance: Finasteride is a thera- puberty with tender subcutaneous nodules that can prog- peutic option that provides benefit for pediatric patients ress to dermal abscess formation. Antiandrogens have been with HS. Further prospective data and randomized con- used in the treatment of HS, and studies have primarily trolled studies will provide helpful information in the man- focused on adult patients. agement of this disease. Observations: We present a case series of 3 pediatric JAMA Dermatol. 2013;149(6):732-735. patients with HS who were successfully treated with oral Published online March 20, 2013. finasteride, resulting in decreased frequency and sever- doi:10.1001/jamadermatol.2013.2874 IDRADENITIS SUPPURA- from that of cyproterone acetate, a previ- tiva (HS) is a chronic in- ously studied antiandrogen in patients flammatory disease that with HS. We outline findings in 3 cases primarily involves skin in presenting during childhood, all in pa- the axillae, groin, and tients who showed significant improve- Hanogenital regions, although disease may ment in disease activity with finasteride extend to the buttocks, chest, scalp, eye- treatment. lids, and retroauricular areas.1 Patients with HS develop exquisitely painful erythem- REPORT OF CASES atous subcutaneous nodules that may heal spontaneously or suppurate and coalesce to form dermal abscesses. There may be PATIENT 1 subsequent sinus tract formation and se- vere scarring. Typically, disease onset oc- A 6-year-old girl presented with preco- curs in the second or third decade of life.2 cious puberty. She developed painful in- Although HS may be seen in prepubertal flamed nodules in the groin at 7 years. Dur- patients,2-5 fewer than 2% of cases occur ing the subsequent year, she had an before the age of 11 years.2 Patients with increase in the number and size of these HS often report a significant negative ef- lesions. She was initially treated by her fect on quality of life, due not only to physi- community physician with topical and oral cal symptoms but also to social stigma as- antibiotics with no success. She also had sociated with the disease.6 Although been taking a 4-month course of isotreti- multiple medical treatments exist, includ- noin, which did not improve her HS le- ing antimicrobials, immunosuppres- sions. At the time she presented to us at sants, and hormonal, laser, and surgical age 13 years, she had extensive lesions con- therapies, no single treatment modality has sistent with HS in the groin and axillae. been found to be universally effective.7 An- There were large, tender, inflamed nod- tiandrogenic medications are among those ules extending to the perianal, perineal re- used to treat HS, but, to our knowledge, gions, and inner thighs. Surgical resec- there are no published pediatric case se- tion of tissue from the left axilla was ries regarding the use of this treatment. We explored as an option for extensive axil- would like to highlight the use of finaste- lary disease, but ultimately the surgical Author Affiliations: Hospital ride as another potential therapy for HS team suggested to pursue medical man- Author Aff for Sick Children, Toronto, in children; finasteride is an antiandro- agement. She continued to develop exten- for Sick Ch Ontario, Canada. gen with a mechanism of action different sive lesions in the axillae, flanks, groin, and Ontario, Ca JAMA DERMATOL/ VOL 149 (NO. 6), JUNE 2013 WWW.JAMADERM.COM 732 ©2013 American Medical Association. All rights reserved. Downloaded From: http://archderm.jamanetwork.com/ by a World Health Organization User on 06/21/2013 inner thighs. She was started on oral minocycline with no significant improvement. Two months later, she was given oral Marvelon (ethinyl estradiol, 0.03 mg, and deso- gestrel, 0.15 mg, on menstrual cycle days 1 through 21). Six months later, there was mild to moderate improve- ment, and oral spironolactone was added to augment her therapy. At 131⁄2 years of age, she continued to have fur- ther flares, requiring oral cephalexin on 2 occasions. At age 14 years, she had a significant flare-up in the axillae, groin, lower abdomen, and inner thighs, requiring a 6-week course of oral cephalexin. She was experiencing considerable emotional distress as a result of her skin dis- ease. She commenced photodynamic therapy at age 141⁄2 years, and minocycline was switched to tetracycline hy- drochloride, in addition to spironolactone, and oral con- Figure 1. At initial presentation, patient 3 had multiple inflammatory traceptive (OC). She underwent amino levulinic acid pho- erythematous nodules on both inner thighs. todynamic therapy (ALA-PDL) monthly. Initially, there was minimal improvement with ALA-PDL. At 151⁄4 years, spironolactone was stopped and finasteride, 5 mg/d, was started and increased 3 months later to 10 mg/d. In con- junction with ALA-PDL and OCs, escalation of finaste- ride to 10 mg/d resulted in clinical improvement with reduction in frequency and severity of flares. Oral tetra- cycline hydrochloride was stopped 6 months after maxi- mum finasteride dose was achieved. During the next 3 years, she had only 3 flares, each of which were treated successfully with brief courses of oral cephalexin. She has currently been receiving this treatment for 6 years. PATIENT 2 A 15-year-old girl with polycystic ovary syndrome, di- agnosed 1 month prior, presented with a 1-year history Figure 2. Patient 3 had tender erythematous nodules in the perianal region at of severe HS lesions in the groin region and on the pos- presentation. terior part of the neck, requiring surgical drainage and intravenous antibiotics. She continued to have flares during treatment with isotretinoin and an OC, which were started within 2 months of presentation. During the next 6 weeks, she had 2 significant flares, one of which required hospitalization for intravenous antibi- (1%) and benzoyl peroxide (5%) gel, oral trimetho- otics. Oral erythromycin estolate was given in combina- prim, and oral finasteride, 1.25 mg/d. After 9 weeks of tion with OCs and isotretinoin. However, the flares per- receiving this treatment regimen, there was minimal sisted for the next month. Isotretinoin was stopped at improvement, so topical silver sulfadiazine was recom- age 151⁄2 years due to poor response to treatment, and mended and the finasteride dose was increased to 2.5 oral finasteride, 5 mg/d, was started at that time, in ad- mg/d. Three months later, the finasteride dose was in- dition to oral erythromycin and OC. With this thera- creased to 5 mg/d because she continued to see new in- peutic combination, the patient’s disease flares have de- flammatory lesions in addition to comedones. Topical creased in frequency and severity during the next 21⁄2 adapalene, 0.3% daily, was used as needed for comedo- years at this writing. nes, and trimethoprim dose was increased slightly. At 9 years of age, she noted significant improvement in PATIENT 3 symptoms and very rare need for topical antibiotics, so her trimethoprim dose was decreased and she contin- A 7-year-old girl presented with a 1-year history of peri- ued receiving finasteride, 5 mg/d. She reported only anal, inner thigh, and axillary disease (Figure 1 and rare need for topical adapalene. She has since continued Figure 2) consisting of painful nodules that would oc- oral trimethoprim and finasteride, as well as topical cur every few weeks to months. A biopsy showed in- clindamycin phosphate (1% wipes) to the groin and ax- flamed cysts, and she was treated with oral erythromy- illae if she has heavy perspiration with physical activity. cin for 2 months with no improvement in her After 1 year of oral trimethoprim and an escalating dose condition. The patient was unable to attend school be- of finasteride (up to 5 mg/d), the patient’s condition cause of pain and her inability to sit for a protracted showed remarkable improvement, with minimal flares time. Erythromycin was stopped, and she was treated (Figure 3 and Figure 4). She has continued to re- with a combination of topical clindamycin phosphate ceive this treatment for a total of 3 years. JAMA DERMATOL/ VOL 149 (NO. 6), JUNE 2013 WWW.JAMADERM.COM 733 ©2013 American Medical Association. All rights reserved. Downloaded From: http://archderm.jamanetwork.com/ by a World Health Organization User on 06/21/2013 testosterone levels. Type II 5␣-reductase is found in hair follicles, whereas type I 5␣-reductase is present in both hair follicles and apocrine glands.14 Although HS has his- torically been considered a disease of the apocrine glands, there is some evidence that its primary mechanism is in- flammation of the terminal follicular epithelium with apo- crine involvement as a secondary phenomenon.15,16 Ac- cordingly, inhibition of 5␣-reductase could improve symptoms of HS by reducing local concentrations of di- hydrotestosterone at the level of the hair follicles. This would explain why other antiandrogens that act by block- ing dihydrotestosterone at the receptor level more glob- ally, such as cyproterone acetate, have not been shown to be universally effective. Finasteride is typically used in male patients to treat Figure 3. After 3 years of finasteride therapy, patient 3 showed significant androgenic alopecia17 or benign prostatic hyperplasia18 resolution of active disease, with a decrease in inflammatory nodules and 19 residual scarring and dyspigmentation on the inner thighs. and less commonly in female patients with hirsutism.
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