Managing Hidradenitis Suppurativa During Pregnancy
Dr. Ted Rosen discusses a recent paper updating dermatologists about the nuances of managing hidradenitis suppurativa during pregnancy and post-partum.
“Hidradenitis suppurativa (HS) and its management have special nuances should it occur during pregnancy and the postpartum period,” said Dr. Ted Rosen, referring to the paper “Dermatologic Management of Hidradenitis Suppurativa and Impact on Pregnancy and Breastfeeding,” published March in Cutis.1
HS most commonly affects women of childbearing age and, therefore, may well occur or flare during pregnancy, according to Dr. Rosen.
Among the practice points from the article, some HS treatments might have teratogenic effects and could be contraindicated during breastfeeding. Pregnancy changes the course of HS.
“Thus, it is important to be aware of how pregnancy may alter the treatment plan for women and impact their choice to breastfeed,” write the authors.
Why This Occurs
“From a physiologic point, during pregnancy humoral immune responses involving [T helper-2] Th-2 cytokines predominate, and sebaceous and eccrine gland activity increases while the activity of apocrine glands decreases,” said Dr. Rosen.
The authors note that HS affecting the apocrine glands of breast tissue could hinder a woman’s abilities to lactate and breastfeed.
“In the postpartum period, if HS causes notable inflammation in the nipple-areolar complex, the patient may experience difficulties with lactation and milk fistula formation, leading to inability to breastfeed,” said Dr. Rosen.
But HS doesn’t affect all pregnant women negatively. About 20% of women with HS experience improvement of symptoms during pregnancy, while the remainder either experience no relief or worsening of symptoms, according to the study.
“The weight gain associated with pregnancy may cause increased skin maceration at intertriginous sites, thereby leading to worsening HS symptoms. Active adipocytes (fat cells) may also worsen HS by secreting [tumor necrosis factor-alpha] TNF-α into circulation, increasing lesional inflammation,” said Dr. Rosen.
Safe Medical Management
“Topical antibiotics and therapeutic washes are safe during pregnancy and breastfeeding, as there is minimal systemic absorption,” said Dr. Rosen.
“Of the commonly used systemic antibiotics, clindamycin is safe during pregnancy and breastfeeding, but the tetracycline family of antibiotics is not considered safe. Erythromycin estolate is contraindicated in pregnancy due to induction of reversible maternal hepatoxicity and jaundice. Erythromycin ethylsuccinate (EES) is the preferred form for pregnant patients.”
Dr. Rosen stressed that all forms of erythromycin should be held for a few weeks postpartum, as exposure to erythromycin in early life has been linked to infantile hypertrophic pyloric stenosis.
“Rifampin is deemed safe during pregnancy and, although excreted into breast milk, has no adverse effect on the neonate.”
Dapsone presents no increased risk for congenital anomalies, according to the paper.
“However, it is associated with hemolytic anemia and neonatal hyperbilirubinemia. Dapsone can be found in high concentrations in breast milk at just over 14% of the maternal dose. There is a risk of the infant developing hyperbilirubinemia if the child is [glucose-6-phosphate dehydrogenase] G6PD deficient. Therefore, the infant should have a G6PD test before a mother taking Dapsone breastfeeds,” said Dr. Rosen.
While quinolone antibiotics are not specifically contraindicated during pregnancy, they can damage fetal cartilage and thus should be reserved only for cases where they are the only effective management tool, according to the paper.
“In general, TNF-α inhibitor use is considered somewhat controversial. There are limited data that support safe use of TNF-α inhibitors prior to the third trimester. TNF-α inhibitors are likely safe when breastfeeding because the drugs have such large molecular weights that they do not enter breast milk in substantial amounts,” said Dr. Rosen.
“Ustekinumab (IL-12/IL-23 inhibitor) and anakinra (IL-1α and IL-1β inhibitor) are FDA category B drugs and have sparse data which supports their use in pregnancy and during breastfeeding.”
“Topical and intralesional steroids are safe in pregnancy and during lactation, but systemic steroids should be used in low doses and for limited periods of time. Prolonged use of systemic steroids during pregnancy may lead to preeclampsia, eclampsia, premature delivery, and gestational diabetes. There also is a small risk of oral cleft deformity in the infant,” said Dr. Rosen.
The use of cyclosporine has been extensively studied in pregnant transplant patients and is considered relatively safe for use in pregnancy despite the fact that blood concentration in the fetus is 30% to 64% that of the maternal circulation, according to the paper.
“Isotretinoin and hormonal interventions, such as oral contraceptives or spironolactone, are contraindicated in pregnancy and during breastfeeding. Spironolactone has been shown to be associated with hypospadias and feminization of the male fetus,” said Dr. Rosen.
The authors conclude that the process for determining which HS treatments are safest and most effective during pregnancy is complex and questions remain.
“Dermatologists need more guidelines and proven safety data in human trials, especially regarding use of biologics and immunosuppressants, to better treat HS in pregnancy.”
Reference:
- Chellappan B, Dang D, Nguyen Q, et al. Dermatologic Management of Hidradenitis Suppurativa and Impact on Pregnancy and Breastfeeding. Cutis. 2022 March;109(3):160-162,E1-E2. doi:10.12788/cutis.0480.
