Variable response of hidradenitis suppurativa to infliximab in four patients

We present a retrospective review of four patients treated with infliximab (5 mg ⁄ kg) for recalcitrant hidradenitis suppurativa (HS). Data including gender, age, previous treatments and therapeutic response are recorded in Table 1. All patients were screened beforehand with a chest X-ray and a Mantoux test to exclude concomitant TB. Patients 1 and 2. Our first two patients were middle-aged women with long-standing severe HS of the axillae, abdomen and groin. Both had received a wide range of systemic treatments and extensive surgery. We treated them with three infusions of infliximab (0, 2 and 6 weeks). In patient 1, there was no evidence of significant clinical improvement after the final infusion. In contrast, patient 2 experienced a dramatic improvement in her skin after her third infusion, with resolution of all her inflammatory lesions. A further infusion of infliximab (5 mg ⁄ kg) was administered a month later in response to a mild flare, and she was subsequently listed for eight weekly infusions. Eleven months after her first infusion, she developed a positive antinuclear antibody titre (1 ⁄ 640; negative before infliximab), associated with a positive perinuclear neutrophil cytoplasmic antibody, and this, associated with arthralgia and diffuse alopecia, suggested an infliximab-induced lupus reaction. A double-stranded DNA and extractable nuclear antigen test were negative, with normal levels of complement. The infliximab was stopped immediately, and the patient’s clinical and serological markers improved. Patient 3. This was a 48-year-old man with a 30-year history of extensive HS and associated pyoderma gangrenosum. On review 1 month after his third and final infusion of infliximab, his HS remained widespread. He currently remains on tacrolimus 5 mg twice daily and minocycline 100 mg twice daily. Patient 4. Our final patient was a 27-year-old man with a long-standing history of HS affecting the axillae and groin, and concomitant perianal Crohn’s disease (CD). In December 2002, the patient was treated with two infusions of infliximab. His symptoms from both his conditions settled well. Unfortunately, his CD re-flared 2 years later, and a further course of infliximab was administered in 2004. During the first infusion of this new series, the patient developed facial swelling and shortness of breath within minutes of commencing the infusion, suggesting the development of antibodies to the infliximab. The infusion was stopped and his CD is currently maintained on azathioprine 50 mg three times daily. His HS is currently unmonitored, as he has since failed to attend his dermatology appointments. HS is a chronic inflammatory condition in which successful medical treatment remains a therapeutic challenge. To date, several cases have been reported in the literature, which cite the success of infliximab in its treatment. T b le 1 P a ti en t d em o g ra p h ic s, p ri o r a n d cu rr en t th er a p ie s a n d re sp o n se to in fl ix im a b in fu si o n (5 m g ⁄k g ).