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• W2895487699 abstract "Hidradenitis suppurativa is a chronic, debilitating, inflammatory skin disease of hair follicles bearing apocrine glands. It is characterized by the presence of inflammatory nodules, abscesses and fistulas in body regions with skinfolds like axillae, or groins [1]. The clinical course can be aggressive, with tissue destruction leading to contractile scars that produce functional limitation and perpetuate the disease. Current treatment guidelines advocate for a combined therapeutic approach both, medical and surgical [2]. In HIV-positive patients, the use of HAART has improved life expectancy and quality of life. Due to this increase in life expectancy, these patients are at risk of developing systemic inflammatory diseases like rheumatoid arthritis, Crohn's disease, psoriasis or hidradenitis suppurativa. Furthermore, HIV-induced immunological alterations could change the clinical course and the response to conventional treatment of inflammatory skin disorders that present in more severe and refractory forms [3]. The use of anti-tumor necrosis factor (TNF) drugs could change the course of the disease and the life of the patients, nevertheless, the use of these drugs in HIV-positive patients is uncommon mainly because of the potential increased risk of infections. There are no clinical trials assessing the effectiveness and safety of these drugs among HIV-positive patients and evidence is limited to case reports and case series [4]. Additionally, TNF-alpha production is elevated in HIV-positive patients, even in patients receiving HAART [5], suggesting possible benefits of anti-TNF drugs in this population. There are few hidradenitis suppurativa cases in HIV-positive patients in the literature [6–9]. The scarce cases that have been reported highlight atypical presentations, aggressive forms and therapeutic challenges. The off-label use of infliximab has been reported in two of them [7,8], but currently there is no data about the use of adalimumab, the sole biologic drug approved for treatment of moderate-to-severe cases of hidradenitis suppurativa [2]. We present the case of a 39-year-old woman suffering from severe axillary hidradenitis suppurativa, Hurley stage III, for 12 years. Previous hidradenitis suppurativa treatments include: oral doxycycline, oral clindamycin with rifampin and several surgical interventions. This clinical management regardless, complete disease control has been never achieved. Quality of life is severely impaired: the Dermatology Life Quality Index (DLQI) score is 18, in the Numeric Rating Scale (NRS), the patient scores 9/10 for pain, 8/10 for pruritus, 8/10 for bad odor and 7/10 for purulent discharge. The patient works as a cleaner and is unable to carry on with her duties because of the pain. Her medical history shows HIV–hepatitis C virus (HCV) co-infection, 20 years ago because of parenteral drug abuse. At diagnosis HIV stage was C3, HCV genotype was 3a and hepatic biopsy showed minimal periportal chronic hepatitis G1. Currently HIV viral load is undetectable under abacavir with lamivudine and rilpivirin and the last CD4+ count shows 1050 cells/μl. With regard to HCV infection, sustained virologic response is present since 2003 after successful treatment with pegylated-interferon and ribavirin. At physical examination, the patient presents wide involvement of both axillae with inflammatory lesions and retractile scars. Ultrasound examination shows a complex multitunnel cutaneous fistula with two tracts in the right axilla, left axilla shows a single fistulous tract, all lesions exhibit high Doppler activity. After screening for latent tuberculosis and discussing with the patient the potential benefits and risks, adalimumab treatment was initiated according to label information and in collaboration with the Infectious Diseases Unit. At week 4, DLQI and NRS for pain, pruritus, bad odor and suppuration were 0. The patient is extremely satisfied as she is able to work again. Physical and ultrasound examinations show an evident clinical improvement with resolution of inflammatory lesions (Fig. 1). After monthly follow-up, at week 16, response is maintained. No laboratory abnormalities are detected, CD4+ count remains stable and HIV and HCV viral loads remain undetectable.Fig. 1: (a and b) Left and right axilla at baseline. (c and d) Left and right axilla after 4 weeks of adalimumab treatment.To the best of our knowledge, this is the first case of hidradenitis suppurativa treated with adalimumab in an HIV-positive patient, highlighting the sustained complete clinical response of adalimumab in a refractory hidradenitis suppurativa patient and the absence of infectious complications. In line with the use of anti-TNF alpha drugs in HIV-positive patients in other inflammatory diseases, adalimumab can be used in refractory HIV or HIV/HCV-positive patients with hidradenitis suppurativa treated with HAART and stable CD4+ counts at baseline [4]. However, it is advisable to closely monitor these patients in collaboration with the infectious diseases specialists, given the lack of robust scientific evidence in this field. Acknowledgements We want to thank the Professor Dr Miguel Angel Lopez Ruz and the Unit of Infectious Diseases of the Hospital Universitario Virgen de las Nieves for their extraordinary work and attitude for interdiscipinary collaboration. We want to thank Professor Dr Alejandro Higuera Matas for improving the English of the manuscript. Conflicts of interest There are no conflicts of interest." @default.
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• W2895487699 date "2018-10-23" @default.
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• W2895487699 title "Severe refractory hidradenitis suppurativa successfully treated with adalimumab in an HIV-positive/hepatitis C virus-positive patient" @default.
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