Treatment of Hidradenitis Suppurativa with SAPHO Syndrome: A Case Review

In a recently published case-based review, the treatment course of a 32-year old patient with comorbid hidradenitis suppurativa (HS) and synovitis, acne, pustulosis, hyperostosis, osteitis (SAPHO) syndrome was described and appropriate approaches for management were summarized.

The male patient presented in 2009 with a “3-year history of multiple interconnecting comedones in the axilla and inguinal regions, as well as scarring from previous lesions.” From 2009 to 2014, initial treatment with antiseptic washes, topical clindamycin (+/- benzoyl peroxide), cloxacillin, tetracycline, cephalexin, doxycycline, amoxicillin/clavulanic acid and desonide cream only provided minimal benefit. The patient presented multiple times to the clinic during his first 6 years of care due to HS lesion flares. These were treated successfully with low-dose intralesional corticosteroid (ILC) injections, however, long-term disease stability was not maintained. 

In December 2014, weekly subcutaneous injections of adalimumab were initiated and in March 2015, the patient was diagnosed with comorbid SAPHO syndrome. Methotrexate 10mg injected weekly was started in December 2015, when it was determined that the efficacy of adalimumab had been reduced. The patient’s methotrexate dose was further increased to 20mg weekly after later complaints of pain in the forearms and left clavicle.

The patient’s current situation, at 40 years-old, shows good control of his HS-SAPHO syndrome. “His successful HS management plan included the following: HS flares relieved by ILC injections as needed, weekly 40mg adalimumab, and weekly 20mg methotrexate/folic acid,” write the authors. Lifestyle modifications, including weight loss, smoking cessation, and increased control of depression, were also implemented during his course of therapy.

Although challenging, HS and SAPHO syndrome can be managed effectively using a variety of agents. HS should be managed using a holistic approach and therapy should be chosen based on disease severity. First-line treatment for mild disease includes topical clindamycin or oral tetracycline antibiotics and second-line agents include clindamycin plus rifampin or adalimumab. ILC is utilized for rapid and local disease treatment only. SAPHO syndrome is managed using agents such as nonsteroidal anti-inflammatory drugs (NSAIDs), intra-articular or systemic steroids, doxycycline, pamidronate, and immunosuppressive agents (methotrexate, sulfasalazine, cyclosporine, and leflunomide).

When managing patients with comorbid HS and SAPHO syndrome, “NSAIDs, corticosteroids, antibiotics, and immunosuppressive agents have been the conventional approach,” the authors state, adding, “Biologic agents have provided an effective, targeted therapeutic option that has changed the way a number of inflammatory conditions, including HS and SAPHO, are managed.”

Reference

Crowley EL, O’Toole A, Gooderham J. Hidradenitis suppurativa with SAPHO syndrome maintained effectively with adalimumab, methotrexate, and intralesional corticosteroid injections. Sage Open Medicine Case Reports, volume 6: 1–3. 2018.