HS Treatment Considerations in Patients with Infections and Malignancy

Conclusions

• For hidradenitis suppurativa patients with chronic infections, treatment can often proceed safely by choosing agents with lower infectious risk and timing immunosuppressive therapy appropriately.
• Latent tuberculosis should be treated with rifampin when possible, while TNF inhibitors require caution and can generally be started after about one month of TB therapy if needed.
• Acitretin, apremilast, and IL-17 inhibitors appear to be relatively safe choices in patients with latent or treated tuberculosis.
• In hepatitis B or C, steroids and rifampin are less attractive options, while metformin and oral contraceptives appear safe and biologics should be paired with antiviral treatment when indicated.
• Biologic hepatitis B reactivation risk is highest with TNF inhibitors, intermediate with IL-12/23 blockade, and lower with IL-17 inhibition.
• In controlled HIV, many HS therapies remain usable, including TNF inhibitors, acitretin, clindamycin, cotrimoxazole, dapsone, metformin, and short low-dose steroid courses.
• For patients with malignancy or a history of cancer, some immunosuppressants such as methotrexate, azathioprine, and cyclosporine should be avoided, especially when recurrence risk is a concern.
• TNF inhibitors may be acceptable in selected patients with prior malignancy, but melanoma is a notable exception.
• IL-17 inhibitors and metformin emerge as especially favorable options for HS patients with a history of malignancy.
• Several hormonal therapies, including spironolactone, oral contraceptives, and finasteride, appear not to increase cancer recurrence risk and can be considered safe in appropriate patients.