Botulinum toxin is a safe and potentially effective treatment alternative in hidradenitis suppurativa (HS) patients who are resistant to standard therapies, according to the authors of a systematic review published in the Journal of Drugs in Dermatology.
How does this review add to the conversation about new treatments for HS? In which HS patients might dermatologists consider botulinum toxin as a treatment option?
I interviewed Jeannette Jakus, MD, MBA, director of clinical research and clinical assistant professor of dermatology at SUNY Downstate Health Sciences University in Brooklyn, N.Y.
Before reading this article, what was your perspective on botulinum toxin as a potential treatment for hidradenitis suppurativa?
As mentioned in the article, patients with HS have a greater risk of hyperhidrosis compared to the general population. In my own practice and experience, patients with HS presenting with hyperhidrosis generally benefit from sweat reduction. I do routinely recommended treatments to reduce sweating in these patients and have considered botulinum toxin injections for some, but the cost of treatments and regular access to the product has been a barrier for my patient population.
How does this review add to the conversation about new treatments for hidradenitis suppurativa?
This review shows that botulinum toxin injections can help improve quality of life and can lead to clinical improvement in patients with HS. In these studies, over 50% of patients had concurrent hyperhidrosis. However, it is not clear whether clinical improvement was more significant in this population compared with those without hyperhidrosis. The use of botulinum toxin in patients with HS and hyperhidrosis seems to be a logical option from a mechanism of action standpoint, but this is less clear in patients without hyperhidrosis and must be further studied. As a starting point, an important takeaway for me is that physicians should better recognize and diagnose hyperhidrosis in HS patients and, when identified, consider treatments such as botulinum toxin as adjunctive treatment options for these patients.
Do you foresee botulinum toxin as a future standard treatment option for hidradenitis suppurativa?
This article was a nice review of the literature and, while the results are impressive, more formal clinical trials or data will be needed before this becomes a standard treatment. For example, we must first identify the ideal candidate for this treatment and the role of hyperhidrosis. As in my experience, insurance coverage and affordability will be an important determinant of whether this becomes a standard treatment or not.
What unique benefits could botulinum toxin provide in comparison with currently available treatments?
Currently available treatments for hyperhidrosis are limited. First-line treatment is prescription strength topical aluminum chloride, which can be irritating and not always effective, especially in HS patients who are already inflamed at baseline. Glycopyrrolate topical and oral are options but can have side effects. Botulinum toxin, on the other hand, is very effective and long lasting with no perceivable side effects. Injections with botulinum toxin are generally tolerable, but may be more painful in patients with HS who are actively inflamed. On the other hand, these patients are also used to receiving injections, so they may be overall more tolerant of the procedure and, in the long run if effective, may decrease the need for or frequency of steroid injections.
In what cases (if any) would you consider botulinum toxin as a therapy for hidradenitis suppurativa?
A good place to start would be in patients with concurrent hyperhidrosis who have failed or not been able to tolerate topical treatments. With more data, botulinum toxin may also be an effective treatment option for patients with HS in the absence of hyperhidrosis.
How should dermatologists interpret this article in light of the larger context of available hidradenitis suppurativa treatments?
Botulinum toxin injections have been safely used in dermatology and other fields for many years over a wide range of indications. This article highlights its potential use in the treatment of hidradenitis suppurativa. Current treatment options for HS are limited and, while more data is needed, dermatologists should feel comfortable offering this as a new potential treatment option for their HS patients, especially those with hyperhidrosis.
Did you enjoy this article? You can find more on hidradenitis suppurativa here.