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Can Certain Drugs Trigger HS To Develop?

Posted on June 14, 2022
Medically reviewed by
Ariel D. Teitel, M.D., M.B.A.
Article written by
Kristopher Bunting, M.D.

The causes of hidradenitis suppurativa (HS), also known as acne inversa, are not well understood, but several genetic and environmental risk factors have been identified. HS causes nodules, lesions, and abscesses in the skin that may connect to form fistulas. Commonly affected areas include the armpits, genitals, and other areas of the body that have many hair follicles and sweat glands.

Rarely, certain drugs may trigger development of HS or worsen an existing case. There are very few reported cases linking HS with specific medications, making it difficult to draw conclusions about the actual effect of those agents on HS. A lot more research is needed before the connections between drugs and HS can be clearly understood.

If you develop new or worsening HS while taking any of these drugs, don’t make any changes before talking with your health care provider. The medication may not be the cause of your symptoms.

What Drugs Are Linked to HS?

Several drugs, including lithium, some types of hormonal birth control, and tumor necrosis factor (TNF)-alpha inhibitors, are believed to trigger or worsen HS in a small minority of people.

Lithium

Lithium carbonate is a prescription medication used to treat bipolar disorder and treatment-resistant depression. The drug has many known side effects, mostly skin conditions.

Lithium use is associated with psoriasis, acne, folliculitis, and other common skin diseases. In a few cases reported in scientific literature, people developed HS while taking lithium, and their symptoms improved after they stopped using the drug.

Recent research has found that people with HS are also more likely to have bipolar disorder, meaning that developing HS after starting lithium may be coincidental. Another study found a possible association between lithium use and HS, suggesting that lithium may worsen existing HS. However, both studies showed that less than 1 percent of people with HS also had bipolar disorder, and most of those were also smokers or were obese, which are known risk factors for HS.

Given the small number of reported cases and the presence of other risk factors, it is difficult to determine if lithium actually triggers HS. However, evidence suggests that it may worsen HS in some individuals.

Hormonal Birth Control

Hormones are believed to play a role in HS development and flare-ups. Combination birth control (containing both estrogen and progestin) is used to prevent pregnancy as well as treat diseases such as endometriosis, uterine fibroids, polycystic ovarian syndrome, and HS in women. Results of a 2021 study showed that combination birth control can improve both symptoms and measurable signs of HS in women with mild to moderate HS.

There are some published reports of women developing HS soon after starting hormonal birth control. However, these reports mostly involve older contraceptives containing levonorgestrel or other progestins known to cause androgenic side effects, such as acne and hirsutism (excess hair growth).

Androgens are sex homones that can worsen symptoms of HS. Drugs such as spironolactone (Aldactone) and finasteride are a type of antiandrogen therapy for HS. Many newer combination birth control pills use antiandrogenic progestins that do not have these side effects and are recommended for the treatment of HS.

The majority of research shows that hormonal birth control is an effective treatment for HS, and only a few specific drugs may cause or worsen HS in some individuals.

TNF-alpha Inhibitors

TNF-alpha is a cytokine, or signaling protein, that promotes inflammation. TNF-alpha plays a role in many chronic inflammatory and autoimmune diseases, including rheumatoid arthritis, inflammatory bowel disease (Crohn’s disease and ulcerative colitis), psoriasis, and HS.

TNF-alpha inhibitors are a type of drug called biologic agents, or simply biologics, that have anti-inflammatory effects on the immune system. TNF-alpha inhibitors include:

  • Adalimumab (Humira)
  • Infliximab (Remicade)
  • Etanercept (Enbrel)
  • Certolizumab pegol (Cimzia)
  • Golimumab (Simponi)

The U.S. Food and Drug Administration (FDA) has approved adalimumab to treat moderate to severe HS. Other treatments include topical or injected corticosteroids, retinoids such as acitretin, and clindamycin.

There have been reports of people developing HS while taking adalimumab and other TNF-alpha inhibitors. New research shows that HS improved or resolved when the medication was stopped or switched. In some people, however, the condition improved with no change in regimen.

Should You Stop Taking Medications Due to HS?

Do not stop taking any prescription medicine without talking to your doctor first. If you are concerned about your medications causing HS, discuss this with your dermatologist.

Some medications, such as lithium, must be tapered off slowly to prevent severe withdrawal effects. Discontinuing other medications, such as TNF-alpha inhibitors, can worsen the disease being treated. The best course of action is to explore treatment options for HS with your doctor and discuss whether stopping or changing medication may improve your HS.

You should always discuss the risks and benefits of medications with your doctor, whether you are starting a new medication or making changes to an existing prescription. Be sure your doctor understands the impact of HS symptoms on your quality of life. The benefits of some drugs may outweigh the risk of side effects, including new or worsening HS.

Fortunately, in many of the reported cases of drugs contributing to HS, simply switching to a slightly different medication improved HS symptoms or led to disease remission — when no HS lesions are detectable.

You Are Not Alone

Hidradenitis suppurativa can be a source of physical pain and emotional distress, affecting both your body and your mind. Know that you are not alone with HS. There is a large community of people experiencing and overcoming the same problems that you are having.

Take time to reach out to others with HS or listen to what they have to say. Living with HS can be a difficult burden, but you do not have to bear it alone.

Talk With Others Who Understand

MyHSteam is the social network for people with hidradenitis suppurativa and their loved ones. On myHSteam, more than 24,000 members come together to ask questions, give advice, and share their stories with others who understand life with HS.

Have you noticed your HS symptoms worsening when you take certain medications? Did you tell your doctor about your concerns? Share your experience in the comments below, or start a conversation by posting on your Activities page.

References
  1. Hidradenitis Suppurativa — DermNet NZ
  2. Why You Need To Take Your Medications as Prescribed or Instructed — U.S. Food and Drug Administration
  3. Lithium — National Alliance on Mental Illness
  4. Lithium — DermNet NZ
  5. Bipolar Disorder — Mayo Clinic
  6. Lithium Augmentation in Treatment-resistant Depression: Clinical Evidence, Serotonergic and Endocrine Mechanisms — Pharmacopsychiatry
  7. Lithium Induced Hidradenitis Suppurativa and Acne Conglobata — Indian Journal of Dermatology, Venereology and Leprology
  8. Lithium Therapy Associated With Hidradenitis Suppurativa: Case Report and a Review of the Dermatologic Side Effects of Lithium — Journal of the American Academy of Dermatology
  9. Hidradenitis Suppurativa and Bipolar Disorders: A Population-Based Study — Dermatology
  10. Hidradenitis Suppurativa and Bipolar Disorders: A Role for Lithium Therapy? — Dermatology
  11. The Role of Androgens and Estrogens in Hidradenitis Suppurativa — A Systematic Review — Acta Dermatovenerologica Croatica
  12. North American Clinical Management Guidelines for Hidradenitis Suppurativa: A Publication From the United States and Canadian Hidradenitis Suppurativa Foundations — Journal of the American Academy of Dermatology
  13. The Role of Oral Contraceptive Pills in Hidradenitis Suppurativa: A Cohort Study — Life (Basel)
  14. Hidradenitis Suppurativa Associated With Use of Oral Contraceptives — The BMJ
  15. Levonorgestrel and Ethinyl Estradiol (Oral Route) — Mayo Clinic
  16. Androgenic Effects of Oral Contraceptives: Implications for Patient Compliance — The American Journal of Medicine
  17. Androgens — Cleveland Clinic
  18. Treatment — Hormonal Therapies — HSDisease.com
  19. Anti-Androgen Therapy — DermNet NZ
  20. New Progestagens for Contraceptive Use — Human Reproduction Update
  21. TNF-Mediated Inflammatory Disease — The Journal of Pathology
  22. TNF-alpha Inhibitors in the Treatment of Hidradenitis Suppurativa — Therapeutic Advances in Chronic Disease
  23. Observational Case Series on Adalimumab-induced Paradoxical Hidradenitis Suppurativa — The Journal of Dermatological Treatment
  24. Hidradenitis Suppurativa (HS): An Unrecognized Paradoxical Effect of Biologic Agents (BA) Used in Chronic Inflammatory Diseases — Journal of the American Academy of Dermatology
  25. Paradoxical Hidradenitis Suppurativa in Patients Receiving TNF-alpha Inhibitors: Case Series, Systematic Review, and Case Meta-analysis — Dermatology
  26. TNFalpha Blockade in Human Diseases: An Overview of Efficacy and Safety — Clinical Immunology
  27. Outcome After Rapid vs Gradual Discontinuation of Lithium Treatment in Bipolar Disorders — Archives of General Psychiatry
  28. Think It Through: Managing the Benefits and Risks of Medicines — U.S. Food and Drug Administration
All updates must be accompanied by text or a picture.
Ariel D. Teitel, M.D., M.B.A. is the clinical associate professor of medicine at the NYU Langone Medical Center in New York. Review provided by VeriMed Healthcare Network. Learn more about him here.
Kristopher Bunting, M.D. studied chemistry and life sciences at the U.S. Military Academy, West Point, and received his doctor of medicine degree from Tulane University. Learn more about him here.

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