Failure of Anakinra in a Case of Severe Hidradenitis Suppurativa

Hidradenitis suppurativa (HS) is a chronic, painful, inflammatory disorder of hair follicles in apocrine-rich areas of the body.¹ It can present with a variety of cutaneous findings, including double comedones, papules, cysts, nodules, draining abscesses, and sinus tracts.¹ The disorder is associated with tremendous morbidity and decreased quality of life. Severe cases can be physically and emotionally debilitating.^2,3 Complicating matters more, there is no cure for HS and treatment is often frustrating and challenging.⁴ Fortunately, the disorder has been gaining a great deal of attention by the medical community in recent years. Recently, Leslie et al. reported efficacy of anakinra, an interleukin 1 receptor antagonist, in the treatment of 5 patients with moderate to severe HS over an 8-week course (mean improvement on Sartorius scoring, 34.8 points).⁵ These results were met with great excitement by dermatologists, many of whom have patients with severe, recalcitrant HS. Herein, we report a case of severe HS unresponsive to anakinra.

We describe a case of a 55-year-old African American male with a several year history of severe Hurley stage III HS affecting the axillae, scrotum, perineum, inguinal areas, buttocks, and intergluteal cleft (Figure 1). The disease affecting the axillae and right inguinal fold was previously excised, resulting in resolution of axillary disease, but with consequential fusion of the scrotum to the right inguinal area in the wake of secondary intention healing. He has been treated with several systemic agents in the past, including oral antibiotics (doxycycline, minocycline and combination therapy with clindamycin and rifampin) and topical antibiotics and washes (clindamycin and benzoyl peroxide) without notable improvement. He was previously treated with acitretin for several months but self-discontinued this medication due to lack of efficacy. He underwent a six-month course of adalimumab 40 mg weekly with significant improvement in lesion pain, suppuration, and drainage, but experienced a rapid relapse following cessation of therapy due to a diagnosis of stage IIB gastric cancer, for which he underwent a partial gastrectomy and five cycles of multi-agent chemotherapy. He is an ex-smoker with a body mass index (BMI) of 21 and no known family history of HS.

Although the patient achieved acceptable relief with adalimumab, he was apprehensive to resume this medication assuming its use was associated with the development of his cancer. Therefore, after seeking approval from the patient’s oncologist, we trialed the patient on anakinra monotherapy with a self-administered 100 mg subcutaneous injection once daily. Prior to treatment, the patient underwent comprehensive baseline laboratory investigations, including a complete blood cell count (CBC) with differential, comprehensive chemistry panel, tuberculin test, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP). He also completed the Dermatology Life Quality Index (DLQI) questionnaire (score of 0-1 is regarded as no effect whereas 21-30 is an extremely large effect of the disease on the patient’s daily life activities and feelings over the last week6) and underwent Physician’s Global Assessment, which assigns a score of 0 (clear) to 5 (very severe).⁷ His labs were notable for a mild leukocytosis of 13.2 x 109/L with a neutrophil predominance, an ESR of 120 mm/hour (normal range, 0-20 mm/hr) and a CRP of 78.1 mg/L (normal range, 1-10 mg/L). Baseline DLQI and PGA scores were 23 and 4, respectively.

At 1-month follow up, the patient reported a mild initial reduction in the pain and drainage of the lesions. Although