Chemotherapy For Acne?
We are all familiar with the concept of chemotherapy for cancer. But how could acne ever get so bad that anyone would be willing to undergo chemotherapy to control it?
There is one kind of acne for which chemotherapy is rapidly becoming the medically prescribed treatment of choice. That awful acne is a condition known as acne inversa, which is also referred to as smoker’s acne, hidradenitis suppurativa, Verneuil’s disease, and pyoderma fistulanas significa. If you have it, however, you probably just call it awful1.
Acne inversa is not acne that pops up on your face or maybe on your neck and shoulders. Instead, it appears in the creases around the groin and in the crack between the buttocks. Like other forms of acne, acne inversa causes pores to become clogged. Unlike other forms of acne, this condition causes pores to become completely clogged with the formation of a sinus2 around the pore.
This condition is literally like having sinus infections spreading through your skin. The pore’s walls collapse to form a pouch that spreads out horizontally in all directions, and the pouch fills with inflammatory compounds and fluid.
Other forms of acne usually involve the overgrowth of “acne bacteria,” Propionibacterium acnes. But this form of acne can involve E. coli, the bacterium that is usually found in feces, strep bacteria, and staph bacteria. It’s not the bacteria, however, that cause the damage. In acne inversa, damage to the skin is caused by the immune system itself3, which keeps this sinus in the skin constantly inflamed.
What are some of the symptoms of acne inversa? There is always pain. This pain is described as burning, throbbing, stabbing, gnawing, or aching. The skin may form stigmata, spontaneous wounds more commonly associated with crucifixion. And in the worst cases, the condition may migrate upwards from the buttocks and groin to the torso and neck. The sinuses may spread from the skin to the rectum, in effect forming a second (or third or fourth) anal aperture, and as the condition goes into the digestive tract, there can be malnutrition and anemia.
Acne inversa is not an exotic disease. Among people of European descent, about 1 in 600 will come down with the condition4 at some point in life. It is slightly more common among African-Americans. People who have the condition are nearly 6 times more likely than people who do not to become morbidly obese, and they also tend to develop diabetes and high cholesterol.
What Can Be Done About Acne Inversa?
One of the most important tasks of medical care in treating acne inversa is making sure that minor infections don’t become major infections. Doctors give antibiotics such as rifampicin and or the combination rifampicin-moxifloxacin-metronidazole to prevent the formation of biofilms5, tough “sheets” of bacteria that are almost impossible for the immune system to penetrate. The doctor may also prescribe treatments for diabetes and high cholesterol. In smokers, there is a greatly increased risk of the development of a form of cancer known as squamous cells carcinoma, which typically becomes very aggressive and spreads to the lungs,
Treating the underlying disease itself, however, is a lot more complicated. Sometimes doctors try an antibiotic called dapsone. For reasons that are not clearly understood, it tends to stop skin inflammation. At home, people who have the disease often use chlorhexidine soap to wash the skin to keep new bacteria from finding their way inside. They may treat the skin with zinc oxide creams or take zinc gluconate supplements by mouth. Making sure the diet contains sufficient vitamin A seems to help.
And doctors may offer laser surgery to cut away severely damaged tissue, prescription bandages to help with lymphedema (swollen lymph glands) blocking circulation to the thighs, and traditional surgery to repair fistulas. But recently doctors have also begun to offer chemotherapy drugs.
Adalimumab, Infliximab, And Etanercept
Although the names sound like they might refer to some trio of brothers thrown into a fiery furnace in the Biblical Book of Daniel, adalimumab, infliximab, and etanercept are medications used to provide the body with regulatory compounds known as TNF-alpha inhibitors. TNF refers to tumor necrosis factor, which is a substance the body makes to fight cancer and infections. A TNF inhibitor stops the inflammatory reaction6 that the healthy body uses to fight cancer and the body afflicted by acne inversa uses to destroy healthy tissue.
These medications have been used for about 20 years to fight hepatitis C. They have been used for about 10 years to fight rheumatoid arthritis and the most severe cases of inflammatory bowel disease. And they are just now being made available to treat this particularly aggressive form of acne.
Do The Medications Actually Work?
Among acne inversa patients who are given etanercept for 1 year, there is, on average, a 9-1/2 month remission from symptoms. Among acne inversa patients who are given adalimumab for one year, there is on average remission lasting 21-1/2 months. Eventually, the symptoms of the disease come back. These drugs are not a cure. But they often provide a break from the disease when antibiotics become intolerable.
Adalimumab, infliximab, and etanercept are not cheap. A single round of treatment will cost in excess of $10,000. Fortunately, even people who do not have health insurance can often get the drug through pharmaceutical company medical assistance programs, which provide the medication for three months at a time either for free or for a nominal charge, usually $25. Families with incomes as high as $94,000 per year, in the United States, may be eligible for pharmaceutical company assistance with the cost of their care. But cost is not the only drawback.
The risk one runs when taking a medication that deactivates one of the functions of the immune system, which is what TNF-alpha inhibitors do, is that a disease will come along that the body is unable to fight. Some people who take these drugs come down with pneumonia7. Taking the pneumonia vaccine will reduce that risk. And a few people who take these drugs develop cancer, although many say that cancer is not as bad as the form of acne these medications treat.
- Sabat R., Tsaousi A., Rossbacher J., Kurzen H., Fadai T., Schwichtenberg U., Schneider-Burrus S., Kokolakis G., Wolk K. Acne inversa/hidradenitis suppurativa: An update. Der Hautarzt. 2017;68(12):999-1006.
- Napolitano M., Megna M., Timoshchuk E.A., Patruno C., Balato N., Fabbrocini G., Monfrecola G. Hidradenitis suppurativa: from pathogenesis to diagnosis and treatment. Clinical, Cosmetic, and Investigational Dermatology. 2017;10:105-115.
- Bergler-Czop B., Hadasik K., Brzezińska-Wcisło L. Acne inversa: difficulties in diagnostics and therapy. Postȩpy dermatologii i alergologii. 2015;32(4):296–301.
- Wollina U., Koch A., Heinig B., Kittner T., Nowak A. Acne inversa (Hidradenitis suppurativa): A review with a focus on pathogenesis and treatment. Indian Dermatology Online Journal. 2013;4(1):2–11.
- Scheinfeld N. Why rifampin (rifampicin) is a key component in the antibiotic treatment of hidradenitis suppurativa: a review of rifampin’s effects on bacteria, bacterial biofilms, and the human immune system. Dermatology Online Journal. 2016;22(6).
- Haslund P., Lee R.A., Jemec G.B. Treatment of hidradenitis suppurativa with tumour necrosis factor-alpha inhibitors. Acta dermato-venereologica. 2009;89(6):595-600.
- Gottlieb A., Menter A., Armstrong A., Ocampo C., Gu Y., Teixeira H.D. Adalimumab Treatment in Women With Moderate-to-Severe Hidradenitis Suppurativa from the Placebo-Controlled Portion of a Phase 2, Randomized, Double-Blind Study. Journal of Drugs in Dermatology. 2016;15(10):1192-1196.
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