Hidradenitis suppurativa after renal transplantation: Complete remission after switching from oral cyclosporine to oral tacrolimus
Authors: Emilie Ducroux, Maria Andrea Ocampo, Jean Kanitakis, Emmanuel Morelon, Denis Jullien, Michel Faure, Sylvie Euvrard
Journal: Journal of the American Academy of Dermatology (2014)

To the Editor: Hidradenitis suppurativa (HS) is a chronic, recurrent inflammatory dermatosis involving apocrine gland−bearing skin, whose management has no formal guidelines.1Jemec G.B. Hidradenitis suppurativa.N Engl J Med. 2012; 366: 158-164Crossref PubMed Scopus (609) Google Scholar In November 2010, a 23-year-old Indian man consulted for severe facial acne associated with suppurating lesions of major body folds, which had started 2 years after he underwent kidney transplantation in 2007 for renal failure of unknown origin. His immunosuppressive treatment included cyclosporine (Cs) 150 mg/day and mycophenolate mofetil 1.5 g/day. Treatment with isotretinoin (20 mg/day) was introduced in April 2010 but led to worsening of facial nodular acne. Subsequently, inflammatory subcutaneous nodules developed on the buttocks, axillae, and groins and evolved in crops. Besides these nodules, physical examination revealed bridged scars, but no interconnecting tracts. Histologic examination of a skin biopsy and cultures ruled out Crohn disease and an opportunistic infection, respectively. The diagnosis was HS grade II according to the Hurley classification. A 6-month course of oxacillin (2 g/day), followed by a combination of rifampicin (600 mg/day) with clindamycin (600 mg/day) for 9 months were ineffective (Fig 1). In February 2012, Cs was replaced with tacrolimus (2 mg/day) based on the hypothesis of a deleterious effect of Cs on pilosebaceous apparatus and of a potential efficacy of tacrolimus as suggested in another report.2Arnadottir M. Jonsson E. Jonsson J. Inactivity of hidradenitis suppurativa after renal transplantation.Transplantation. 2006; 82: 849Crossref PubMed Scopus (6) Google Scholar In November 2012, all inflammatory lesions had disappeared (Fig 2).Fig 2Hidradenitis suppurativa. All facial and axillary inflammatory lesions were cleared in a few months on tacrolimus, leaving unsightly scars.View Large Image Figure ViewerDownload Hi-res image Download (PPT) To our knowledge, this patient is the first case of HS appearing in the setting of organ transplantation. Although a fortuitous association cannot be excluded, considering the patient's age, the clinical scenario speaks in favor of an iatrogenic origin of HS. Indeed, rare cases of iatrogenic HS have been reported.3Ma L. Dominguez A.R. Collins G.R. Kia K.F. Cockerell C.J. Hidradenitis suppurativa, eruptive melanocytic nevi, and keratosis pilaris-like eruption in a patient treated with vemurafenib.Arch Dermatol. 2012; 148: 1428-1429Crossref PubMed Scopus (24) Google Scholar Even if several Cs-responsive cases of HS exist,4Blok J.L. van Hattem S. Jonkman M.F. Horváth B. Systemic therapy with immunosuppressive agents and retinoids in hidradenitis suppurativa: a systematic review.Br J Dermatol. 2013; 168: 243-252Crossref PubMed Scopus (98) Google Scholar Cs is known to induce hyperplasia of the pilosebaceous apparatus.5Leyral C. Beylot-Barry M. Vergier B. Begueret H. Dromer C. Doutre M.S. et al.Cyclosporine-induced follicular eruption.Ann Dermatol Venereol. 2008; 135: 58-62Crossref PubMed Scopus (6) Google Scholar Isotretinoin may also have played an aggravating role. This patient is similar to one suffering from HS for more than 20 years, in whom treatment with Cs had been ineffective.2Arnadottir M. Jonsson E. Jonsson J. Inactivity of hidradenitis suppurativa after renal transplantation.Transplantation. 2006; 82: 849Crossref PubMed Scopus (6) Google Scholar He was cured at the age of 40 years, a few months after kidney transplantation, while receiving tacrolimus and mycophenolate mofetil as immunosuppressive treatment. We recently observed another case of HS that appeared within 2 years after transplantation, for which we suggested a switch from Cs to tacrolimus. Although tacrolimus and Cs exert very similar immunosuppressive effects, the former proved more effective than the latter against HS in these cases. This may be due to the fact that tacrolimus exerts fewer effects on the pilosebaceous apparatus. This observation suggests that patients in whom HS develops while on Cs should be switched to tacrolimus.