Hormonal Therapies for HS

Hidradenitis suppurativa (HS) is a chronic, painful inflammatory skin disease that begins when clogged hair follicles cause bumps. Treatments are available to help manage the condition, but there is no cure for HS. Since there is no cure, the goals of HS treatment are to reduce symptoms, relieve pain, and heal wounds to prevent infection.¹

Increased androgens (male hormones) in the skin may contribute to the development of hidradenitis suppurativa (HS) in some people. For that reason, hormonal therapies are sometimes used to relieve HS symptoms, including pain and lesions.²

Signs of high levels of androgens in people with HS include:³

• Acne
• Excess male-pattern hair growth in women (hirsutism)
• Irregular menstrual periods
• High levels of androgen in the blood
• Infertility

Some studies have found no difference in levels of androgen in women with HS compared to a matched sample of women without HS. However, changing hormone levels appear to affect the course of the disease. Studies show that HS causes flares before menstrual periods, after childbirth, and as menopause approaches. Nearly half of women with HS report that the disease decreases after menopause.^3-7

How do hormone therapies work?

Androgens are hormones that are present in both young men and women during puberty. Testosterone is a well-known androgen. Androgens are also the precursors of estrogen. This means androgens are converted to estrogens by chemicals in the body.⁸

In HS, clogged hair follicles cause bumps that lead to symptoms like papules, nodules, abscesses, and sinus tracts. The hair follicles in the armpits, groin, and buttocks area are surrounded by sweat and sebaceous glands. These are glands that secrete sebum, an oily matter that lubricates the skin and hair.⁸

These glands have 2 kinds of enzymes that turn testosterone into a stronger androgen hormone called 5-dihydrotestosterone (5-DHT). Testosterone and 5-DHT stick to androgen receptors on the sebaceous glands. This causes the glands to secrete more sebum, which increases inflammation and HS symptoms. Hormone therapy can help to keep testosterone and 5-DHT levels balanced, reducing HS symptoms and flares.⁸

Examples of hormone therapies for HS

Many different hormone therapies are used for people with mild to moderate HS. They may also be used along with other drugs to treat severe HS. They include:⁹

• Ethinyl estradiol
• Norgestrel
• Spironolactone (Aldactone)
• Finasteride (Propecia, Proscar)
• Metformin

Ethinyl estradiol, norgestrel, and cyproterone acetate for HS treatment

Ethinyl estradiol, norgestrel, and cyproterone acetate (CypA) hormones are often used in birth control pills. Ethinyl estradiol and norgestrel are forms of the female hormones estrogen and progestin. CypA is not available in the United States.¹⁰

In one study, researchers studied women with HS taking birth control pills with ethinyl estradiol and norgestrel. They compared their HS symptoms to women taking birth control pills with ethinyl estradiol and CypA. HS improved or completely cleared in half the women using either treatment.^9,10

Spironolactone for HS treatment

Spironolactone is an androgen blocker that was developed for the treatment of high blood pressure. It is to treat HS in females only. Researchers in 1 study found that just over half of women treated with a combination of ethinyl estradiol, CypA, and spironolactone experienced an improvement in their HS symptoms.^9,11

In women treated with spironolactone alone, nearly 90 percent showed improvement. More than half had complete remission of their HS.⁹

Researchers recommend spironolactone as a first-line treatment for women with mild to moderate HS.¹¹

Finasteride for HS treatment

Finasteride is an anti-androgen that is used for treating enlargement of the prostate gland and male-pattern hair loss in men. It is also used to treat excessive hair growth in women.¹⁰

Studies have found that finasteride is effective for treating HS when used alone or with other drugs, regardless of the duration or extent of the disease. It reduces the frequency and severity of flares in adults, teens, and children. It is cost-effective and well-tolerated.¹⁰

More research is needed to find out the best timing, dosage, and duration of treatment, as well as any complications of long-term use in younger people.¹⁰

Metformin for HS treatment

Metformin is a type of drug called a biguanide. It is mainly used to treat type 2 diabetes. It has androgen-blocking effects. Limited research on metformin showed promise in treating HS. One study found that about 70 percent of participants had improvement in symptoms and quality of life after being treated with metformin.¹²

However, this study was limited, with only 25 participants. More research is needed to confirm if metformin is a reliable treatment for HS.¹²

What are the possible side effects of hormone therapy?

Side effects can vary depending on the specific drug you are taking. Common side effects of hormone therapies include:^2,9,10,12-15

• Breast pain in women and enlargement of breasts in men
• Decreased sex drive (libido)
• Dizziness
• Flu-like symptoms
• Hot flashes
• Headaches
• Mood swings
• Nausea, abdominal pain, and diarrhea
• Weight gain

These are not all the possible side effects of hormone therapy. Talk to your doctor about what to expect when taking hormone therapy. You also should call your doctor if you have any changes that concern you when taking hormone therapy drugs.

Things to know about hormone therapy

Pregnant women with HS should not use hormonal therapy because of risks to their unborn baby. Talk to your doctor if you are pregnant or plan to become pregnant.²

Before beginning treatment for HS, tell your doctor about all your health conditions and any other drugs, vitamins, or supplements you take. This includes over-the-counter drugs.

Hormone therapies are just one part of HS treatment. Other approaches may include different drugs, surgery, diet and lifestyle changes, and alternative medicine.