Psoriasis Inversa in Patient with Hidradenitis Suppurativa: A Case Report

Abstract

Background Psoriasis and hidradenitis suppurativa (HS) are chronic inflammatory dermatoses with major negative impact on quality of life and significant comorbidities. The prevalence of intertriginous psoriasis varies in many studies – from 12% to 36% among European patients with psoriasis [1]. Coexistence of psoriasis and HS has been reported, nonetheless, we found no previous case reports that discussed psoriasis inversa (PI) and HS as comorbidities. Objectives To report a case of HS with PI that was successfully treated with methotrexate. Methods We present a case report of a 46-year-old female who was successfully treated with rifampicin and clindamycin for HS and methotrexate for PI. Results Patient with a 4-years history of HS presented to our clinic. She had a medical anamnesis of rheumatoid arthritis in remission and hypothyroidism. Clinical examination revealed multiple inflammatory nodules, draining fistulas in axillary regions, hyperpigmentation in groin and buttocks (Hurley stage II, IHS4- 19 points, pain VAS- 6 points, DLQI- 2 points), body mass index was 30.46 kg/m2. Complete blood cell count, chemistry panel revealed normal values. Treatment with rifampicin 600 mg daily and clindamycin 300 mg two times per day were started and continued for 10 weeks with a significant improvement of HS lesions (IHS4-0 points, pain VAS-0 points, DLQI- 0 points). After 7 months patient presented with erythematous, scaly plaques in flexural areas (BSA-10%, DLQI-9 points). The culture for Candida spp. and patch test with European baseline series of contact allergens and additions were negative. Skin biopsy showed psoriasiform acanthosis of the epidermis, mild perivascular and perifollicular lymphocytic infiltrate. Oral acitretin 30 mg daily was started but due to the adverse effects (spreading rash, itching, nausea) was discontinued in two weeks. Therefore, treatment was changed to methotrexate 10 mg per week subcutaneously with folic acid following day. After 1 month there was a good reduction in inflammatory activity with regression of erythema and this response continued over the 4-month treatment period (BSA-1%, DLQI-0 points). Discussion HS and psoriasis are onsidered chronic inflammatory diseases suggesting the existence of common pathogenetic links [2]. This case of HS and PI shows that first line medications for treatment could be traditional immunomodulatory therapy – methotrexate. In case of exacerbations or intolerance of treatment biological therapy retain as reservoir for the treatment in the future.