What is the best treatment approach for a postpartum patient with hidradenitis suppurativa (HS) who is breastfeeding?

Treatment of Hidradenitis Suppurativa in Postpartum Breastfeeding Patients

For postpartum patients with hidradenitis suppurativa who are breastfeeding, adalimumab 40 mg weekly is the strongly recommended first-line biologic therapy, while oral azithromycin, erythromycin, amoxicillin/clavulanic acid, or metronidazole are safe systemic antibiotic options that should be initiated or continued to prevent disease progression and improve quality of life. 1, 2

First-Line Biologic Therapy

• Adalimumab is the preferred biologic during breastfeeding, with a strong recommendation based on moderate-quality evidence, dosed at 40 mg weekly 1, 2
• Biologics are large proteins that transfer minimally into breast milk and are poorly absorbed by the infant's gastrointestinal tract, making them safe during breastfeeding 1
• If the patient was well-controlled on a biologic during pregnancy, continuation postpartum is recommended 1, 2
• Infliximab can be used with an approach similar to other HS patient populations 1
• Certolizumab pegol should only be continued in select cases if the patient benefitted during pregnancy, as efficacy data in HS is limited 1
• Exercise caution with anti-IL-17 agents (secukinumab, bimekizumab) and ustekinumab given minimal available data in breastfeeding 1

Systemic Antibiotic Options

Preferred Safe Antibiotics

• Oral azithromycin is a safe first-line choice during breastfeeding 1, 2, 3
• Oral erythromycin is safe, particularly for penicillin-allergic patients 1, 2, 3
• Oral amoxicillin/clavulanic acid is safe and effective 1, 2, 4
• Oral metronidazole is safe during breastfeeding 1, 2, 3
• Oral rifampin can be used with an approach similar to other HS patient populations 1, 2

Antibiotics Requiring Caution

• Oral clindamycin should be used with caution as it may increase the risk of gastrointestinal side effects in the infant, including diarrhea and candidiasis 1, 2, 3
• Oral doxycycline use must be limited to 3 weeks maximum without repeating courses, and only if no suitable alternative antibiotic is available 1, 2, 3

Anti-Androgen and Metabolic Modulators

• Metformin is safe during breastfeeding and recommended for mild to moderate HS or as combination therapy, especially beneficial for those with metabolic comorbidities 1, 2
• Estrogen-containing oral contraceptives are safe and may be initiated 6-8 weeks postpartum to avoid impacting milk production, especially when contraception is desired 1, 2

Systemic Immunomodulators

• Prednisone ≤20 mg daily can be considered for acute, widespread flares during breastfeeding 1, 2
• If a dose >20 mg daily is required, patients should wait at least 4 hours prior to breastfeeding 1
• Cyclosporine may be used following general HS guidelines, but should be limited to select treatment-refractory cases 1

Topical Therapies

• Topical antibiotics, chlorhexidine antiseptic washes, bleach baths, and zinc pyrithione antiseptic washes are safe options during breastfeeding 2
• These agents have minimal systemic absorption and can be used similarly to the general HS population 1

Important Monitoring Considerations

• Monitor breastfed infants for gastrointestinal effects when the mother is taking systemic antibiotics, as antibiotics can alter intestinal flora 2, 3
• Antibiotics in breast milk could potentially cause falsely negative cultures if the breastfed infant develops a fever requiring evaluation 3, 4
• Consult with a pediatrician about the timing of administering live vaccines to infants with in-utero biologic exposure from maternal HS management during pregnancy 2

Treatment Algorithm Based on Disease Severity

• Use Hurley staging and Physician Global Assessment (PGA) to guide treatment intensity 2
• Routinely assess patient-reported outcomes, including Dermatology Life Quality Index (DLQI), itch, and pain using Visual Analogue Scale 2
• For mild disease: Consider topical therapies, antiseptic washes, and metformin 1, 2
• For moderate disease: Initiate systemic antibiotics (azithromycin, erythromycin, or amoxicillin/clavulanic acid) with or without metformin 1, 2
• For severe or refractory disease: Strongly consider adalimumab 40 mg weekly as first-line biologic therapy 1, 2

Common Pitfalls to Avoid

• Do not discontinue effective biologic therapy postpartum without clear contraindication, as disease flares are common in the postpartum period 1, 5, 6
• Avoid tetracyclines (except short-term doxycycline ≤3 weeks) and spironolactone, which are contraindicated during breastfeeding 5, 6
• Do not delay treatment initiation, as more than half of women with HS report experiencing postpartum flares 5, 6
• Avoid using clindamycin as first-line when safer alternatives like azithromycin or amoxicillin/clavulanic acid are available 1, 2