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CORRESPONDENCE Table of Contents  
Ahead of print publication
Botulinum toxin type A therapy for hidradenitis suppurativa: A case series

 Department of Dermatology, Venereology and Allergology, Faculty of Medicine, Medical University of Gdańsk, Gdańsk, Poland

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Date of Submission24-Nov-2022
Date of Decision05-Mar-2023
Date of Acceptance06-Mar-2023
Date of Web Publication25-May-2023

How to cite this URL:
Kadylak D, Baranska-Rybak W. Botulinum toxin type A therapy for hidradenitis suppurativa: A case series. Dermatol Sin [Epub ahead of print] [cited 2023 May 28]. Available from: https://www.dermsinica.org/preprintarticle.asp?id=377563

Dear Editor,

Hidradenitis suppurativa (HS) is a chronic inflammatory dermatosis that mainly affects the intertriginous areas with relapsing painful or tenderness nodules, draining abscesses, and sinus tracts.[1] Diabetes mellitus, hypertension, dyslipidemia, and metabolic syndrome are more common in patients with HS.[2] HS leads to a significant decrease in patients' quality of life, and its treatment still remains a therapeutic challenge and often does not bring the desired effects. Therefore, new treatment options are constantly being sought. Botulinum toxin (BoNT) is an exotoxin produced by the bacterium Clostridium botulinum and widely used in several indications, including neurological diseases and esthetic medicine. In this article, we described three cases of HS (Hurley stage II) treated off-label with BoNT type A (BoNT-A).

The patients signed the consent for off-label use of BoNT-A. A 125 U Speywood vial of abobotulinumtoxinA (aboBoNT-A, Azzalure) was reconstituted with 1.25 mL of 0.9% normal saline and was injected intradermally about 1 cm apart, 5 U in 0.05 mL each injection, about 25 injections in one anatomical area. No local anesthesia was used. The effectiveness was evaluated at baseline and at 3 and 6 months by means of Dermatology Life Quality Index (DLQI) and digital imaging.

The first case was a 34-year-old female with the diagnosis of HS for 10 years, previously treated with oral tetracyclines, isotretinoin, and topical clindamycin without long-term improvement. Physical examination was normal except for a painfully inflamed nodule with granulomatosis and scars of the axillae. A 125 U Speywood of the aboBoNT-A was injected into each axilla. No new inflammatory changes appeared 3 and 6 months after the procedure. At the site of the previous nodule, epithelialization was observed after 3 months, and after 6 months, complete healing of the lesions followed by scarring [Figure 1]. In the follow-up 12 months after the procedure, no inflammatory lesions were observed.
Figure 1: Patient 1. (a) Before the aboBoNT-A injection procedure, (b) 3 months after the procedure, and (c) 6 months after the procedure. BoNT-A: Botulinum toxin type A.

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The second case was a 20-year-old female with revealed numerous inflammatory nodules and scars of the groin area. Previous treatment included oral clindamycin with rifampicin for 12 weeks and then oral isotretinoin for 6 months with good improvement, but the patient discontinued the drug due to the hair loss and excessive dryness of the skin. In the treatment, we proposed aboBoNT-A, a 125 U Speywood, which was injected into each groin. No new inflammatory lesions appeared 3 and 6 months after the procedure [Figure 2]. At the site of the previous nodules, scars were observed.
Figure 2: Patient 2. (a) Before the aboBoNT-A injection procedure, (b) 3 months after the procedure, and (c) 6 months after the procedure. BoNT-A: Botulinum toxin type A.

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The third case was a 19-year-old female with inflamed nodules, suppurating sinus tracts, abscesses, and scarring of the axillae. Previously treated with oral isotretinoin, oral tetracyclines, and topical clindamycin. The patient underwent deroofing of sinus tracts from the upper part of the left axilla. After the procedure, the wound healing was impeded, and then, aboBoNT-A injections were performed, which resulted in a significant improvement in healing. A 125 U Speywood of the aboBoNT-A was injected into each axilla. During the observation, a reduction of nodules and sinus tracts was noticed, also several nodules healed with noticeable scars.

In each case, the peri- and postprocedural period was uneventful and well tolerated. An increase in the quality of life as measured by the DLQI score was observed in all cases. Moreover, patients reported decreased itching and pain sensations.

In the literature, BoNT-A and BoNT-B have been used experimentally in the treatment of HS with good clinical improvement, but the role of BoNT in the pathogenesis of HS remains unclear.[3],[4],[5],[6] It has been suggested that BoNT directly decreases apocrine sweat production, which may decrease the tendency for follicular rupture and the spread of follicular material through the dermis and exacerbates inflammation and formation of sinus tracts.[7] None of our patients suffered from hyperhidrosis; however, in patients with this condition, BoNT reduces sweat excretion and therefore decreases moist environments for bacterial proliferation.[7]

BoNT-A appears to be a new, promising, and safe treatment method for HS. Further research will need to demonstrate the effectiveness of BoNT in the treatment of HS and to standardize protocols.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Data availability statement

The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Chu CB, Li WL, Lin SH, Hsu CK, Yang CC, Tsai SJ. The influence of gender and smoking on hidradenitis suppurativa: A retrospective study of 161 patients in Taiwan. Dermatologica Sin 2021;39:125-31.  Back to cited text no. 1
Alatas ET, Biteker M, Alatas OD. Aortic stiffness in hidradenitis suppurativa: A case-control study. Dermatol Sin 2021;39:182-5.  Back to cited text no. 2
  [Full text]  
Grimstad Ø, Kvammen BØ, Swartling C. Botulinum toxin type B for hidradenitis suppurativa: A randomised, double-blind, placebo-controlled pilot study. Am J Clin Dermatol 2020;21:741-8.  Back to cited text no. 3
Campanati A, Martina E, Giuliodori K, Bobyr I, Consales V, Offidani A. Two cases of Hidradenitis suppurativa and botulinum toxin type a therapy: A novel approach for a pathology that is still difficult to manage. Dermatol Ther 2019;32:e12841.  Back to cited text no. 4
Shi W, Schultz S, Strouse A, Gater DR. Successful treatment of stage III hidradenitis suppurativa with botulinum toxin A. BMJ Case Rep 2019;12:e226064.  Back to cited text no. 5
Khoo AB, Burova EP. Hidradenitis suppurativa treated with Clostridium botulinum toxin A. Clin Exp Dermatol 2014;39:749-50.  Back to cited text no. 6
Shih T, Lee K, Seivright JR, De DR, Shi VY, Hsiao JL. Hyperhidrosis treatments in hidradenitis suppurativa: A systematic review. Dermatol Ther 2022;35:e15210.  Back to cited text no. 7

Correspondence Address:
Damian Kadylak,
Department of Dermatology, Venereology and Allergology, Medical University of Gdańsk, 17 Mariana Smoluchowskiego Street, Gdańsk 80-214
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ds.DS-D-22-00198


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