Hidradenitis suppurativa (HS) is a chronic inflammatory skin condition characterized by painful, recurring abscesses, nodules, and tunnels, primarily affecting areas like the armpits, groin, and buttocks. Since HS disproportionately affects women of childbearing age, family planning requires significant consideration. Successfully navigating a pregnancy with HS requires proactive planning and close collaboration with a multidisciplinary medical team, including a dermatologist and an obstetrician-gynecologist. The primary goal is to optimize disease control before conception to ensure the healthiest possible environment for both the parent and the developing fetus.
Optimizing Disease Control Before Conception
Pre-conception counseling is a foundational step, ideally beginning months before actively trying to conceive. Controlling systemic inflammation from HS is paramount, as chronic inflammatory states may be associated with adverse pregnancy outcomes like preeclampsia or preterm birth. Achieving low disease activity or remission minimizes the risk of severe flares, which are challenging to treat safely during gestation.
Lifestyle adjustments are crucial for disease management and reproductive health. Smoking cessation is strongly recommended, as tobacco use is a well-established trigger for HS severity and is linked to numerous pregnancy complications. Optimizing body mass index (BMI) is also beneficial, as obesity is a common comorbidity that can worsen HS symptoms and complicate pregnancy. Incorporating an anti-inflammatory diet, which focuses on whole foods and minimizes processed items, may help lower the body’s overall inflammatory burden.
These interventions should be implemented alongside regular monitoring of inflammatory markers. Tracking indicators like C-reactive protein (CRP) provides a baseline measure of systemic inflammation. Establishing this comprehensive health profile before conception allows the medical team to make informed adjustments.
Reviewing Medication Safety and Adjustments
A thorough review of all current medications is a primary step in pre-conception planning due to the potential for fetal harm. Certain treatments commonly used for HS must be stopped immediately due to severe teratogenic risks. Oral retinoids, such as isotretinoin and acitretin, are strictly contraindicated and require a mandated washout period of up to several months before conception can be safely attempted. Methotrexate, an immunosuppressant, also falls into this high-risk category and must be discontinued well in advance.
Other medications require careful management or switching to safer alternatives. Tetracycline antibiotics, including doxycycline and minocycline, are typically discontinued because they can affect fetal bone and tooth development, particularly after the first trimester. Anti-androgen agents, like spironolactone, are also stopped before conception, as they can interfere with fetal sexual development. In these cases, a physician will transition the patient to pregnancy-compatible therapies to maintain disease control.
Specific biologics, often used for moderate-to-severe HS, have a more favorable safety profile and may be maintained under supervision. Tumor necrosis factor-alpha (TNF-\(\alpha\)) inhibitors, such as adalimumab and certolizumab pegol, have accumulated safety data in pregnancy. Certolizumab pegol is notable for minimal placental transfer. Most monoclonal antibodies are typically discontinued during the third trimester to limit high-level transfer to the fetus. Topical treatments, including clindamycin and antiseptic washes like benzoyl peroxide, are generally considered safe options throughout pregnancy due to minimal systemic absorption.
Addressing Specific Fertility Considerations
While most women with HS have normal fertility, the condition presents specific considerations that may complicate conception. Chronic systemic inflammation, a defining feature of HS, can potentially affect reproductive function. Elevated levels of inflammatory markers like TNF-alpha are thought to interfere with the hormonal signals necessary for successful ovulation and implantation.
A strong association exists between HS and Polycystic Ovary Syndrome (PCOS), a hormonal disorder that is a leading cause of infertility. Studies indicate the prevalence of PCOS in women with HS is significantly higher than in the general population. This dual diagnosis compounds the challenge, as PCOS involves hormonal imbalances and irregular ovulation, which directly impede the ability to conceive.
For those trying to conceive for six to twelve months without success, consulting a Reproductive Endocrinologist (RE) is recommended. An RE can assess underlying fertility metrics and discuss options such as assisted reproductive technologies (ART), including in vitro fertilization (IVF). Maintaining low HS disease activity is beneficial during fertility treatments, as chronic inflammation may negatively influence ART outcomes.
Managing Hidradenitis Suppurativa During Pregnancy and Postpartum
The course of HS during pregnancy is unpredictable, as hormonal shifts cause varied effects on disease activity. Some women experience an improvement in symptoms, particularly during the second and third trimesters, while others may see their condition worsen or remain unchanged. Given the potential for flares, maintaining open communication with the dermatology and obstetrics teams is paramount for a safe pregnancy.
Should a flare occur, treatment must prioritize fetal safety, often relying on topical therapies, local steroid injections, or certain systemic antibiotics like clindamycin. Metformin, which is sometimes used as an adjunct treatment for HS, is generally considered safe and may be continued. The decision to continue a biologic agent into the third trimester requires a careful risk-benefit discussion, balancing the need for disease control against minimizing infant exposure before birth.
Delivery planning must also take into account the location of HS lesions. While a vaginal delivery is often possible, lesions near the perineum, vulva, or groin may increase the risk of tears or infection in those areas. If a C-section is planned, the surgical site must be carefully chosen to avoid active lesions, tunnels, or heavily scarred skin. The postpartum period carries a significant risk of disease flare-up, often attributed to rapid hormonal changes and the stress of childbirth, necessitating a proactive plan for safe management while breastfeeding.