**9. Treatment**

With a little-known entity with few studies, this treatment is not protocolized [15] (**Table 5**). Nonsteroidal anti-inflammatory drugs (NSAIDs), sulfasalazine, systemic corticosteroids, colchicine, methotrexate, and antibiotics such as tetracyclines have been used with varying results.

NSAIDs and analgesics are used as a symptomatic treatment of disease. There is no NSAID that has shown to be more effective than other. Almost all patients receive NSAIDs, obtaining a good result, but due to recurrence, loss of efficacy, or progression of disease, it is necessary to establish other treatments.

As we have said before, it is believed that this disease might have an infectious origin, mainly *Propionibacterium acnes*, so several antibiotics have been used, although they have not been proved to be really effective. Tetracyclines have been shown to be effective in controlling severe forms of acne [16].

Immunosuppressants, such as sulfasalazine or methotrexate, have been used in cases resistant to NSAIDs [17] and antibiotics, and although they have shown improvement in some patients, results have not been conclusive, and there are studies in this regard.

The use of bisphosphonates has been described as effective, although the majority of cases in which it has been used have been endovenous. Bisphosphonates are synthetic analogs of pyrophosphate; their function is to inhibit bone resorption by altering the function and metabolism of osteoclasts. Due to these properties, they have been used in treatment of primary and secondary osteoporosis, Paget's disease, bone metastasis, and disorders of bone metabolism [18].

Pamidronate and zoledronic acid have been used. Pamidronate has been used at a dose of 60 mg/day IV in a single dose, during a very short cycle of days in a row or repeating the dose several months later [19]. In most cases an improvement in pain and in the evolution of


**Table 5.** SAPHO syndrome treatment.

the disease was found. This is due to an action on bone remodeling that interferes with the production of proinflammatory cytokines.

Zoledronic acid is the most potent bisphosphonate and is usually used in hypercalcemias of tumoral origin. It has been used at a dose of 4 mg IV in a single dose with repetition at 6 months if there was no improvement [20], obtaining good results (decrease in pain and regression of disease).

In the treatment with biological therapy, anti-tumor necrosis factor (TNF) drugs have been used with promising results.

Although NSAIDs usually control pain and inflammation, it is often necessary to use diseasemodifying drugs to improve symptoms. In this regard, it seems that IV bisphosphonates have been the most effective, but the dose and interval have not been unified.

Biological therapy also seems to show effectiveness [21]. More trials with these drugs would be needed to test their effectiveness against this disease and protocol the number of doses, the amount, and the interval between them.
