Hidradenitis suppurativa

Published on 19/03/2015 by admin

Filed under Dermatology

Last modified 22/04/2025

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Hidradenitis suppurativa

Gregor B.E. Jemec

Evidence Levels:  A Double-blind study  B Clinical trial ≥ 20 subjects  C Clinical trial < 20 subjects  D Series ≥ 5 subjects  E Anecdotal case reports

image

Hidradenitis suppurativa (HS) is a common, chronically relapsing skin disease, characterized by recurring inflammed painful nodules and malodorous discharge, abscess and sinus formation, and scarring. The disease is located in the axillae, the genitofemoral area, the perianal area, and the sub-mammary area in women. It is a follicular disease, dictinct from acne vulgaris and staphylococcosis or simple primary infections. Pain and suppuration cause considerable morbidity and significantly reduces quality of life in patients.

Management strategy

HS is a clinical diagnosis. No pathognomonic test exists. Early diagnosis relies on recognition of recurrent, multifocal, painful inflammatory lesions, often bilaterally, in the axillae or anogenital regions. Preclinical changes can be identified with ultrasound or histological investigation. Age of onset is usually in the third decade of life.

According to Hurley stage I lesions are often ‘blind’ boils, i.e., deep and rounded. Gradually scarring and sinus formation occur in separate areas of the affected regions (stage II), and ultimately scarring and sinuses coalesce to form stage III lesions. Early lesions can remit with medical treatment. Once sinus tracts are established the treatment options are more limited and the disease more chronic. Patients can often be managed by a structured approach, although many will ultimately require surgery.

Clinically HS can often be distinguished from furunculosis (often big randomly occuring boils, and not limited to inverse areas) or epidermal cysts (usually solitary lesions). Microbiology is most useful in later stages of disease when superinfection may occur. Early lesions are frequently sterile on routine culture of swabs. Suspicion of mycobacterial infection, metastasis or Crohn disease requires specific investigations.

Current medical practice is mainly empirical. A three-stage approach gives structure to patient management. The first stage consists of topical treatment. Topical clindamycin has been shown to have an effect on early lesions in a double-blind, placebo-controlled study. Systemic tetracycline may be used as an alternative (500 mg twice a day). Lesions may also be treated with resorcinol 15% twice a day.

More severe cases can be treated with a combination of oral clindamycin 300 mg twice a day and rifampicin 300 mg twice a day. Specific treatment should be directed at superinfections, and can involve oral amoxicillin with clavulanic acid (500/125 mg) two tablets three times a day. Patients may also benefit from acitretin 25 mg two or three times a day, although this treatment is often limited by side effects and teratogenicity. Hormonal therapy with cyproterone acetate may be helpful in some females but requires high and continued use which raises safety concerns.

The second stage of treatment involves intralesional corticosteroids or minor surgery, i.e., localized excisions or exteriorization of sinus tracts.

The third stage of treatment involves major surgery, or palliative medication. Surgical intervention should involve excision of the affected tissue or careful laying open of all sinus tracts, but NOT lancing. The recurrence rate is inversely proportional to the extent of surgery: wide extensive surgery offers a better chance of remission. Palliative medication includes systemic anti-inflammatory drugs such as adalimumab, oral corticosteroid, dapsone, and infliximab. An initial anti-inflammatory response may be followed by relapse, and superinfection may intervene as a further complication. HS shows little sign of improvement with isotretinoin.

General measures that reduce smoking, pressure and shearing forces at affected sites are advisable, as is weight loss in the obese.

First-line therapies

imageTopical clindamycin B
imageOral tetracycline B
imageSurgery B

Second-line therapies

image Clindamycin and rifampicin B
image Retinoids D
image Intralesional corticosteroids E

Third-line therapies

image TNF-α monoclonal antibodies A
image Dapsone D
image Immunosuppressants D

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