Hidradenitis Suppurativa: Diagnosis and Management

CLINICAL ACTIONS:

Hidradenitis suppurativa (HS), also known as acne inversa (AI) is a chronic, recurrent inflammatory disease of the apocrine sweat glands located in the axillae, groin, genitals, perineal and perianal regions, buttocks, and infra- and intermammary areas. Women are affected more often than men, and the disease is more common among African Americans

  • Ask about a history of chronic/recurrent abscesses with postpubertal onset
  • On physical exam, look for
    • Tender symmetric, multiple deep inflamed intertriginous lesions
    • Abscesses, sinus tracts and scarring in more advanced cases
  • Use the Hurley system for staging
    • Stage 0: No active HS
    • Stage I: Localized abscess, no sinus tracts
    • Stage II: Recurrent abscesses with sinus tracts, scarring, single or multiple widely separated lesions
    • Stage III: Diffuse involvement, multiple interconnected sinus tracts and abscesses
  • Cultures of lesions are sterile or grow mixed flora

SYNOPSIS:

HS is a chronic relapsing inflammatory disease of the apocrine glands (folliculopilosebaceous units).  Multiple factors including genetic, immunological, behavioral and endocrine are possible underlying mechanisms. The impact of the disease on self-esteem and quality of life can be severe, thus the importance of early diagnosis and treatment.  While some of the treatments for more severe cases outlined below will be beyond the scope of a general women’s health practice, the use of antibiotics and oral contraceptives along with lifestyle changes and patient education can limit and/or reduce outbreaks.

KEY POINTS:

Lifestyle Changes

  • Weight loss if overweight or obese, smoking cessation, avoidance of tight-fitting, restrictive clothing

Topical Agents/Disinfectants

  • Chlorhexidine, peroxides, and permanganate soaks are sometimes used, but minimal evidence to support effectiveness
  • Older studies suggest that 15% resorcinol may be of benefit

Antibiotic Regimens

  • Mild disease
    • 1% topical clindamycin applied twice daily
  • Mild or moderate disease unresponsive to topical treatment
    • Tetracycline 500 mg twice daily or
    • Doxycycline/minocycline 50-100 mg twice daily
  • Moderate or severe disease
    • Rifampin 300 mg twice daily plus clindamycin 300 mg twice daily for 10 weeks (most well studied) may induce remission

Antiandrogen Regimens

  • Combined oral contraceptives, particularly those with third generation progestins such as gestodene, norgestimate or desogestrel
    • Combined oral contraceptive with drospirenone may be especially beneficial
  • Finasteride, a 5α-reductase inhibitor, is effective

Corticosteroids

  • Intralesional triamcinolone 3 mg to 5 mg
  • Can be used in mild cases without chronic lesions

Biologics

  • Tumor necrosis factor-α blockers (such as adalimumab which is FDA approved), interleukin blockers and other immunosuppressive agents may be helpful for moderate to severe disease
  • Consider in patients who
    • Require long-term antibiotic treatments
    • Experience flares when antibiotic treatments were stopped
  • May be beyond scope of primary care providers
  • Consider referral for recalcitrant cases

Surgical approaches

  • Mild to moderate cases
    • Carbon dioxide laser evaporation of lesions or
    • Deroofing of chronic lesions and sinus tracts or
    • Skin-tissue sparing excision with electrosurgical peeling (STEEP)
  • Severe HS is treated with local or wide local excision with either primary closure, secondary intention, flap advancement or grafting

Diagnosis code: L73.2

Learn More – Primary Sources:

Images: Dermatology Information System

Clinical Epidemiology and Management of Hidradenitis Suppurativa

JAMA Review: Hidradenitis Suppurativa: Advances in Diagnosis and Treatment

Hidradenitis Suppurativa: A guide for the practicing physician

Review of Current Immunologic Therapies for Hidradenitis Suppurativa

Swiss Practice Recommendations for the Management of Hidradenitis Suppurativa/Acne Inversa

North American clinical management guidelines for hidradenitis suppurativa: A publication from the United States and Canadian Hidradenitis Suppurativa Foundations – Part I: Diagnosis, evaluation, and the use of complementary and procedural management

North American clinical management guidelines for hidradenitis suppurativa: A publication from the United States and Canadian Hidradenitis Suppurativa Foundations – Part II: Topical, intralesional, and systemic medical management