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Hidradenitis Suppurativa

Treatment

First-line therapy: The first-line therapy for mild to moderate hidradenitis suppurativa is topical or systemic antibiotics. For very severe disease, systemic immunosuppression, specifically with anti-TNF-alpha inhibitors, may be first-line.

First steps

Medical

  • Culture draining sinus tracts or abscesses for aerobic and anaerobic bacteria.
  • Give full-dose oral antibiotics effective against the isolated organisms for 1 month. Tetracycline (500 mg t.i.d..), amoxicillin (500 mg b.i.d.), cephalosporins (such as cephalexin 500 mg b.i.d.), and clindamycin (300 mg b.i.d.) have all been used with variable results. The combination of clindamycin with rifampin (both 300 mg b.i.d.) may have slightly increased efficacy over use of a single antimicrobial agent alone.
  • For mild disease, prescribe topical clindamycin solution to be applied to the affected areas twice daily. Combination with a benzoyl peroxide containing gel or wash can help to prevent development of antibiotic-resistant bacterial colonization.
  •  For severe disease, anti-tumor necrosis factor (TNF) alpha inhibitors can be highly effective and is supported by evidence. Of the available modalities, infliximab (5–8 mg/kg given weeks 0, 2, 6, 10, then every 6 to 8 weeks) is superior in its efficacy and should be combined with low-dose methotrexate (5–7.5 mg/ week) in order to avoid the production of infliximab neutralizing antibodies.

Surgical

  • Incise and drain fluctuant abscesses.
  • Inject triamcinolone acetonide 5–10 mg/cc into all non-fluctuant inflammatory areas. This may be repeated at intervals of 2–4 weeks.
  • Local areas may be totally excised, if small, with good results 

Ancillary steps

Encourage obese patients with disease in the intertriginous areas to lose weight.

Subsequent steps

Initial positive response

  • Continue oral antibiotics and taper them slowly over 3-6 months. If the disease recurs, reculture and repeat initial management.
  • Because relapse and persistence is the rule, even patients who have responded well to conservative therapy may be offered more extensive surgical procedures, especially for axillary disease (see below).

Initial treatment failure

Medical treatment

For severe cases only, a limited course of systemic corticosteroids (prednisone 0.5–1 mg/kg/day) for 1–2 weeks will significantly reduce inflammation. When combined with appropriate antibiotics, corticosteroids may also allow the disease to be controlled.

Surgical treatment


  •  Extensive surgical procedures usually offer the only hope for the severely affected.
  • For axillary disease, total excision of the affected axillary areas is of only moderate morbidity and gives excellent results. After their recovery, patients are in general quite satisfied with the long-term, usually permanent remission.
  • Genitocrural hidradenitis can also be totally excised, but often extensive grafting or prolonged healing is required owing to the large areas of involvement. Despite this, after recovery most patients are satisfied.

Pitfalls

  • These disease processes are aggressive, and they require aggressive management to obtain disease control.
  • Tetracycline is contraindicated in pregnancy (after the 14th week of gestation) and in children under the age of 8 due to bone/teeth toxicity.
  • Patients face a twofold risk of carcinoma in these conditions. If the disease is chronic, squamous cell carcinomas, which may be fatal, may occur. In addition, there is an increased risk of cutaneous carcinoma in the areas with chronic wounds or in areas treated with local radiation. Any suspicious non-healing lesion requires biopsy.
  • Inflammatory bowel disease may cause perirectal and/or genital sinus tracts and abscesses. These may be misdiagnosed as hidradenitis.

When to refer to a dermatologist

  • When the diagnosis is not clear.
  • When a biopsy is required to exclude the possibility of cutaneous Crohn’s disease, considered especially in the setting of perianal, buttock, or genitocrural disease.
  • To start systemic immunosuppression with anti-TNF alpha inhibitor medication.