Hidradenitis Suppurativa: Hope to End the Heartache
Thomas N. Helm, MD
Helm TN. Hidradenitis suppurativa: hope to end the heartache. Consultant360. Published online October 27, 2016.
Over the years, it has become clear to me that individuals suffering from hidradenitis suppurativa (HS) need emotional support and encouragement as much as medical care.
In pain and uncomfortable, affected patients often are embarrassed and depressed. Education and hope help combat the frustration and despair that many patients feel. HS often presents with tender nodules and cysts in intertriginous areas. Antibiotics are prescribed along with incision and drainage procedures that provide short-term relief but fail to address the overall process.
In pain and embarrassed, affected patients lift up pus-soaked bandages to reveal comedones, pustules, and even sinus tracts. As the disease progresses, scars and tunnel-like tracts develop in the skin. Severity of lesions in presenting patients is often characterized by the Hurley clinical staging system, in which single or multiple abscesses are classified as stage I, and recurrent abscesses that are associated with sinus tracts and scarring are classified as stage II. When diffuse involvement with interconnected tracts is noted, patients are classified as having stage III involvement.
Although incision and drainage, avoidance of trauma, gentle cleansing, and use of topical antibiotics such as clindamycin are typically effective first-line therapies, punch unroofing of lesions—which allows nodules to drain before deep tunnels and sinuses form—is preferred over limited incisional procedures. Sinus openings can be explored with a malleable metal probe, and the overlying skin resected with sterile scissors. Smaller lesions can be opened by punch excision. A carbon dioxide laser can also be used for unroofing some of these lesions. Diseased tissue and scar tissue can often be removed in a sparing manner rather than extensive resection of an entire area. Judicious excision followed by secondary intention healing often works well as part of the treatment approach, but the treatment process may take weeks or even months. Plain petrolatum or zinc oxide protective ointment applied to gauze or non-adherent pads (eg, telfa) is helpful for wound dressings. It is important to avoid using products in which gauze fragments can crust into the wound. Intralesional corticosteroids can reduce swelling and pain and may abort early lesions. Systemic antibiotics such as minocycline, doxycycline, or clindamycin are helpful, but emphasis must be placed on ensuring that scarring does not lead to more cyst formation and deeper sinus tracts.
Unfortunately, many patients may have HS for decades. In women, menopause may signal the beginning of quiescence. Early and appropriate therapy is the main stage of treatment. Once stage II or III disease has developed, a multidisciplinary approach to therapy is often required.
The emotional aspects of disease must also be addressed, often with the help of knowledgeable counselors and mental health professionals. Disordered sleep and depression may exacerbate underlying metabolic syndrome or dyslipidemia.
Newer tumor necrosis factor (TNF) α inhibitors such as adalimumab and infliximab have shown to be beneficial and offer hope as a promising new avenue for treatment. Although isotretinoin works extremely well for nodulocystic acne, the effect may be less dramatic in cases of HS. Subcutaneous injections of ustekinumab (an interleukin-12/23 inhibitor) as well as etanercept injections have been associated with improvement. Early diagnosis, an holistic approach to care, judicious surgical intervention, and emotional support all can help affected individuals regain control of their disease and lives. Understanding that treatment requires a long-term partnership with your patient will help set appropriate expectations and help establish an effective treatment plan.
Thomas N. Helm, MD, is clinical professor of dermatology and pathology at the State University of New York at Buffalo.