Review Article

Treatment Options for Hidradenitis Suppurativa

Sara M. James, MD, and Barbara B. Wilson, MD

Part 4 of this 4-part series discusses the treatment of hidradenitis suppurativa. The first, second, and third parts discussed the clinical presentation of the disease, grading systems used to score its severity, and its pathophysiology.

 

HS usually requires a combination of therapies for control. End goals for therapy include pain reduction, treatment of secondary bacterial infection, prevention of new lesions, and treatment of existing lesions to minimize sinus tract formation and scarring.1 Patients should be advised to avoid skin trauma and manipulation of the lesions. Loose clothing is preferred, and antiseptic soaps should be used to regularly cleanse the lesions.2 Soaking in a tub with ¼ cup bleach added to ½ bathtub of water, several times a week, will decrease bacterial colonization of the skin and may decrease secondary infection. Lifestyle modifications including weight loss and smoking cessation may be beneficial. Topical therapy can be used for localized disease, but widespread or severe disease necessitates systemic therapy or surgery.3

Antibiotics

Antibiotics are first line therapy for the initial treatment of HS and can be administered topically or systemically. Topical clindamycin is the best-studied topical agent, and it has been shown to successfully prevent and treat flares of HS.4 Clindamycin has no effect on follicular occlusion and likely works by treating and preventing secondary infection of the lesions.
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The Hurley System: Grading Severity for Hidradenitis Suppurativa
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Although systemic antibiotics can be used to quiet active lesions, they are not curative, and prolonged use may lead to resistance. Systemic antibiotics are typically reserved for moderate or refractory mild disease. Relapse rates are high after discontinuation.2 Antibiotics with anti-inflammatory or immunomodulatory properties, such as clindamycin, doxycycline or minocycline, are most effective. Additionally, the use of dapsone is supported by a number of case studies, because it inhibits neutrophil chemotaxis.4 Despite anecdotal evidence for the utility of systemic antibiotics, one double-blinded study found no difference between systemic tetracyclines and topical clindamycin in the treatment of stage 1 or 2 Hurley disease.5 Combinations of antibiotics have yielded more promising results. After 10 weeks of clindamycin-rifampin combination therapy, 8 of 14 patients achieved remissions of 1 to 4 years.6

Hormonal therapy

Despite conflicting evidence about the role of hormones in the pathogenesis of HS, clinical trials support the use of hormonal therapies for women with HS, including ethinyl estradiol/cyproterone acetate, ethinyl estradiol/norgestrel, and finasteride. Anti-androgens such as cyproterone combined with estrogen improved disease in a randomized, controlled trial but required high doses with unclear safety profiles.2,7 In fact, one retrospective chart review showed a superior response to hormonal therapies compared with antibiotics.4

Immunomodulation

Immunosuppressive therapy targets the inflammation associated with HS. There have been reports of patients being treated successfully with cyclosporine, prednisone, and azathioprine.4 Intralesional corticosteroids can be used as an adjunct to other therapies in order to speed resolution of active lesions in mild to moderate disease. However, the injections are often too painful to be tolerated. There are no controlled trials to support the effectiveness of corticosteroids.3

Biologic agents are a newer area of potential treatment for moderate to severe disease, but trials have had inconsistent results. Infliximab is the tumor necrosis factor α inhibitor with the most data to support its use in HS.1 In a randomized, double-blinded trial, infliximab 5 mg/kg intravenous infusions were administered at 0, 2, and 6 weeks with a significant reduction in disease severity and improvement in quality of life measures.8 However, patient response is unpredictable and may decrease over time, and there are potential serious adverse effects.3,4 One study of adalimumab showed a clinical response in only 17.6% of patients in the treatment group (9 of 51 patients).9 Etanercept similarly has not been proven as an effective treatment for HS.3

Lasers and radiation

Lasers are becoming a more popular mode of HS treatment. Compared with topical treatments, the 1064-nm neodymium-doped yttrium aluminum garnet laser decreased inflammation, fibrosis, and scarring after monthly treatments for 3 months with healing by secondary intention. The carbon dioxide laser has been used for unroofing of scars and sinus tracts, with low rates of recurrence.3 Radiation therapy has also been used, but a wide range of responses and techniques have been reported, and adverse effects limit its use.3,4

Surgical options

A surgical procedures is needed for definitive treatment of lesions in order to remove the foci of the disease. Additionally, scarring is not amenable to medical management.3 However, even after surgical intervention, HS may recur.10 There are a number of surgical approaches, including incision and drainage, punch debridement, deroofing, and wide excision. Incision and drainage, or lancing, is generally not recommended because recurrence is highly likely. This method provides short-term relief for painful lesions, but lesions may not readily drain.3

Conclusion

HS is a chronic, disabling disease with unclear pathophysiology and no cure. Early diagnosis is crucial to prevent progression to severe disease. More controlled trials and studies that directly compare treatment modalities are needed in order to define a set of clear treatment guidelines.

Patients with HS often experience embarrassment due to the disfigurement and malodorous drainage from chronic, painful abscesses. Not surprisingly, HS negatively impacts quality of life measures and work performance as manifested by the decreased ability to hold a full-time job and increased work absences.11 Patients with HS have higher rates of depression than controls.11 Therefore, when treating patients with HS, it is important to screen for depression and provide appropriate support and patient education. Support groups have been proposed as an effective way for HS patients to cope with the stress of their disease.12

References:

  1. Gill L, Williams M, Hamzavi I. Update on hidradenitis suppurativa: connecting the tracts. F1000Prime Rep. 2014;6:112. doi:10.12703/P6-112.
  2. Slade DEM, Powell BW, Mortimer PS. Hidradenitis suppurativa: pathogenesis and management. Br J Plast Surg. 2003;56(5):451-461.
  3. Jemec GBE. Hidradenitis suppurativa. N Engl J Med. 2012;366(2):158-164.
  4. Alikhan A, Lynch PJ, Eisen DB: Hidradenitis suppurativa: a comprehensive review. J Am Acad Dermatol. 2009;60(4):539-561.
  5. Jemec GBE, Wendelboe P. Topical clindamycin versus systemic tetracycline in the treatment of hidradenitis suppurativa. J Am Acad Dermatol. 1998;39(6):971-974.
  6. Mendonça CO, Griffiths, CEM. Clindamycin and rifampicin combination therapy for hidradenitis suppurativa. Br J Dermatol. 2006;154(5):977-978.
  7. Mortimer PS, Dawber RPR, Gales MA, Moore RA. A double-blind controlled cross-over trial of cyproterone acetate in females with hidradenitis suppurativa. Br J Dermatol. 1986;115(3):263-268.
  8. Grant A, Gonzalez T, Montgomery MO, Cardenas V, Kerdel FA. Infliximab therapy for patients with moderate to severe hidradenitis suppurativa: a randomized, double-blind, placebo-controlled crossover trial. J Am Acad Dermatol. 2010;62(2):205-217.
  9. Kimball AB, Kerdel F, Adams D, et al. Adalimumab for the treatment of moderate to severe hidradenitis suppurativa: a parallel randomized trial. Ann Intern Med. 2012;157(12):846-855.
  10. Wiseman MC. Hidradenitis suppurativa: a review. Dermatol Ther. 2004;17(1):50-54.
  11. Esmann S, Jemec GBE. Psychosocial impact of hidradenitis suppurativa: a qualitative study. Acta Derm Venereol. 2011;91(3):328-332.
  12. Kurek A, Johanne Peters EM, Sabat R, Sterry W, Schneider-Burrus S. Depression is a frequent co-morbidity in patients with acne inversa. J Dtsch Dermatol Ges. 2013;11(8):743-749.