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Hidradenitis suppurativa

Hidradenitis suppurativa ( HS ) is a chronic , inflammatory , recurrent debilitating disease of the hair follicle that usually presents after 
puberty with painful , deep-seated , inflamed lesions in the
 apocrine gland bearing areas of the body , most commonly the axilla ,
 inguinal and anogenital regions
 Also known as Verneuil’s disease or acne inversa

Epidemiology- Prevalence appears to be 1 % to 4 % of the general population Occurs more commonly in women ( reports controversial ) Females more likely to have a family history and men had a tendency for more severe disease and associated acne Disease of the young- average age at presentation is 26 yrs for ♀ and 31 for ♂ No racial predilection

Cause- Cause unclear – complex disease
 Multifactorial and various factors can play a role as
○ occlusion of the apocrine duct by a keratinous plug
○ defects of follicular epithelium and bacterial overgrowth
○ role of hormones- happens after puberty and can flare with menstrual cycle
○ smoking – role of nicotine
○ autoimmune – associated with certain disorders as thyroid disease , 
Inflammatory bowel disease, Sjogren’s syndrome
 Acne vulgaris
 Obesity Athletes Genetic component Host defense defects Chemical irritants ( eg deodorants ) and mechanical irritation ( depilation , shaving ) Heat ( ↑ in summer ) Oral contraceptive pill Zinc deficiency – may predispose

Disease burden- Chronic disabling disorder Relentless progression and can cause keloids , contractures & immobility Disease can progress to scarring and sinus formation Distressing , recurrent disease that impairs quality of life – sig psychological impact Risk of depression , sexual impairment Often misdiagnosed and patients undergo repeat and unnecessary investigations

Hurley staging- Stage 1 – abscess formation single or multiple without sinus tracts or scarring Stage 2 – recurrent abscesses with tract formation and cicatrisation , single or multiple , widely separated lesions Stage 3 – diffuse or near-diffuse involvement or multiple interconnected tracts and abscesses across the entire area

Disease classification – consider using 
Hurley staging – treatment will depend on disease severity.Often poor response to previous antibiotic therapy

Pyoderma Arthritis Inflammatory bowel disease- eg Crohn’s Sponyloarthropathy Anaemia Metabolic syndrome

Pain management Weight loss Smoking cessation Treatment of superinfection Dressings if suitable Warm compresses Screen for depression

Hidradenitis complications – Contractures and reduced mobility Sinus tracts , fistula , scarring Squamous cell carcinoma Lymphoedema Localised infection / cellulitis Chronic pain Systemic amyloidosis Possibly anaemia

Consider referring early as treatment often multidisciplinary – aim is to
 prevent or limit scarring. A recent high-quality cross sectional study of more than 40,000 patients and meta analysis of prior studies suggests a 1.5 to 3 fold risk of type 2 diabetes in patients with HS , with a prevalence of up to 30 %. Patients with physical signs of diabetes , hypertension, obesity , and / or hyperlipidaemia are at a higher risk and should be screened. 
Risk of PCOS is also increased significantly.

Clindamycin topical ( first line ) Metronidazole topical Chlorhexidine topical Hexachlorophene topical Dermol 500 lotion wash Tetracycline 500 mg bd for 2 months
PCDS suggests Lymecycline 408 mg od Doxycyline 100 mg bd for 2 months Minocycline 100 mg bd for 2 months Combination therapy
Clindamycin 300 mg bd + Rifampicin 300 mg bd for 3 months ( PCDS ) Flucloxacillin can be used as a short course for acute flare ups ( BAD )

OTHER TREATMENT OPTIONS AS PER BAD 
GUIDELINES
 Combination treatment if no response to initial treatment with oral tetracycline Acitretin ( specialist use ) Dapsone ( specialist use ) Metformin consider for those who have diabetes and HS or in females with HS and PCOS/ pregnancy

LINKS AND RESOURCES

PATIENT INFORMATION

BAD leaflet on HS http://www.bad.org.uk/shared/get-file.ashx?id=88&itemtype=document

Dermnet NZ on HShttps://dermnetnz.org/topics/hidradenitis-suppurativa/

HS Foundation with resources for patients and professionals https://www.hs-foundation.org/

HS Trust for patients in UK https://www.hstrust.org/

British Skin Foundation on HS https://www.britishskinfoundation.org.uk/hidradenitis-suppurativa

FURTHER READING FOR CLINICIANS

Canadian Family Physician on HS https://www.cfp.ca/content/cfp/63/2/114.full.pdf

BAD guideline on management of HS https://www.ncbi.nlm.nih.gov/pubmed/30552762

A comparison of international management guidelines on HS https://www.karger.com/Article/FullText/503605

North American clinical management guidelines for hidradenitis suppurativa: A publication from the United States and Canadian Hidradenitis Suppurativa Foundations https://www.jaad.org/article/S0190-9622(19)30367-6/fulltext

European S1 guideline on management of HS https://www.epgonline.org/uk/guidelines/european-s1-guideline-for-the-treatment-of-hidradenitis-suppurativa-acne-inversa.html

 

 

References Diagnosis and management of hidradenitis suppurativa BMJ 2013 ; 346 ;f2121 Medscape Hidradenitis Suppurativa Aug 2017 Marina Jovanovic et al Interventions for hidradenitis suppurativa Cochrane Database Sys Rev 2015 Oct ( Abstract ) Interventions for Hidradenitis Suppurative : Updated Summary of an Original Cochrane Review JAMA Dermatol 2017 May ( Abstract ) BMJ Best Practice Hidrandeitis suppurativa European Dermatology Forum – Guideline on Hidradenitis suppurativa RACGP Hidradenitis suppurativa – Management , comorbidities and monitoring Evidence-based approach to the treatment of hidradenitis suppurativa / acne inversa , based on the European guidelines for hidradenitis suppurativa ( Abstract ) Hidradenitis Suppurativa : A Treatment Challenge Am Fam Physician 2005 First Consult Hidradenitis Suppurativa April 2011 Hidradenitis suppurativa : Treatment of Skin Disease : Comprehensive Therapeutic Strategies , 101 , 314-315 Complications of hidradenitis suppurativa Semin Cutan Med Surg 2017 Jun ;36 (2) : 29-85 
( Abstract ) http://www.pcds.org.uk/clinical-guidance/hidradenitis-suppurativa#management British Association of Dermatologists guidelines for the management of hidradenitis suppurativa ( acne inversa ) 2018 Volume 180 Issue 5 May 2019 North American clinical management guidelines for hidradenitis suppurativa : A publication from the Unites States and Canadian Hidradenitis Suppurativa Foundations July 2019 Volume 81 , Issue 1 , Pages 76-90

 

 

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