Hidradenitis suppurativa

A review of this complex condition on A4Medicine. Not very uncommon to see a frustrated patient with this devastating condition. No clear evidence-based guideline exists to aid in the management of HS.

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

Consider referring early as treatment often multidisciplinary – aim is to
 prevent or limit scarring

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 )

Antiandrogens Botox Intralesional corticosteroids Oral retinoids Biological agents – TNF alpha inhibitors
○ Adalimumab
○ Etanercept
○ Infliximab Spironolactone ( premenstural flare ) Dapsone ( sulphonamide antibiotic with anti-inflammatory properties ) Zinc ( oral treatment ) Metformin