Aggressive treatment needed for hidradenitis suppurativa

Noah Scheinfeld, MD, JD, recommended a combination of oral clindamycin and oral rifampin daily for the treatment of hidradenitis suppurativa.

Hidradenitis suppurativa (HS) is a plague for patients but an area ripe for dermatologic researchers. Treatment advances such as biologics and more effective surgical techniques are improving patient outcomes, but there have been almost no randomized controlled trials in HS.

“This is an interesting time in HS,” said Abrar A. Qureshi, MD, MPH, professor and chair of dermatology at the Brown University Warren Alpert Medical School in Providence, Rhode Island. “What little data we have is from case studies and experiential reports. This is the ideal place for a dermatologist who wants to launch a career in a relatively common, yet almost totally unstudied disease.”

Despite the lack of data, HS is easy to spot — at least in the moderate to advanced stages. No other condition produces the same characteristic lesions with subdermal voids and sinuses, multiple comedomes and painful, oozing, malodorous abscesses. The most common locations are groin, inframammarial, axial, flanks, the nape of the neck, and skin folds in obese patients.

HS also exhibits unique chronicity.

“You can get almost sure diagnosis with one simple question,” said Christopher Sayed, MD, assistant professor of dermatology at the University of North Carolina Medical School. “Just ask ‘Have you had outbreaks of boils during the last six months?’ The answer is 100 percent sensitive and 91 percent specific, with a positive predictive value of 92 percent in a small sample,” he said. “If the patient has had at least two boils, you have even better confirmation.”

HS appears to begin with follicular occlusion, leading to cyst formation, which generates acute inflammatory nodules that evolve into chronic cutaneous suppurative inflammation and tunnels.

Treatment must be aggressive and personalized to prevent progression, he added. There are a variety of medical and surgical alternatives, from combination antibiotics to biologic agents and removal of affected tissue.

Doxycycline as monotherapy is not effective, cautioned Noah Scheinfeld, MD, JD, assistant professor of dermatology at Weill Cornell Medical College. He recommended a combination of oral clindamycin and oral rifampin daily for a minimum of 10 to 12 weeks as first-line therapy.

Oral isotretinoin is ineffective against HS, but acitretin seems to work alone and in combination with other agents. Cyclosporine helps about half of patients, while azathioprine and methotrexate do not. Intralesional triamcinolone can help, particularly in combination with deroofing abscesses every two weeks.

Biologics can be effective. Trials to date are few and small, but there are positive results from treating the systemic inflammation seen in HS, said Alexandra Boer Kimball, MD, MPH, professor of dermatology at Harvard Medical School.

Infliximab shows positive clinical results and very good quality of life improvements at 5 mg/kg after eight weeks, she said. Dosing can be escalated if needed, although more data are needed.

Adalimumab seems to be effective if dosed weekly rather than biweekly. In small trials, etanercept showed no effect, ustekinumab showed mixed response, and anakinra appears to help.

Surgical therapy can be even more effective.

“You have to get rid of those epithelial spaces,” said Paul Hazen, MD, clinical professor of dermatology at Case Western University. Less invasive procedures, such as incision and drainage, may relieve pain, but do nothing to the disease itself because the mass of inflamed material remains. If diseased tissue remains, expect recurrence.

Dr. Hazen recommended unroofing the cavity, then curetting the interior. The mass can also be excised using a CO2 laser, which gives recurrence rates of less than 2 percent.

Evan Garfein, MD, chief of plastic and reconstructive surgery at Montefiore Medical Center in New York, is similarly insistent.

“My strategy is to clear all of the disease I possibly can as long as I see a road to reconstruction,” he said. “I treat HS like cancer and resect everything.”

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