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AlexanderSalava

Hidradenitis Suppurativa

Essentials

  • Hidradenitis suppurativa (acne inversa) is a chronic, intrinsic skin disorder belonging to the group of acneiform disorders, characterised by recurrent abscesses and scarred lesions in flexural areas such as the groin or armpits.
  • Acute abscesses can be treated by incision and systemic antimicrobial treatment, as necessary.
  • Patients often need long-term topical maintenance therapy and, in some cases, long courses of antimicrobials or other systemic treatment.
  • In severe cases, operative treatment may be required.
  • The disease may impair the quality of life greatly, causing significant psychosocial suffering and functional problems.
  • Weight loss and smoking cessation will help.

Epidemiology

  • Onset often in early adulthood but may also occur at a later age.
  • Prevalence is estimated at 0.4-1.7%; the disease is probably underdiagnosed and undertreated.
  • Clear statistical association with smoking, overweight, metabolic syndrome, and type 2 diabetes
  • Possibly increased prevalence of axial spondylarthropathy, ankylosing spondylitis and inflammatory bowel disease (Crohn's disease, in particular).

Symptoms and findings

  • Diagnostic features include chronic and recurrent abscesses and scarred lesions in flexural areas (linear scar, cysts, nodules and keloids, fistulas).
  • In some cases, acneiform (comedones and scarring folliculitis) or weeping and ulcerative lesions (pyogenic granuloma, ulceration or erosion) can be seen in flexural areas.
  • These usually occur bilaterally and typically in the groin or armpits.
  • Patients often have either a history of or ongoing acne on the face and upper trunk. Severe forms of acne (acne conglobata) can also be seen.

Differential diagnosis

  • Recurrent folliculitis or furunculosis (usually with lesser symptoms and no definite scarring of the skin) Skin Abscess and Folliculitis
  • Abscess (usually caused by Staphylococcus aureus, individual, asymmetric, more randomly located, clearly purulent) Skin Abscess and Folliculitis
  • Ringworm (common in the groin; after topical corticosteroids have been used, the lesions may become more papulopustular and resemble abscesses, ‟tinea incognito”) Dermatomycoses
  • Skin manifestations of Crohn's disease (the groin and perianal area, ulceration, soft nodules, fistulas associated with the bowel disease) Crohn's Disease
  • Skin cancer, lymph node or skin metastases (for instance, individual, sharply defined, poorly healing ulcers or abscess-like lesions, or enlarged lymph nodes in the groin, or other signs of malignancy)
  • Extremely rare in Finland: lymphogranuloma venereum Rare Sexually Transmitted Diseases: Chancres (groin), dermal actinomycosis (groin, armpits), skin tuberculosis (scrophuloderma spreading from lymph nodes)

Workup

  • The diagnosis is based on clinical findings.
  • Find out about any aggravating factors.
    • Smoking is a significant external factor.
    • Obesity
    • Hygiene and cosmetic products, such as fatty ointments, mechanical occlusion, friction, in some patients a hot environment, sweaty work, spending time in a hot climate
    • Internal factors (e.g. medicines, such as corticosteroids, lithium, iodine, antiepileptic medication, testosterone, anabolic steroids)
  • Bacterial culture from abscess if resistance to antimicrobial medication is suspected
  • Samples for microscopy and fungal culture, as necessary, when ringworm is suspected.
  • If inflammatory bowel disease (such as Crohn's disease Crohn's Disease) or ankylosing spondylitis Axial Spondyloarthritis and Ankylosing Spondylitis is suspected, targeted testing should be carried out.
  • In the case of poorly healing, unilateral or atypical lesions, take a skin biopsy, as necessary, to exclude malignancy.

TreatmentInterventions for Hidradenitis Suppurativa

  • Reduction of irritating factors and maceration by using talcum powder, for example
  • In overweight people weight reduction, in smokers smoking cessation
  • The disease often leads to associated psychiatric problems (depression, anxiety) that are important to treat.
  • The treatment is symptomatic. Long-term maintenance treatment is usually necessary.
  • Washing of the affected areas with antiseptic skin wash and use of benzoyl peroxide gel or cream, alone or combined with clindamycin solution, can be used for topical treatment.
  • Topical use of acne medication can also be tried (examples):
  • At the acute stage, topical treatment should be intensified by using the medication daily for 1 to 2 months, for instance, and subsequently, when symptoms have calmed down, 2 to 3 times weekly as long-term therapy.
  • Exacerbations can be treated by incision of individual abscesses and systemic antimicrobial treatment. The first line antimicrobial drugs are flucloxacillin 750-1000 mg 3 times daily, sulpha-trimethoprim 160 mg/500 mg twice daily or cephalexin 500 mg 3 times daily, for a total of 7 to 10 days. In case of hypersensitivity, clindamycin can be used.
    • A course of analgesics, such as paracetamol or an NSAID, is often also required.
  • In mild but widespread, as well as in severe cases, topical treatment should be combined with long-term systemic antimicrobial treatment (of 2 to 3 months), such as a tetracycline-group drug (e.g. 500 mg tetracycline twice daily, 300 mg lymecycline twice daily or 100 mg doxycycline once daily). Clindamycin (300 mg twice daily) has also been used as an alternative.
  • Topical treatments and systemic antimicrobial treatments can, on a case-by-case basis, be combined with antiandrogen treatment in women and metformin therapy in women and men, as a maintenance treatment (to reduce exacerbations).
    • Antiandrogen treatment may be beneficial for female patients: an antiandrogen combined oral contraceptive (e.g. cyproterone acetate and ethinylestradiol)Hormonal Contraceptionor spironolactoneAcne.
    • Spironolactone is used as a single dose of 25-100(-200) mg or divided into two doses. Typical maintenance dose is 75-100 mg, starting with a small dose and increasing it according to response every few weeks (laboratory monitoring of plasma potassium, plasma sodium, plasma creatinine is recommended).
    • Some female and male patients benefit from metformin (especially if the patient has metabolic syndrome). The starting dose in HS is usually 500 mg once daily, titrated, if necessary, upwards every few weeks. The maximum daily dose is usually 1 500 mg divided into 2-3 doses. Response to treatment is usually achieved slowly (within 3-6 months).
  • Intralesional glucocorticoid injections (e.g. triamsinolone 20 mg/ml) have also been used for individual inflamed nodules. Typically 0.1-0.5 ml of solution is injected superficially into the inflamed nodule (the risk of skin atrophy and other glucocorticoid adverse effects must be weighed).
  • Laser therapy may also be effective (e.g. ablative laser therapy, deroofing or laser epilation).

Specialist consultation

  • A dermatologist should be consulted in severe cases resistant to treatment.
  • In the case of single cystic, chronically suppurative lesions consult a plastic surgeon, as necessary.
  • Good results have also been obtained with more extensive excision and reconstruction performed by a plastic surgeon.
  • In the case of severe psychological problems (e.g. severe depression), consult a psychiatrist

    References

    • Fortoul MC, Macias Martinez B, Ventura Rodriguez D, et al. A Retrospective Review of Laser Therapy for Treatment of Hidradenitis Suppurativa. Ann Plast Surg 2023;91(6):758-762 [PubMed]
    • Ingram JR, Bates J, Cannings-John R, et al. Treatment of Hidradenitis Suppurativa Evaluation Study (THESEUS): a prospective cohort study. Br J Dermatol 2023;(): [PubMed]
    • Maskan Bermudez N, Hargis A, Yaghi M, et al. Hidradenitis Suppurativa: Surgery, Lasers, and Emerging Techniques. Surg Technol Int 2023;42(): [PubMed]
    • Molinelli E, Sapigni C, Simonetti O, et al. Alexandrite laser as an adjuvant therapy in the management of mild to moderate hidradenitis suppurativa: A controlled prospective clinical study. J Am Acad Dermatol 2022;87(3):674-675 [PubMed]
    • Jfri A, Nassim D, O'Brien E, et al. Prevalence of Hidradenitis Suppurativa: A Systematic Review and Meta-regression Analysis. JAMA Dermatol 2021;157(8):924-931. [PubMed]
    • Sivanand A, Gulliver WP, Josan CK, et al. Weight Loss and Dietary Interventions for Hidradenitis Suppurativa: A Systematic Review. J Cutan Med Surg 2020;24(1):64-72. [PubMed]
    • Patel KR, Lee HH, Rastogi S, et al. Association between hidradenitis suppurativa, depression, anxiety, and suicidality: A systematic review and meta-analysis. J Am Acad Dermatol 2020;83(3):737-744. [PubMed]
    • Bui TL, Silva-Hirschberg C, Torres J, et al. Hidradenitis suppurativa and diabetes mellitus: A systematic review and meta-analysis. J Am Acad Dermatol 2018;78(2):395-402. [PubMed]
    • Gulliver W, Zouboulis CC, Prens E, et al. Evidence-based approach to the treatment of hidradenitis suppurativa/acne inversa, based on the European guidelines for hidradenitis suppurativa. Rev Endocr Metab Disord 2016;17(3):343-351. [PubMed]
    • Ingram JR, Collier F, Brown D, et al. British Association of Dermatologists guidelines for the management of hidradenitis suppurativa (acne inversa) 2018. Br J Dermatol 2019;180(5):1009-1017 [PubMed]
    • Verdolini R, Clayton N, Smith A, et al. Metformin for the treatment of hidradenitis suppurativa: a little help along the way. J Eur Acad Dermatol Venereol 2013;27(9):1101-8 [PubMed]
    • Kraft JN, Searles GE. Hidradenitis suppurativa in 64 female patients: retrospective study comparing oral antibiotics and antiandrogen therapy. J Cutan Med Surg 2007;11(4):125-31 [PubMed]