Review Article

Hidradenitis Suppurativa: An Overview

Chetan Dhoble, MD

AUTHOR:
Chetan Dhoble, MD

CITATION:
Dhoble C. Hidradenitis suppurativa: an overview. Consultant360. Published online December 1, 2016.

 

Hidradenitis suppurativa (HS) is a chronic skin disease of the sweat gland at the terminal epithelium and involves intertrigenous areas like the axillary, under the breasts, inner thighs, groin, and perianal. HS is a progressive disabling disorder that can cause keloids, contractures, and immobility. It primarily affects the folliculopilosebaceous unit.

HS typically presents with erythema as its earliest sign. Over time, the erythema develops into lesions, which become very painful and uncomfortable. The Hurley clinical staging system (HCSS) is used to assess HS severity. Mild cases (HCSS stage 1) present with single or multiple abscess without sinus tracts and scarring. Moderate cases (HCSS stage 2) are characterized by inflammatory nodules, recurrent abscesses, sinus tracts, and scarring. Severe cases (HCSS stage 3) are characterized by diffuse involvement with multiple interconnected tracts and abscesses across the entire area.

The condition is diagnosed solely on the basis of the patient’s history and physical examination, along with its typical sites of infection and its relapsing nature. No lab tests, imaging studies, or blood cultures are recommended.1-3

Although HS is not common in the United States, affecting only 1% to 2% of the population, primary care providers should be aware of presentation symptoms and potential treatment options. Simple measures like patient education about hygiene poorly controlled or untreated HS may lead to serious complications, including strictures, contractures, lymphedema, anemia, arthritis, or squamous cell carcinoma. If HS goes untreated, disfigurement may lead to patient depression and suicide. While working in India as a primary care physician, I encountered a young beautiful woman with HS. She had 2 kids. Her husband left her thinking that she had some type of sexually transmitted disease. She was very depressed and had attempted suicide on multiple occasions. It is very important not only to treat HS, but also to understand the psychological impact of the disease on the patients. 

Treatment options are based on the severity of the disease. Presentation of HS can range from painful papules, pustules, and/or inflamed nodules in mild cases to abscesses, sinuses, and scars in severe cases. Mild cases without sinus tracts or cicatrization/scarring can be treated conservatively by maintaining local hygiene, smoking cessation, wearing loose clothes, preventing skin trauma, using antiseptic and antiperspirant agents, and applying warm compresses. In addition, topical antibiotics like clindamycin, resorcinol, or intralesional corticosteroids can be prescribed.

Moderate to severe cases of HS can be treated with oral antibiotics, anti-androgens like spironolactone or finasteride, incision and drainage, unroofing, and excision. Depending on case severity, surgery may be warranted. Surgery options range from punch debridement mini-unroofing to wide surgical excision.

In refractory cases, tumor necrosis factor (TNF) α inhibitors (ie, adalimumab), oral retinoids (ie, acitretin and isotretinoin), or immunosuppressants (ie, systemic glucocorticoids, cyclosporine, ustekinumab, anakinra, and tacrolimus) can be used.4-8

Chetan Dhoble, MD, is a PGY1 in Pediatrics at The Brooklyn Hospital Center in Brooklyn, New York.

REFERENCES:

  1. Jemec GBE. Hidradenitis suppurativa. N Engl J Med. 2012;366(2):158-164. doi:10.1056/NEJMcp1014163.
  2. Wortsman X, Jemec GBE. Real-time compound imaging ultrasound of hidradenitis suppurativa. Dermatol Surg. 2007;33(11):1340-1342. doi:10.1111/j.1524-4725.2007.33286.x.
  3. Wortsman X, Rodriguez C, Lobos C, Eguiguren G, Molina MT. Ultrasound diagnosis and staging in pediatric hidradenitis suppurativa. Pediatr Dermatol. 2016l;33(4):e260-e264. doi:10.1111/pde.12895.
  4. Blok JL, van Hattem S, Jonkman MF, Horváth B. Systemic therapy with immunosuppressive agents and retinoids in hidradenitis suppurativa: a systematic review. Br J Dermatol. 2013;168(2):243-252. doi:10.1111/bjd.12104.
  5. Rambhatla PV, Lim HW, Hamzavi I. A systematic review of treatments for hidradenitis suppurativa. Arch Dermatol. 2012;148(4):439-446. doi:10.1001/archdermatol.2011.1950.
  6. Shuja F, Chan CS, Rosen T. Biologic drugs for the treatment of hidradenitis suppurativa: an evidence-based review. Dermatol Clin. 2010;28(3):511-524. http://dx.doi.org/10.1016/j.det.2010.03.012.
  7. Gulliver WP, Jemec GBE, Baker KA. Experience with ustekinumab for the treatment of moderate to severe hidradenitis suppurativa. J Eur Acad Dermatol Venereol. 2012;26(7):911-914. doi:10.1111/j.1468-3083.2011.04123.x.
  8. Rose RF, Goodfield MJD, Clark SM. Treatment of recalcitrant hidradenitis suppurativa with oral ciclosporin. Clin Exp Dermatol. 2006;31(1):154-155. doi:10.1111/j.1365-2230.2005.01983.x.