Hidradenitis Suppurativa: A FrequentlyMissed Diagnosis, Part 2: Treatment Options

C M E1 AMA PRA

Category 1 CreditTMANCC

3.0 Contact Hours

Shirley C. Wang, MD & Clinical Research Coordinator & University Health Network & Toronto, Ontario, Canada

Sheila C. Wang, PhD & Resident & Department of Dermatology, McGill University & Montreal, Quebec, Canada

Afsaneh Alavi, MD, MSc, FRCPC & Assistant Professor & Department of Medicine (Dermatology), University of Toronto &Ontario, Canada

Raed Alhusayen, MD, MSc (Clin Epi), FRCPC & Assistant Professor & Sunnybrook Health Sciences Centre & University ofToronto & Ontario, Canada

Morteza Bashash, PhD & Research Fellow & Dalla Lana Faculty of Public Health & University of Toronto, Ontario, Canada

R. Gary Sibbald, BSc, MD,MEd, FRCPC (MedDerm), MACP, FAAD,MAPWCA & Professor of Public Health andMedicine &University of Toronto & Toronto, Ontario, Canada & Director & International Interprofessional Wound Care Course & Masters ofScience in Community Health (Prevention & Wound Care) & Dalla Lana School of Public Health & University of Toronto & PastPresident, World Union of Wound Healing Societies & Clinical Editor & Advances in Skin &Wound Care & Philadelphia, Pennsylvania

Dr Alavi has disclosed that she was a consultant to AbbVie and Janssen; her institution is a recipient of grant funding from AbbVie; her institution was a recipient of payment for lecturesincluding speakers’ bureau from AbbVie and Janssen; and her spouse/partner (if any), has disclosed that he/she has no financial relationships with, or financial interests in, any commercialcompanies pertaining to this educational activity. Dr Sibbald has disclosed that he is a recipient of grant funding, consulting fee/honorarium, travel support, and participation fees fromAbbVie; and his spouse/partner (if any), has disclosed that he/she has no financial relationships with, or financial interests in, any commercial companies pertaining to this educationalactivity. Dr Alhusayen has disclosed that he is a consultant to Abbott and Janssen; and his spouse/partner (if any), has disclosed that he/she has no financial relationships with, or financialinterests in, any commercial companies pertaining to this educational activity. The remaining coauthors and their spouses/partners (if any), have disclosed that they have no financialrelationships with, or financial interests in, any commercial companies pertaining to this educational activity.

All staff and planners, including spouses/partners (if any), in any position to control the content of this CME activity have disclosed that they have no financial relationships with, or financialinterests in, any commercial companies pertaining to this educational activity.

The authors have disclosed that none of the treatments of hidradenitis suppurativa are approved by the US Food and Drug Administration as discussed in this article.

Lippincott CME Institute has identified and resolved all conflicts of interest concerning this educational activity.

To earn CME credit, you must read the CME article and complete the quiz and evaluation on the enclosed answer form, answering at least 13 of the 18 questions correctly.

This continuing educational activity will expire for physicians on August 31, 2016, and for nurses on August 31, 2017.

If you need CME or CE STAT, take the test online at: http://cme.lww.com for physicians and www.nursingcenter.com for nurses. Complete CE/CME information is on the last page of this article.

Editor’s note: This is the second part of this continuing education topic. ‘‘Hidradenitis Suppurativa: A Frequently Missed Diagnosis, Part 2: A Review of Pathogenesis, Associations, andClinical Features’’ was published in the July 2015 issue.

PURPOSE:

To provide an overview of treatment recommendations for hidradenitis suppurativa (HS).

TARGET AUDIENCE:

This continuing education activity is intended for physicians and nurses with an interest in skin and wound care.

OBJECTIVES:

After participating in this educational activity, the participant should be better able to:

1. Describe current recommendations for treatment of HS.

2. Identify warnings, adverse effects, and implications for patient education.

AUGUST 2015

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ABSTRACT

Hidradenitis suppurativa (HS) is a chronic inflammatorydisorder of the intertriginous area. Patients with HS have severalchallenges to their quality of life and activities of everyday living,including malodor, purulent discharge, and discomfort. There isoften a delay in diagnosis and appropriate treatment. The needfor cosmetically acceptable local treatments and dressingapplication makes this disease an important challenge for woundcare specialists. The choice of optimal treatment varies dependingon the disease severity, expert knowledge, the availability of aninterprofessional team, and patient factors.KEYWORDS: hidradenitis suppurativa, inflammatory folliculardisorder, wound care

ADV SKIN WOUND CARE 2015;28:372–80; quiz 381-2.

INTRODUCTIONHidradenitis suppurativa (HS) is a chronic debilitating disease

that significantly affects the quality of life of an active, young

adult population. The large burden of HS and its comorbidities

highlight the need for an interprofessional team approach.

Typically, HS is more common in females mainly involving the

axilla and groin (Figure 1), whereas the perineum and buttocks

are commonly involved in males (Figure 2). Despite multiple

studies, a diversity of expert opinion remains on the optimal stepwise management of HS. The US Food and Drug Admin-

istration (FDA) has not approved any treatments for HS. The

recommendations in this article are based on the scientific

literature, expert knowledge of the authors, published consensus

documents, and patient experience.

GENERAL MEASURESEpidemiological data suggest an association of HS with systemic

diseases, including metabolic syndrome, psychiatric disorders,

and hyperandrogenism.1 The Mayo Clinic (http://mayocl.in/

1hZDzm2) defines metabolic syndrome as a cluster of conditions

that can be remembered by A-increased blood sugar (hemoglo-

bin A1c), B-increased blood pressure, C-abnormal cholesterol,

and D-diet with excess body fat around the waist, all of which

increase an individual’s risk of heart disease, stroke, and diabetes.

The patient’s body weight and lifestyle choices may contribute to

HS. For example, the association of HS and a high body mass

index, along with smoking, warrants weight loss counseling and

smoking cessation. Current adult obesity guidelines include a

lifestyle modification program that ideally involves:

& reduced caloric intake by 500 to 1000 kcal/d,

& 30 minutes of moderate-intensity physical activity 3 to 5 times

per week and an eventual increase to 60 minutes or more on

most days,

& cognitive-behavior therapy.2

Figure 1.

THEAXILLA,GROIN,AND INFRAMMARYAREPREDOMINANTLY

INVOLVED IN FEMALE PATIENTS

Figure 2.

THEGLUTEAL, INGUINAL INVOLVEMENTISPREDOMINATELY

SEEN IN MALE PATIENTS

ADVANCES IN SKIN & WOUND CARE & AUGUST 2015373WWW.WOUNDCAREJOURNAL.COM

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If satisfactory weight-loss progress is not achieved, pharma-

cotherapy and bariatric surgery should be considered. The same

lifestyle modifications should be recommended to patients

with metabolic syndrome, with the additional option of ini-

tiating metformin.3

To help patients with smoking cessation, the clinical approach

begins with an assessment of the patient’s willingness to quit,

and every tobacco user who accepts treatment should be offered

assistance.3 The combination of counseling and smoking cessa-

tion medication is more effective than either option alone. It is

important to note that although lifestyle modifications (such as

weight loss or smoking cessation) have been shown to improve

the symptoms of HS, they do not cure the disease.4,5 Friction from

clothing increases local pain; thus, patients with HS are advised

to avoid wearing tight clothes. In addition, excessive heat and

humidity are known triggers. Avoidance of these climate condi-

tions, such as staying indoors in air conditioning when needed,

may help relieve symptoms. Other potential triggers, although

not causative factors, include the use of deodorants, shaving,

and depilation.

Some expert clinicians recommend warm compresses, topical

antiseptics, and antibacterial soaps to help soothe HS-involved skin.

TOPICAL TREATMENTS AND LOCALWOUND CAREBecause there are no FDA-approved treatments for HS, clinicians

must rely on available evidence to treat patients’ symptoms.

To date, there are very few studies that focus on optimal local

wound care in patients with HS. The choice of local dressing is an

important part of the management. Dressings with high absor-

bency are commonly used. Experts suggest that tubular net

bandages or placing superabsorbent pads or materials in the

seams of clothing are the best ways to keep the wound dressings

in place because of the topography. In general, superabsorbent

dressings are best to treat actively draining lesions or postopera-

tive wounds, with extensive and generous application of simple

white petrolatum, zinc oxide paste, or film-forming liquid acrylate

on the marginal skin to prevent the primary dressing from stick-

ing to the wound. In addition, adhesive tape should be avoided

to minimize trauma to inflamed skin.

Daily gentle cleansing of the affected areas may help to reduce

odor and the occurrence of secondary infection. Consider gentle

antiseptic washes with a lower risk of allergic or irritant contact

dermatitis. Some patients have had success with water-based

chlorhexidine preparations and were instructed to avoid wash-

cloths, harsh sponges/loofahs, or brushes that may cause un-

necessary trauma and skin irritation.

Postoperative wounds were studied by Chen et al6 with a ret-

rospective chart review of HS cases managed surgically between

2005 and 2010. The authors calculated that approximately half of

the patients received negative-pressure wound therapy using the

vacuum-assisted closure system, followed by delayed closure.

The other half received immediate primary closure at the time of

their excision. Wound closure averaged 2.2 months with negative-

pressure wound therapy and 2.7 months in the control group.

The authors also concluded that local excisions may heal with

secondary intention, closed at the time of surgery, delayed with

direct closure, or with skin grafts.

PHARMACOLOGIC TREATMENTSA variety of pharmacologic treatments have been successfully

administered, but as noted, to date, the FDA has not approved

any medical treatment specifically for the treatment of HS.7

AntimicrobialsMany therapeutic algorithms recommend antimicrobials (often

with anti-inflammatory properties) in all severity stages of HS8–10;

however, only a few review articles offer specific recommenda-

tions. Many of the antimicrobial agents that are successful in

HS may be effective because of their antibacterial and anti-

inflammatory properties (eg, tetracyclines, clindamycin). The

majority of published reports recommend initial therapy with

rifampicin combined with clindamycin or a tetracycline.11–14

Matusiak et al15 found that the most commonly prescribed anti-

microbials (eg, tetracycline, doxycycline, minocycline) were in-

effective against cultured isolates.16–18

Topical antimicrobials, including topical clindamycin and

topical resorcinol, have been studied.10,11,16 Topical clindamycin

0.1% was compared with placebo in 27 patients who completed

the study. At the end of the first, second, and third months, the

clindamycin-treated subjects had fewer abscesses, inflammatory

nodules, and pustules (P < .01). Topical resorcinol 15% cream

was a successful treatment when used twice daily in a case study

of 12 patients.17 Resorcinol has topical antiseptic and keratolytic

properties. The most significant effect of this treatment was

noticed in superficial lesions, such as pustules and papules, but

not in deep-seated cysts and sinuses.18

In managing patients with HS, clinicians also must consider that

the use of topical treatments is associated with the risk of allergic

and irritant contact dermatitis to the active agent or components of

the vehicle (Figure 3). The authors also suggest that maintenance

or long-term oral therapy can be provided with the help of

tetracyclines (or erythromycin and related macrolides) due to

their anti-inflammatory properties. Oral dapsone has been used

in mild cases, but the effect appears to be lower in comparison

with the combination of clindamycin and rifampicin.19 In ad-

dition, the HS lesions will not promptly respond to systemic

antimicrobials without surgical debridement and appropriate

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topical wound care, along with selective intralesional steroid

injections for the associated inflammatory response.

Retinoids. Two oral retinoid drugs, isotretinoin (13-cis-RA

[retinoic acid]) and acitretin have been studied clinically for the

treatment of HS. Zouboulis et al20 studied the effect of these

retinoids utilizing an in vitro sebocyte model. The authors con-

cluded that 13-cis-RA was a potent inhibitor of both cell

proliferation and lipid synthesis in human sebocytes, but that

acitretin decreased only lipogenesis in this model. Blok et al21

reviewed the results of 174 patients enrolled in 7 studies that

evaluated the effect of oral isotretinoin patients with HS. The

combined study report concluded that there was

& significant improvement in 18% of patients,

& moderate improvement in 17% of patients, and

& no response in 64% of patients.

In a more recent study, Puri and Talwar22 compared the effects

of oral acitretin combined with surgical excision to oral acitretin

alone. There was a low 20% recurrence rate in the group of

patients who received both oral acitretin and surgical excision

compared with a 40% recurrence rate in the group that received

oral acitretin alone. In summary, the results from the use of oral

retinoids are disappointing, but may be helpful as adjunct agents

in some difficult-to-control patients.22 Acitretin was viewed as a

more promising agent; however, it is often poorly tolerated,

especially when doses exceed 20 mg daily.23

Corticosteroids. An intralesional injection of a topical cor-

ticosteroid (eg, triamcinolone 8 to 20 mg/mL, with injections of

up to 3 to 6 mL per visit every 3 to 6 weeks) is commonly per-

formed to reduce individual lesion pain and acute erythema/

swelling.7 These injections should be avoided if there is clinical

evidence of infection.

Oral prednisone reduces inflammation, facilitates the heal-

ing of existing HS lesions, and prevents future lesions from

forming. Commonly prescribed prednisone doses for disease

control may vary from 20 to 50 mg. The adverse effects of oral

steroids (weight gain, diabetes, loss of muscle mass, bone frac-

tures, and so on) must be measured against the therapeutic

benefit of using oral steroids compared with other available

treatment options. To the authors’ knowledge, no recent, formal

studies have been conducted on the efficacy of corticosteroids

as part of HS management.

Although the exact role of immune dysregulation in the path-

ogenesis of HS is unknown, it has been demonstrated to have an

impact (see ‘‘Immune Dysregulation’’ in Part 1 of this article

series in the July 2015 issue of Advances in Skin & Wound Care).

Thus, clinicians are increasingly prescribing immunosuppressive

agents as part of the management of HS. Anti-TNfa inhibitors,

anti-IL17/23, and anti-IL1 inhibitors have been used in the man-

agement of HS. Different immunosuppressive medications

including methotrexate have been used in case reports.

Biologics. Evidence that inhibitors of tumor necrosis factor

(TNF) effectively improved HS symptoms in patients who were

primarily being treated for Crohn disease led to the investigation

of anti-TNF agents as an effective treatment for HS. Serum and

skin (lesional, perilesional) TNF- levels are higher in patients with

HS compared with control subjects.24,25 A growing number of stud-

ies have highlighted the efficacy of infliximab and adalimumab,

both anti-TNF agents, in the management of HS.26–28 Bahillo

Monne et al27 found favorable outcomes with adalimumab treat-

ment, with improvement somewhat slower than the responses

with infliximab. Moriarty et al29 described the results of using

infliximab on a 4-week basis in 11 patients with severe HS. The

authors reported that all patients experienced initial disease

improvement assessed by visual analog scale, Dermatology Life

Quality Index (DLQI), and the physician’s clinical assessment.

While on this regimen, the patients experienced secondary in-

fection of HS lesions, respiratory tract infections, tonsillitis, minor

weight gain, and lymphoma. Newer biological treatments that

inhibit interleukin 1 (anakinra) require further study before they

can be recommended for HS patients.

Antiandrogens. A hormonal connection with HS has been

suggested by several studies (see the ‘‘Hormones’’ section in the Part 1

Figure 3.

CONTACT DERMATITIS IS COMMONLY SEEN ASSOCIATED

WITH THE CONTINUOUS DISCHARGE (CONTACT IRRITANT

DERMATITIS) AND TOPOGRAPHY

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article). The observation of female predominance,30,31 premen-

strual flare-ups, and improvement of HS during pregnancy32

suggest that androgens may be a contributing factor. In some

women with HS, symptoms often correlate with hormonal fluc-

tuations during the menstrual cycle. Previously reported studies

have linked improvement in HS lesions with oral contraceptive

pills and spironolactone.33 Published reports also documented

some male HS patient benefits from finasteride.34,35 More re-

cently, Randhawa et al36 investigated finasteride as an effective

treatment of HS in children and adolescents. The 3 pediatric pa-

tients in this study were treated with oral finasteride in com-

bination with oral contraceptives and/or oral antibiotics. The

authors observed decreased disease flare frequency and severity

with no significant adverse effects. As a result, the authors sug-

gested that finasteride might be a suitable additive therapy for

refractory female HS cases and for judicious use in pediatric

patients with clear communication of the risks and benefits of

the drug.

Metformin. As an antidiabetic agent, metformin provides

some benefit in HS. Arun and Loffeld,37 who presented a case

of a 50-year-old woman with longstanding HS and type 2 diabetes

mellitus, first documented the use of metformin in the treatment

of HS. The patient was taking metformin 500 mg 3 times daily for

more than 5 years until she gained significant control of her

glycemic levels and was subsequently taken off of metformin. The

authors observed that while on metformin the patient’s HS

lesions remained stable and did not require recurrent courses of

antibiotic therapy. However, with the discontinuation of met-

formin, the patient reported a flare-up of her HS lesions. More

recently, Verdolini et al38 reported significant reduction in the

Sartorius score, which was described in Part 1, and the number

of workdays lost among 25 patients with HS who were treated

with metformin. In addition, the DLQI significantly improved in

16 cases. The authors conclude that metformin helps control HS

with very few adverse effects. Based on their results, they suggest

using metformin as an alternative to current treatments, in-

cluding long-term antibiotics.

PAIN MANAGEMENTDespite the painful effects of this chronic, debilitating disease,

few studies have documented treatment for the effective pain

control of HS. Clinicians should accept the patient’s report of

pain. This statement is supported by the findings of a recent study

on the correlation and validity of patient and investigator assess-

ment of disease severity and pain.39 Each of the 20 HS patients

graded a single representative inflammatory nodule in terms of

tenderness and flare, and the investigator graded the level of

erythema. Subsequently, all patients underwent high-resolution

ultrasound scanning of their representative nodule, and the diam-

eter of the nodule was measured to reflect the degree of in-

flammation. The authors found that the patient assessment of

flare activity and pain and the investigator assessment of ery-

thema were strongly associated with morphological changes

identified by ultrasound, suggesting that patients tend to accu-

rately report flare and pain levels and investigators acutely ob-

served the resulting erythema.

Pain control often starts with grading the severity of pain on a

0- to 10-point numerical rating scale, with ‘‘0’’ being no pain and

‘‘10’’ slamming the car door on your finger, and ‘‘5’’ representing a

bee sting. Nociceptive pain (gnawing, aching, tender, throbbing)

often responds to acetaminophen, with a starting dose of 1 g

3 times per day, and the use of alternative agents such as non-

steroidal anti-inflammatory drugs and aspirin. More severe pain is

often treated with opioids, short- and long-acting weaker (codeine),

and subsequently, stronger agents (morphine, hydromorphone).

A fentanyl patch can be used for resistant pain. Neuropathic pain

is often described as burning, stinging, shooting, and stabbing.

Treatment of neuropathic pain may include second-generation

tricyclic agents, such as nortriptyline or desipramine. Scheinfeld40

concluded that when treating HS-related pain that is unresponsive

to topical analgesics, gabapentin and pregabalin should be first-

line therapy because of fewer adverse effects compared with tri-

cyclics or the serotonin and norepinephrine reuptake inhibitors,

duloxetine and venlafaxine. Also, gabapentin and pregabalin can be

combined with acetaminophen, nonsteroidal anti-inflammatory drugs,

and cyclooxygenase 2 inhibitors. In cases of HS accompanied by de-

pression, gabapentin or pregabalin can be combined with duloxe-

tine, which should be tried first and venlafaxine second, if needed.

Scheinfeld40 also reviewed the use of topical agents in the

treatment of HS-related pain. The author summarized that

topical 1% diclofenac should be offered first to a patient who

presents with HS and complains of pain centered on the skin.

Topical ketamine may also be a useful tool for the treatment of

pain. Commercially available topical 5% doxepin may cause

drowsiness, and some clinicians may order lower-dose com-

pounded formulations.

NEW AND TRADITIONAL SURGICALAPPROACHESTraditional surgical approaches to HS management have in-

cluded incision and drainage (I&D), punch debridement, de-

roofing, and excision. It has been suggested that I&D of individual

nodules should generally be avoided because they provide only

short-term relief and tend to recur with no long-term benefit.41

Margesson and Danby42 suggested the practice of punch de-

bridement over I&D, which is a mini unroofing procedure. Punch

debridement involves deeply excising the acutely inflamed folli-

culopilosebaceous unit (FSPU) within an inflammatory nodule

using a 5- to 7-mm circular punch instrument identical to that

used in a punch biopsy. The FSPU is excised with a small amount

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of the surrounding tissue and is followed by aggressive debride-

ment using digital pressure. The curettage or simple scrubbing

is done with gauze wrapped around a cotton-tipped swab. The

goal is to remove the ‘‘bulge’’ of the FSPU that contains the stem

cells hypothesized to be responsible for inducing growth of the

proliferative mass (amorphous material deposited in the dermis)

and the sinus tracts.

Surgical excision of the affected skin tissue in HS with ade-

quate free margins is the criterion-standard treatment for pre-

vention of recurrence7 (Figure 4). The classic deroofing technique

and wide excision are regarded as the preferred surgical methods

for treated HS Hurley Stage I/II and II/III, respectively.43,44

However, the goal of surgery is to completely remove the lesional

tissue, while sparing as much healthy tissue as possible, making

Hurley Stage II/III disease a surgical challenge.45

Skin-Tissue–Sparing Excision withElectrosurgical Peeling ProcedureBlok et al45 proposed a new surgical technique for severe HS

that combines the advantages of both wide excision and the

deroofing technique: skin-tissue–sparing excision with electro-

surgical peeling (STEEP) procedure. The STEEP procedure is

performed under general anesthesia and involves electrosur-

gical incision of the sinus roof with a wire loop tip coupled to an

electrosurgery device.

All lesional tissue, including fibrosis that is identified by

palpation, is removed from the incision on to the deeper skin

layers by successive tangential electrosurgical transections or

peeling. The epithelialized sinus floors and subcutaneous fat

are left intact where possible. Hemostasis is achieved by the

coagulation mode of the electrosurgery device, and wounds are

left open to heal by secondary intention. Generally, patients can

leave the hospital on the day of surgery. Blok et al45 have per-

formed the STEEP procedure on 156 patients with Hurley

Stage II/III disease between 2004 and 2013. Patients have re-

ported low recurrence rates, rapid healing, and an improvement

in DLQI responses. The authors proposed the STEEP procedure

as a promising tissue-saving surgical technique for HS Hurley

Stage II/III as an alternative to laser surgery that can be per-

formed by trained dermatological surgeons.

Split-Thickness Skin GraftAxillary HS has been historically treated with excision of the

affected tissue, and the surgical defect was left to heal by sec-

ondary intention or was grafted with a split-thickness skin graft

(SSG).46 Although an SSG can produce satisfactory results in

patients with mild to moderate disease, in more severe disease it

can predispose to graft contraction, reduced range of movement of

the shoulder, restrictive scarring, prolonged recovery, and an

increased number of subsequent surgical procedures.47–49 More

recently, postexcision HS wounds have been treated with a num-

ber of surgical procedures, including local, regional, and free

flaps (fasciocutaneous V-Y flap, Limberg flap, and musculocu-

taneous flaps). In particular, perforator flaps, including the

thoracodorsal artery perforator (TDAP) flap, have been reported

as advantageous for reconstruction of the soft-tissue defect after

excision.50–52 Wormald et al46 conducted a prospective study

comparing the use of TDAP flap and SSG for the reconstruction

of the axilla following excision of extensive or recurrent axillary

HS, with focus on both operative and patient-related outcomes.

The authors found a significantly longer length of surgery for the

TDAP group, a finding that is supported already in the litera-

ture.53,54 The TDAP cohort had a higher rate of revision surgery,

whereas the SSG group required a significantly greater number

of follow-up appointments in the clinic. The authors summarized

that a TDAP flap may provide a more definitive surgical solution

compared with the SSG technique, requiring fewer clinic appoint-

ments and a shorter period of follow-up and thus is potentially

more cost-effective despite the longer length of surgery.

Genitoperineal HS ResectionFor genitoperineal HS resection in males, partial or total scrotectomy

is almost always required with care to avoid causing injury to the

Figure 4.

SURGICAL APPROACH TO REMOVE CYSTS, TUNNELS,

CICATRIZATION, AND SCAR

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spermatic cords and testes.55 Perineal disease is resected with care

to avoid injury to the anal sphincter muscles. If both genital-

perineal (anterior) and anal and/or buttock (posterior) disease

resections are recommended, they should be resected in separate

procedures to avoid an arduous and intolerable recovery period.

The anterior tissue of the perineum and genitals is treated first, and

then a referral to a general surgery or plastic surgery practitioner

is suggested for posterior treatment. The complete resection

and reconstruction with skin flaps and grafts provide a viable

treatment for patients with primary genital HS disease. After

surgical debridement of HS, extended soft tissue defects are the

usual result, requiring plastic reconstruction in this site.

CryoinsufflationIf surgical treatment is declined, and systemic therapies should

be avoided in certain patients, a new technique using cryoin-

sufflation (CI) was proposed by Pagliarello et al.56 The authors

presented the case of a female patient in her 30s who pre-

sented with HS Hurley Stage II. She was being treated with oral

contraceptives, topical clindamycin, and monthly intralesional

corticosteroids. However, she decided to become pregnant and

therefore was searching for an alternative treatment, devoid of

teratogenic effects. Effective therapy was necessary because the HS

seriously interfered with sexual intercourse and indirectly with her

planned pregnancy. Surgical treatment was offered and declined.

To control the patient’s HS symptoms and simultaneously dis-

continue her systemic medical therapy, the authors proposed CI, a

modified spray cryotherapy performed by injecting liquid nitrogen

(LN) through an ordinary needle directly into the HS tracts. As

the LN enters infected sinuses, it boils and vaporizes, and quickly

disperses into all communicating pockets because of the large

expansion ratio of liquid to gas. The authors suggested delivering

the LN in a pulsed method to avoid overexpansion and prevent

excessive pain and formation of ‘‘iceballs.’’

The patient received monthly treatment sessions that allowed

focused scarring to replace the sinuses and caused minimal

damage to the skin surface. In total, the authors treated the patient

with 3 monthly treatment sessions, and they reported that no

recurrence was observed after 6 months. Neither hypopigmentation

nor scarring was observed, and the patient was very satisfied

with the results.

In conclusion, the authors proposed CI as a novel, easily con-

ducted, well-tolerated, and inexpensive alternative as monotherapy

or as a useful adjunctive therapy that can be effectively combined

with all other treatments to rapidly achieve symptom relief. Al-

though surgery plays an important role in the management of

HS, the choice of surgery should be individualized based on

patient preference, the Hurley stage, extent of involvement, and

location of the disease.57

THE ROLE OF PHOTODYNAMIC ANDLASER THERAPY

Photodynamic TherapyPhotodynamic therapy (PDT) is effective against acne vulgaris,58

which has led to its use against HS. Earlier studies have reported

the effective treatment of HS by PDT, but they were small case

studies with varying results and variations in the photosensi-

tizers, light sources, and treatment regimens used.59,60 The pro-

posed mechanism of action of PDT in HS involves absorption of

aminolevulinic acid and an increased production of protopor-

phyrin IX in hair follicles compared with other tissues.61 In addi-

tion, the main mechanisms suggested for PDT against acne

vulgaris, including sebum production and reduced follicular

occlusion,44 may also play a role against HS.

Topical PDT is found to be effective when applied to early super-

ficial HS lesions. Researchers, however, have found that the main

limitations of PDT are the low absorption of photosensitizer and

low penetration of the light source.62,63 For this reason, Valladares-

Narganes et al64 proposed a new approach by applying intrale-

sional PDT using a laser diode attached to an optical cable. The

authors suggested that intralesional PDT is less invasive than surgery,

well-tolerated, effective, and less expensive than systemic therapy.

Carbon Dioxide LaserThe use of carbon dioxide laser for HS has been reported in

5 studies.54,65 Lapins et al66 studied carbon dioxide lasers on

24 patients with HS, with 22 of 24 patients having no recurrence after

27 months. Hazen and Hazen67 treated 185 sites in 61 patients

with a carbon dioxide laser and marsupialization technique, with

183 recurrence-free sites during a follow-up period of 1 to 19 years.

Nd:YAG LaserThe long-pulsed 1064-nm Nd:YAG laser is an alternative modality

for the management of HS. The Nd:YAG laser causes a selective

photothemolysis of the follicular units and adjacent inflamma-

tions. Tierney et al68 studied the Nd:YAG laser on 22 patients with

HS Stages II and III and demonstrated a significant decrease in

severity of HS in 3 months (65.3%). Xu et al69 studied a long-

pulsed 1064-Nm Nd:Yag Laser on 19 patients with Hurley

Stage II HS disease. The severity of HS significantly decreased for

both the axillary site (P = .008) and the inguinal site (P = .001).

CONCLUSIONHidradenitis suppurativa is a chronic inflammatory disorder that

commonly involves the intertriginous area. The concerns of malodor,

discharge, and discomfort, along with the need for cosmetically

acceptable local treatments and dressing application, make this

disease an important challenge for wound care specialists. The

ADVANCES IN SKIN & WOUND CARE & VOL. 28 NO. 8 378 WWW.WOUNDCAREJOURNAL.COM

Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.

lack of randomized clinical trials for most HS therapeutic modalities

complicates optimal treatment selection. The choice of treatment

varies depending on the disease severity, the expert knowledge of

the prescribing healthcare professional, and patient factors (Table).

The associated medical and psychological factors significantly af-

fect patient health and adherence to treatment. It is important to

approach HS as a systemic disease with an interprofessional team.

PRACTICE PEARLS

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& HS is chronic disorder of the intertriginous area

& Malodor, discharge, and discomfort in HS and lack of stan-

dardization among treatment modalities makes this disease an

important challenge for wound care specialists

& HS is a systemic disease, therefore management of HS should

be done by an interprofessional healthcare team and address

both medical and psychological patient factors

Table.

MANAGEMENT OF HIDRADENITIS SUPPURATIVA

ADVANCES IN SKIN & WOUND CARE & AUGUST 2015379WWW.WOUNDCAREJOURNAL.COM

Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.

43. van der Zee HH, Prens EP, Boer J. Deroofing: a tissue-saving surgical technique for the treat-

ment of mild to moderate hidradenitis suppurativa lesions. J Am Acad Dermatol 2010;63:475-80.

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sinuses by deroofing in hidradenitis suppurativa. Dermatol Surg 2012;38:494-7.

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50. Bieniek A, Matusiak L, Okulewicz-Gojlik D, Szepietowski JC. Surgical treatment of hidradenitis

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51. Slade DE, Powell BW, Mortimer PS. Hidradenitis suppurativa: pathogenesis and manage-

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52. Oritz CL, Castillo VL, Pilarte F, Barraguer EL. Experience using the thoracodorsal artery perfo-

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54. Rambhatla PV, Lim HW, Hamzavi I. A systematic review of treatments for hidradenitis

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follicles of mice after systemic administration of 5-aminolevulinic acid correlates with

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aminolevulinic acid does not lead to clinical improvement in hidradenitis suppurativa.

Br J Dermatol 2005;152:803-4.64. Valladares-Narganes LM, Rodrıguez-Prieto MA, Blanco-Suarez M, Rodriguez-Lage C,

Garcia-Doval I. Treatment of hidradenitis suppurativa with intralesional photodynamic

therapy using a laser diode attached to an optical cable: a promising new approach. Br J

Dermatol 2015;172:1136-9.65. Finley EM, Ratz JL. Treatment of hidradenitis suppurativa with carbon dioxide laser excision

and second-intention healing. J Am Acad Dermatol 1996;34:465-9.

66. Lapins J, Sartorius K, Emtestam L. Scanner-assisted carbon dioxide laser surgery: a retro-

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67. Hazen PG, Hazen BP. Hidradenitis suppurativa: successful treatment using carbon dioxide

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68. Tierney E, Mahmoud BH, Hexsel C, Ozog D, Hamzavi I. Randomized control trial for the

treatment of hidradenitis suppurativa with a neodymium-doped yttrium aluminium garnet

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Arch Dermatol. 2011;147(1):21-8.

For more than 127 additional continuing education articles related to skin and wound care topics, go to NursingCenter.com/CE.

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