HIDRADENITIS SUPPURATIVA

Review By :

Dr. Mohammad Baghaei

Cosmetic Scientist

HIDRADENITIS SUPPURATIVA

Disease of the follicle

Deep tender nodules in the groin, axilla,

buttocks

Difficult to treat

May respond to Accutane

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What is hidradenitis suppurativa?

Hidradenitis suppurativa is a chronic, recurrent,

and painful disease in which there is inflammation

in areas of the apocrine sweat glands. These

glands are found mainly in the armpits and groins.

Within hidradenitis there is a blockage of the hair

follicles. This causes a mixture of boil-like lumps,

areas leaking pus, and scarring.

Hidradenitis tends to begin in early life, and is

more common in women, black and

Mediterranean people. It affects about 1% of the

population. Hidradenitis often starts at puberty,

and is most active between the ages of 20 and 40

years, and in women, can resolve at menopause.

It is 3 times more common in females than in

males.

hidradenitis suppurativa

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What are the clinical features of

hidradenitis suppurativa? Risk factors include:

1. Other family members with hidradenitis suppurativa

2. Obesity and insulin resistance/metabolic syndrome

3. Cigarette smoking

4. Follicular occlusion disorders: acne conglobata, dissecting cellulitis,

pilonidal sinus

5. Inflammatory bowel disease (Crohn disease)

6. Rare autoinflammatory syndromes associated with abnormalities of

PSTPIP1 gene*

* PAPA syndrome (Pyogenic Arthritis, Pyoderma gangrenosum and Acne), PASH syndrome (Pyoderma

gangrenosum, Acne, Suppurative Hidradenitis) and PAPASH syndrome (Pyogenic Arthritis, Pyoderma

gangrenosum, Acne, Suppurative Hidradenitis)

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What causes hidradenitis suppurativa?

Hidradenitis suppurativa is an

autoinflammatory disorder. Although the exact

cause is not yet understood, contributing

factors include:

o Friction from clothing and body folds

o Aberrant immune response to commensal

bacteria

o Follicular occlusion

o Release of pro-inflammatory cytokines

o Inflammation causing rupture of the

follicular wall and destroying apocrine

glands and ducts

o Secondary bacterial infection

o Certain drugs

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Signs

Hidradenitis can affect a single or multiple

areas in the armpits, neck, submammary

area, and inner thighs. Anogenital

involvement most commonly affects the

groin, mons pubis, vulva (in females),

sides of the scrotum (in males), perineum,

buttocks and perianal folds

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Signs

Signs include:

Open and closed comedones

Painful firm papules and larger nodules

Pustules, fluctuant pseudocysts and

abscesses

Pyogenic granulomas

Draining sinuses linking inflammatory

lesions

Hypertrophic and atrophic scars

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Severity

The severity and extent of hidradenitis suppurativa is

recorded at assessment and when determining the impact

of a treatment. The Hurley system describes three distinct

clinical stages:

1. Solitary or multiple, isolated abscess formation without

scarring or sinus tracts

2. Recurrent abscesses, single or multiple widely

separated lesions, with sinus tract formation

3. Diffuse or broad involvement, with multiple

interconnected sinus tracts and abscesses.

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Severity

Severe hidradenitis (Hurley Stage 3) has been

associated with:

Male gender

Axillary and perianal involvement

Obesity

Smoking

Disease duration

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What is the treatment for hidradenitis

suppurativa?

General measures:

Weight loss; follow low-glycaemic, low-dairy diet

Smoking cessation: this can lead to improvement within a few months

Loose fitting clothing

Daily unfragranced antiperspirants

If prone to secondary infection, wash with antiseptics or take bleach baths

Apply hydrogen peroxide solution or medical grade honey to reduce

malodour

Apply simple dressings to draining sinuses

Analgesics, such as paracetamol (acetaminophen), for pain control.

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Medical management of hidradenitis

suppurativa

Medical management of hidradenitis

suppurativa is difficult. Treatment is

required long term. Effective options are

listed below.

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Antibiotics

• Topical clindamycin, with benzoyl peroxide to

reduce bacterial resistance

• Short course of oral antibiotics for acute

staphylococcal abscesses, eg flucloxacillin

• Prolonged courses (minimum 3 months) of

tetracycline, metronidazole, cotrimoxazole,

fluoroquinolones or dapsone for their anti-

inflammatory action

• Six-to-twelve week courses of the

combination of clindamycin (or doxycycline)

and rifampicin for severe disease

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Antiandrogens

Long-term oral contraceptive pill; antiandrogenic

progesterones drospirenone or cyproterone

acetate may be more effective than standard

combined pills. These are more suitable than

progesterone-only pills or devices.

Spironolactone and finasteride

Response takes 6 months or longer.

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Immunomodulatory treatments for

severe disease

Intralesional corticosteroids into nodules

Systemic corticosteroids short-term for flares

Methotrexate, ciclosporin, and azathioprine

TNFα inhibitors adalimumab and infliximab,

used in higher dose than required for psoriasis,

are the most successful treatments to date. Note

that paradoxically, they may sometimes induce

new-onset hidradenitis suppurativa

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Other medical treatments

Metformin in patients with insulin

resistance

Acitretin (unsuitable for females

of childbearing potential)

Isotretinoin – effective for acne

but appears unhelpful for most

cases of hidradenitis

Colchicine

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Surgical management of hidradenitis

suppurativa

Incision and drainage of acute abscesses

Curettage and deroofing of nodules, abscesses and

sinuses

Laser ablation of nodules, abscesses and sinuses

Wide local excision of persistent nodules

Radical excisional surgery of entire affected areaa

Nd:YAG laser hair removal

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The End