Treatment Options for Hidradenitis Suppurativa

Introduction

Hidradenitis suppurativa(HS) represents a chronic inflammatory dermatological condition manifesting with recurrent suppurative nodules, cutaneous abscesses, and subsequent development of subcutaneous fistulae with scar formation. The pathology significantly impacts psychosocial functioning due to purulent exudate and associated malodor.

The condition primarily affects apocrine-rich anatomical regions, notably the axillary, inguinal, perianal, perineal, and inframammary areas. HS exhibits significant comorbidity with metabolic syndrome, cardiovascular pathologies, inflammatory bowel disease, and axial spondyloarthropathy.

The etiopathogenesis remains incompletely elucidated, complicating therapeutic approaches. While mild cases respond to conservative management including lifestyle modification and antimicrobial therapy, moderate-to-severe disease presents significant therapeutic challenges due to refractory nature to conventional interventions.

Quality of life impact is substantial, manifesting through psychological morbidity, occupational impairment, intimate relationship dysfunction, chronic algesia, and substance use disorders. This emphasizes the necessity for expeditious diagnosis and implementation of efficacious therapeutic strategies.

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1. Lifestyle & General Management

A. Lifestyle Modifications

• Smoking cessation
• Wearing loose cotton clothing
• Weight reduction programs
• Avoiding tight undergarments, jeans, belts and bras

B. General Management Strategies

• Pain management protocols
  • Options for acute pain during flare-ups include topical resorcinol, topical diclofenac, acetaminophen, ibuprofen, naproxen, intralesional corticosteroid injections, incision and drainage, and tramadol.
• Specialized wound care: Recommended dressings should be absorbent, non-irritating, and have antibacterial properties
• Psychological support systems

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2. Medical Treatment Options

A. Topical Treatments

• Clindamycin 1% solution twice daily.
• Resorcinol 15% preparation twice daily
• Medicated skin cleansers: 4% chlorhexidine solution

B. Intralesional Therapy

• Triamcinolone injections for solitary inflammatory nodules.
• Botulinum toxin (BTX) injections, primarily used for axillary hyperhidrosis, may benefit HS patients by reducing sweating and inflammation.

C. Systemic Antibiotics

• Treatment Protocols:

1. Doxycycline: 50-100mg twice daily initially for 3 months.
2. Combined therapy:
   • Clindamycin 300mg twice daily
   • Rifampicin 600mg daily
   • Duration: 12 weeks
3. Triple therapy:
   • Moxifloxacin 400mg daily
   • Rifampicin 10mg/kg daily
   • Metronidazole 500mg thrice daily
   • Duration: up to 12 weeks

D. Hormonal Therapy

Hormonal therapy is often considered for female HS patients due to the potential role of androgens in HS development.

• Spironolactone :100-150 mg daily
• Cyproterone Acetate: 25-50 mg daily.
• Finasteride: 1.25-10 mg/day.
• Metformin: 500 mg 2-3 times daily.
• Oral Contraceptives (OCPs): ethinylestradiol 30–50 mg once daily.

E. Biologic Therapy

• Treatment Regimens:

1. Adalimumab(FDA-approved):
   • Week 0: 160mg subcutaneous
   • Week 2: 80mg subcutaneous
   • Maintenance: 40mg weekly
2. Secukinumab(FDA-approved):
   • Initial: 300mg weekly for 5 weeks
   • Maintenance: 300mg every 4 weeks
3. Anakinra:
   • 100 mg daily for 12 weeks.
4. Infliximab:
   • Initial: 5 mg/kg intravenously at weeks 0, 2, and 6.
   • Maintenance: every 6–8 weeks, depending on patient response and tolerance.

F. Other treatment options

• Retinoids
  • Acitretin: Not recommended for women of childbearing age, as pregnancy should be avoided for up to three years after stopping treatment.
  • Isotretinoin(limited efficacy)
• Cyclosporine
• Methotrexate
• Zinc gluconate 45- 90 mg (taken with food) and copper 2- 4 mg (supplements should be taken separately, at different times).

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3. Surgical Interventions

• Incision and drainage
• Deroofing technique
• Complete excision
• Laser therapy: Nd:YAG or CO₂
• Laser hair removal.

Hidradenitis Suppurativa Patient Visit Checklist

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References

• Essentials of hidradenitis suppurativa: a comprehensive review of diagnostic and treatment perspectives.[link]
• Current Medical and Surgical Treatment of Hidradenitis Suppurativa—A Comprehensive Review[link]
• Hidradenitis suppurativa (syn. acne inversa).[link]
  

#Treatment Options for Hidradenitis Suppurativa