Hidradenitis suppurativa
Hidradenitis suppurativa ( HS ) is a chronic , inflammatory , recurrent debilitating disease of the hair follicle that usually presents after puberty with painful , deep-seated , inflamed lesions in the apocrine gland bearing areas of the body , most commonly the axilla , inguinal and anogenital regions Also known as Verneuil’s disease or acne inversa
Epidemiology- Prevalence appears to be 1 % to 4 % of the general population Occurs more commonly in women ( reports controversial ) Females more likely to have a family history and men had a tendency for more severe disease and associated acne Disease of the young- average age at presentation is 26 yrs for ♀ and 31 for ♂ No racial predilection
Cause- Cause unclear – complex disease Multifactorial and various factors can play a role as ○ occlusion of the apocrine duct by a keratinous plug ○ defects of follicular epithelium and bacterial overgrowth ○ role of hormones- happens after puberty and can flare with menstrual cycle ○ smoking – role of nicotine ○ autoimmune – associated with certain disorders as thyroid disease , Inflammatory bowel disease, Sjogren’s syndrome Acne vulgaris Obesity Athletes Genetic component Host defense defects Chemical irritants ( eg deodorants ) and mechanical irritation ( depilation , shaving ) Heat ( ↑ in summer ) Oral contraceptive pill Zinc deficiency – may predispose
Disease burden- Chronic disabling disorder Relentless progression and can cause keloids , contractures & immobility Disease can progress to scarring and sinus formation Distressing , recurrent disease that impairs quality of life – sig psychological impact Risk of depression , sexual impairment Often misdiagnosed and patients undergo repeat and unnecessary investigations
Hurley staging- Stage 1 – abscess formation single or multiple without sinus tracts or scarring Stage 2 – recurrent abscesses with tract formation and cicatrisation , single or multiple , widely separated lesions Stage 3 – diffuse or near-diffuse involvement or multiple interconnected tracts and abscesses across the entire area
Disease classification – consider using Hurley staging – treatment will depend on disease severity.Often poor response to previous antibiotic therapy
Pyoderma Arthritis Inflammatory bowel disease- eg Crohn’s Sponyloarthropathy Anaemia Metabolic syndrome
Pain management Weight loss Smoking cessation Treatment of superinfection Dressings if suitable Warm compresses Screen for depression
Hidradenitis complications – Contractures and reduced mobility Sinus tracts , fistula , scarring Squamous cell carcinoma Lymphoedema Localised infection / cellulitis Chronic pain Systemic amyloidosis Possibly anaemia
Consider referring early as treatment often multidisciplinary – aim is to prevent or limit scarring. A recent high-quality cross sectional study of more than 40,000 patients and meta analysis of prior studies suggests a 1.5 to 3 fold risk of type 2 diabetes in patients with HS , with a prevalence of up to 30 %. Patients with physical signs of diabetes , hypertension, obesity , and / or hyperlipidaemia are at a higher risk and should be screened. Risk of PCOS is also increased significantly.
Clindamycin topical ( first line ) Metronidazole topical Chlorhexidine topical Hexachlorophene topical Dermol 500 lotion wash Tetracycline 500 mg bd for 2 months PCDS suggests Lymecycline 408 mg od Doxycyline 100 mg bd for 2 months Minocycline 100 mg bd for 2 months Combination therapy Clindamycin 300 mg bd + Rifampicin 300 mg bd for 3 months ( PCDS ) Flucloxacillin can be used as a short course for acute flare ups ( BAD )
OTHER TREATMENT OPTIONS AS PER BAD GUIDELINES Combination treatment if no response to initial treatment with oral tetracycline Acitretin ( specialist use ) Dapsone ( specialist use ) Metformin consider for those who have diabetes and HS or in females with HS and PCOS/ pregnancy
LINKS AND RESOURCES
PATIENT INFORMATION
BAD leaflet on HS http://www.bad.org.uk/shared/get-file.ashx?id=88&itemtype=document
Dermnet NZ on HS –https://dermnetnz.org/topics/hidradenitis-suppurativa/
HS Foundation with resources for patients and professionals https://www.hs-foundation.org/
HS Trust for patients in UK https://www.hstrust.org/
British Skin Foundation on HS https://www.britishskinfoundation.org.uk/hidradenitis-suppurativa
FURTHER READING FOR CLINICIANS
Canadian Family Physician on HS https://www.cfp.ca/content/cfp/63/2/114.full.pdf
BAD guideline on management of HS https://www.ncbi.nlm.nih.gov/pubmed/30552762
A comparison of international management guidelines on HS https://www.karger.com/Article/FullText/503605
North American clinical management guidelines for hidradenitis suppurativa: A publication from the United States and Canadian Hidradenitis Suppurativa Foundations https://www.jaad.org/article/S0190-9622(19)30367-6/fulltext
European S1 guideline on management of HS https://www.epgonline.org/uk/guidelines/european-s1-guideline-for-the-treatment-of-hidradenitis-suppurativa-acne-inversa.html
References
- Diagnosis and management of hidradenitis suppurativa BMJ 2013 ; 346 ;f2121
- Medscape Hidradenitis Suppurativa Aug 2017 Marina Jovanovic et al https://emedicine.medscape.com/article/1073117-overview
- Ingram, John R et al. “Interventions for hidradenitis suppurativa.” The Cochrane database of systematic reviews vol. 2015,10 CD010081. 7 Oct. 2015, doi:10.1002/14651858.CD010081.pub2
- Ingram JR. Interventions for Hidradenitis Suppurativa: Updated Summary of an Original Cochrane Review. JAMA Dermatol. 2017;153(5):458–459. doi:10.1001/jamadermatol.2017.0432)
- BMJ Best Practice Hidrandeitis suppurativa https://bestpractice.bmj.com/topics/en-gb/1047
- Zouboulis, C., Desai, N., Emtestam, L., Hunger, R., Ioannides, D., Juhász, I., Lapins, J., Matusiak, L., Prens, E., Revuz, J., Schneider‐Burrus, S., Szepietowski, J., van der Zee, H. and Jemec, G. (2015), European S1 guideline for the treatment of hidradenitis suppurativa/acne inversa. J Eur Acad Dermatol Venereol, 29: 619-644. doi:10.1111/jdv.12966
- RACGP Hidradenitis suppurativa – Management , comorbidities and monitoring https://www.racgp.org.au/afp/2017/august/hidradenitis-suppurativa-management-comorbidities-and-monitoring/
- Gulliver, Wayne et al. “Evidence-based approach to the treatment of hidradenitis suppurativa/acne inversa, based on the European guidelines for hidradenitis suppurativa.” Reviews in endocrine & metabolic disorders vol. 17,3 (2016): 343-351. doi:10.1007/s11154-016-9328-5
- Hidradenitis Suppurativa : A Treatment Challenge
- First Consult Hidradenitis Suppurativa April 2011
- Hidradenitis suppurativa : Treatment of Skin Disease : Comprehensive Therapeutic Strategies , 101 , 314-315
- Yuan JT, Naik HB. Complications of hidradenitis suppurativa. Seminars in Cutaneous Medicine and Surgery. 2017 Jun;36(2):79-85. DOI: 10.12788/j.sder.2017.022.
- Hidradenitis suppurativa (syn. acne inversa) Primary Care Dermatology Society via http://www.pcds.org.uk/clinical-guidance/hidradenitis-suppurativa#management
- Ingram, J., Collier, F., Brown, D., Burton, T., Burton, J., Chin, M., Desai, N., Goodacre, T., Piguet, V., Pink, A., Exton, L. and Mohd Mustapa, M. (2019), British Association of Dermatologists guidelines for the management of hidradenitis suppurativa (acne inversa) 2018. Br J Dermatol, 180: 1009-1017. doi:10.1111/bjd.17537
- North American clinical management guidelines for hidradenitis suppurativa: A publication from the United States and Canadian Hidradenitis Suppurativa Foundations Alikhan, Ali et al. Journal of the American Academy of Dermatology, Volume 81, Issue 1, 91 – 101 https://plu.mx/plum/a/?doi=10.1016/j.jaad.2019.02.068
- Schmitt, Juliano Vilaverde et al. “Risk factors for hidradenitis suppurativa: a pilot study.” Anais brasileiros de dermatologia vol. 87,6 (2012): 936-8. doi:10.1590/s0365-05962012000600024