Hidradenitis Suppurativa

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Hidradenitis Suppurativa

• B. Wayne Blount, MD, MPH

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Objectives

• List the diagnostic criteria for Hidradenitis
  Suppurativa (HS)
• Know the usual presentation for HS
• List the pertinent parts of the focused history
  P.E. for HS
• Name the severity assessment stages of HS
• Name the 1st line treatment options for HS
• List some of the alternative treatments for HS

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Definition

• A chronic disease characterized by chronic or
  recurrent abscesses, sinus tracts and scarring of
  apocrine gland-bearing skin
• Prevalence of
• 1

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• Can occur in children, BUT most often appears
  after puberty
• Rare among aged
• Prognosis is poor, as one hallmark is chronicity

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Where is apocrine gland-bearing skin ?
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Diagnostic Criteria

• Typical lesions
• Typical topography
• Chronicity and recurrences

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Typical lesions

• Deep-seated painful nodules
• Abscesses
• Draining sinuses
• Bridged scars
• Open comedones

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Painful Nodules
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Abscess
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Draining Sinus
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Bridged Scars
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Open Comedones
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Diagnostic Criteria

• Typical lesions
• Typical topography
• Chronicity and recurrences

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Typical Topography

• Axillae
• Groin
• Perineum
• Perianal
• Buttocks
• Infra- Inter- mammary folds

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Axillae
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Groin
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Perineum Perianal
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Buttocks
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Mammary Folds
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Etiology

• Unknown
• An orphan disease
• Several hypotheses none proven

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Risk Factors

• Smoking
• Overweight
• Female preponderance
• Routine cultures are most often negative.
• In abscesses, numerous bacteria are recovered

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Diagnostic Criteria

• Typical lesions
• Typical topography
• Chronicity and recurrences

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Diagnosis ?

• Recurrent boils in last 6 months?
• In Armpits or groin?

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Clinical Presentation

• Classified into primary and secondary lesions
• Primary Solitary nodules, boils or abscesses
• Secondary Sinuses, Scars. result from
  repetitive attacks

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Clinical Presentation

• Multifocal often subclinical in predisposed
  areas

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Differential Diagnoses

• Carbuncles
• Furuncles
• Bartholins abscess
• Epidermal cysts
• Lymphogranuloma venereum
• Nodular acne
• Pilonidal Cyst
• Crohns

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Complications

• Acute infections
• Lymphatic obstruction
• Squamous cell carcinoma
• Depression
• Anemia
• Malaise
• Fistuale

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Severity Assessment

• Hurley stages based on degree of inflammation
  fibrosis
• Hurley stage 1 Abscess(es) without sinuses or
  scarring
• Hurley 2 recurrent abscesses with tract
  formation scarring
• Hurley 3 Multiple interconnected tracts
  abscesses thruout an entire area

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Hurley Stage 1
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Hurley Stage 2
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Hurley Stage 3
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Hurley Stage 3
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Sartorius Score

• Based on of regions involved, number of lesions
  of types of lesions, Distance between 2
  lesions, if all lesions are separated by normal
  skin.

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• Dont forget to ask the patient how much pain
  there is and their quality of life of flares

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Treatment

• Medical
• Topical
• Systemic
• Surgical
• Traditional
• Laser
• Other

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MedicalTopical

• Clindamycin B Rec
• 15 Resorcinol peels C Rec
• Intralesional TAC C Rec for single lesions

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MedicalSystemic

• Clindamycin Rifampicin (both 300 mg BID X 3
  months) B Rec
• TCN 500 mg BID x 3 months B Rec
• Immunosupressants
• Steroids B Rec, but get rebound flares when
  stopped
• Cyclosporine B Rec
• TNF-a inhibitors B Rec, Etanercept, adalimumab,
  Infliximab
• Methotrexate D Rec

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MedicalSystemic

• Dapsone B Rec
• Anti-androgens C Rec
• Isotretinoin D Rec

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Surgical

• The principal treatment for chronic, relapsing
  severe HS B Rec
• The wider the excision, the better C Rec
• Healing by 2ndary intention is better C Rec
• HS is a generalized disease at onset, so will get
  recurrences at sites in regions no6t
  surgerized.

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Surgical

• Laser More appropriate for intermediate
  severity B Rec

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Other Treatments

• Oral Zinc Salts (90 mg of zinc gluconate) B Rec
  for Hurley Stages 1 2
• Botulinum B Rec
• Cryotherapy D Rec
• Radiotherapy C Rec, afetr others have failed
• Smoking cessation A Rec
• Weight loss A Rec

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Treatment

• Varies with disease severity, frequency of
  exaccerbations and patient goals.
• Multimodal therapy is usual
• Stage 1 or early disease (no or little scarring)
  topical clindamycin BID
• 1 lesion at a time localized surgery or topical
  medical Rx

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Treatment

• This is a chronic disease
• Cannot just I D put on 10 day course of ABX
• Manage expectations
• Follow Up and shared decision-making

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Treatment

• Intermediate severity
• Systemic medical and consider surgery

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Treatment

• Severe disease use all options as needed

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Summary

• Chronic disease
• Diagnostic criteria
• Severity assessment
• Treatment guided by severity
• Relatively poor outcomes