Hidradenitis Suppurativa Treatment & Management

Updated: May 19, 2016
  • Author: Marina Jovanovic, MD, PhD; Chief Editor: William D James, MD  more...
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Treatment

Medical Care

The ideal treatment of hidradenitis suppurativa (HS) should provide a high likelihood of cure with a low recurrence rate, as well as minimal inconvenience and loss of work time. Medical management is recommended in early stages, whereas surgery should be performed as early as possible after the formation of abscesses, fistulas, scars, and sinus tracts [5] (see Surgical Care). Treatment may include the following:

  • Local hygiene and ordinary hygiene
  • Weight reduction in patients who are obese
  • Use of ordinary soaps and antiseptic and antiperspirant agents (eg, 6.25% aluminum chloride hexahydrate in absolute ethanol)
  • Application of warm compresses with sodium chloride solution or Burow solution
  • Wearing of loose-fitting clothing
  • Laser hair removal
  • Cessation of cigarette smoking
  • Medical anti-inflammatory or antiandrogen therapy such as oral or topical antibiotics, intralesional triamcinolone, spironolactone, or finasteride
  • Biological therapy

In one study, nearly one quarter of patients were unable to list any measure that helped their condition, despite an average disease duration of nearly 19 years. This outcome indicates that the available treatments for hidradenitis suppurativa are, on the whole, still unsatisfactory. Surgical approaches, which were used in almost half the patients, were included in those treatments. [4]

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Surgical Care

Surgery is necessary at times, especially in chronic hidradenitis suppurativa. Wide surgical excision, with margins well beyond the clinical borders of activity, remains the most definitive surgical therapy. [5] With this technique, sufficient resection of the lesion is the most important issue. [7] Although recurrence rates may be lower with surgery that is more aggressive, recurrences continue. [10, 11] After radical excision, the disease recurred in 33% of the patients. [11] Surgery is most valuable in the chronic and recurrent stages of hidradenitis suppurativa. [5, 7]

More limited surgical intervention consisting of unroofing abscesses and sinus tracts, with vigorous curettage of the base, and secondary-intention healing can be valuable in some cases.

Electrosurgery should be considered a top alternative in the treatment algorithm of hidradenitis suppurativa. [80]

Nonsurgical procedures are only supportive, but they are important either before or after surgery. [5, 44, 7, 81] If the disease is diagnosed and treated early, secondary systemic complications can be prevented and the extent of surgery can be limited. [7]

Radical surgery is considered by many to be the only cure for hidradenitis suppurativa, although a cure can be achieved only in the particular area excised. [34] Patients should be warned that new lesions may develop at a site that was not apparent at the time of their initial surgery. [44]

Relatively minor surgical techniques

Numerous helpful and relatively minor surgical techniques include drainage; exteriorization; Nd:YAG laser treatment; curettage; electrocoagulation of the sinus tracts; simple excision of the troublesome areas with direct closure; placement of local cutaneous flaps, musculocutaneous flaps, pedicled and free flaps, or skin grafts; and secondary-intention healing. [13, 14, 15]

Local incision and drainage of purulent lesions are often required in the acute phase, and, although these procedures are helpful in providing short-term relief, recurrent inflammation is almost inevitable. [71] Deroofing of sinus tracts and curettage of fistulous tracts have distinct roles as preliminary treatments before more definitive intervention, and are especially suited for recurrent hidradenitis suppurativa lesions at fixed locations in Hurley I or II stage, particularly in the acute phase of perianal disease. [1] An alternative surgical approach may be used in so-called bridging lesions. These lesions have 2 distant cutaneous orifices connected by a subcutaneous fistula. Periorificial fusiform skin incisions are made parallel to the skin folds, followed by a viral blue dye injection for accurate visualization of the fistula tract, and the subcutaneous tubular fibrotic tissue is completely removed en bloc. [15]

When disease is chronic and extensive, removal of the affected area and the adjacent apocrine glandular zone to 2 cm beyond the diseased portion is the best option to minimize recurrence. The block of tissue excised should be adequately wide and sufficiently deep. To ensure that the deep coils of the apocrine gland are removed, the subcutaneous tissue down to the deep fascia, or at least 5 mm of subcutaneous fat, should be excised. The extent of the sinus tracts is intraoperatively marked by injecting 3-5 mL of a methyl-violet solution. Complete surgical excision is achieved when all color-coded areas are fully removed. In cases where blue-stained areas occurred in the operative field, further re-excisions must be performed to ensure complete clearance. [7]

Minor procedures can include exteriorization and laying open of tracts and electrocoagulation and excision and primary closure (eg, the Pollock procedure). [82] Total wide excision with healing by secondary intention or with the use of flaps and grafts can also be considered. Skin grafts could include Thiersch split-thickness grafts, meshed grafts, or Wolfe full-thickness grafts. [83, 84] Flaps could include rotation flaps or free flaps. [85, 86]

Surgical excision using the carbon dioxide laser and second-intention healing are often associated with good results and minimal complications. Healing usually occurs in 4-8 weeks. Use of the laser procedure is now advocated in patients with severe perianal hidradenitis suppurativa and the complex perianal fistula disease (PAD). With the carbon dioxide laser, lesions are ablated by vaporizing the tissue in layers until all macroscopically abnormal tissue is removed. This method effectively eradicates septic tracts and pockets while preserving sphincter function. The lesions are vaporized from the inside and out until surrounding healthy tissue is reached, superficially and deep. In this way, the technique can be tissue sparing and at the same time radical. [1] It also obviates diversion with or without proctectomy. [87]

Moreover, scanner-assisted carbon dioxide laser makes ablation quicker, smoother, and more precise and allows for early treatment of hidradenitis suppurativa lesions that were previously managed with less effective local conservative remedies. [88] Carbon dioxide laser treatment should be considered as a treatment option in patients with Hurley stage II. [89]

The goal of surgery is to achieve complete removal of lesional tissue, but it is important to spare as much healthy tissue as possible to prevent the formation of serious contractures. In order to gain both goals the Skin-Tissue sparing Excision with Electrosurgical Peeling (STEEP) procedure was developed. Wide excisions reach into the healthy deep subcutaneous fat, but the STEEP procedure with its successive tangential transsections leaves the epithelialized bottoms of the sinus tracts and a large extent of the subcutaneous fat intact, leading to more superficial and smaller defects. STEEP is done with the patient under general anesthesia. For the performance of the multiple transversal sections, electrosurgery has some important advantages over the carbon dioxide laser, since transversal electrosection is more easily controlled and adjusted by the surgeon. This leaves the epithelialized sinus bottom intact and allows deep excision of fibrotic and inflammatory tissue at the same time, while a carbon dioxide laser removes a continuous horizontal plane of one depth, making it less precise and less tissue sparing. [9]

A prospective, randomized, controlled study for patients with stage II to III hidradenitis suppurativa was designed in order to assess the 1064-nm Nd:YAG laser effectiveness in the treatment for hidradenitis suppurativa. After a 3-month laser session was administrated, the percentage change in severity of the disease from baseline was significant for all anatomic sites combined and each individual anatomic site as well. Thus, the effectiveness of this hair epilation device supports the primary follicular pathogenesis of hidradenitis suppurativa. [16] More research is needed before Nd:YAG laser can be established as a standard treatment for hidradenitis suppurativa. [1]

Other techniques

Adequate excision to eradicate the disease often results in a defect that precludes primary closure; therefore, other techniques must be used to achieve wound healing.

The method of reconstruction depends on the size and the location of the defect. [7] In lesions that can be completely resected, the surgical procedure to cover the lesions should be selected to suit the size and the site of the defect. Negative-pressure dressings are particularly useful in the treatment of wounds requiring closure with skin grafts. [13, 90] However, in lesions that cannot be completely resected, the use of a musculocutaneous flap is recommended. [14] A reliable musculocutaneous perforator flap based on the musculocutaneous branches of the thoracodorsal vessels is very suitable for covering the axillary vessels and aesthetics of the axilla, [91] the option of choice for recurrent disease. [1] If the defect is too large for primary suturing or local cutaneous flaps, it can be covered with polyurethane foam sheets to induce formation of granulation tissue. [7]

Although accurate comparative assessment of the various surgical approaches is difficult because of the incomplete reporting of long-term results and the limited number of controlled clinical trials, skin grafting is generally considered unsuitable in the management of inguinoperineal disease. When compared with healing by secondary intention, split-thickness skin grafting is less preferred among patients, even those with axillary disease. Those who advocate excision and healing by secondary intention claim that this technique permits adequate disease clearance and results in a cosmetically acceptable scar, superior to that obtained by skin grafting, with little limitation of movement. [12]

A report on five patients treated for stage III vulvar hidradenitis suppurativa showed that the only one patient who was managed without split-thickness skin grafting developed an introital stricture and this was the only patient who regretted undergoing surgical excision for hidradenitis suppurativa. [92]

The width of the excision, and not the wound closure technique, influence the therapeutic outcome. [28] Recurrence after surgery is likely if excision is inadequate or if the distribution of apocrine glands is unusually wide. [12, 7, 14] The recurrence rate in patients treated with radical surgery varies considerably depending on the site affected; the highest rate is 50% in the submammary region. [12] An overall recurrence rate of 2.5% has been estimated after wide surgical excision, with a median postoperative follow-up of 36 months. [7]

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Radiological Care

In one series, radiation therapy by irradiation with single doses of 0.5-1.5 Gy to total doses of 3.0-8.0 Gy was given as a treatment option for hidradenitis suppurativa. [93] The use of x-rays in depilating doses to achieve temporary epilation has been suggested. The possible beneficial effects of laser epilation do, however, suggest that hair removal may be of independent importance. [33]

Nonablative radiofrequency therapy can be used for patients with Harley stage I and II. [17]

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Diet

Patients who are obese should be advised to lose weight. [5]

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Activity

Some patients can obtain relief from their condition by making certain lifestyle changes and by engaging in activities such as swimming, bathing, avoiding smoking, and wearing loose-fitting clothing. [4, 5] In order to relieve symptoms, avoidance of excessive heat and humidity, which are known triggers, by staying indoors in air conditioning can be helpful. Other potential triggers, although not causative factors, include the use of deodorants, shaving, and depilation. [5]

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Complications

Complications of hidradenitis suppurativa include local and systemic infections resulting from the spread of microorganisms [94] and, in rare cases, septicemia. Other complications may include the following:

  • Restricted mobility of the limbs resulting from marked fibrosis and scarring may occur, particularly with axillary disease. [35]
  • With perianal disease, anal fistula formation is common. Although the etiology of anal fistulas remains unknown, the infection theory is widely accepted. Repeated or persistent abscess formation in the anal glands between the external and internal sphincters may be required for fistula formation. [91] Rectal and urethral fistulas are rare. [63]
  • Swelling and elephantiasis nostras that occur after streptococcal infection may be superimposed on hidradenitis suppurativa lesions, leading to severe enlargement and distortion of the external genitalia. [71]
  • In male patients, severe ulcerative genital disease can cause destruction of the prepuce. [95]
  • Chronic inflammatory reactions, such as anemia, proteinuria, hypoproteinemia, amyloidosis, interstitial keratitis, and renal disease, rarely occur. [63, 71]
  • It was shown by standard incidence rate (SIR) that hidradenitis suppurativa patients have a higher overall incidence of cancer (SIR = 1.5; 1.1-1.8) compared with the general population. The incidence of nonmelanoma skin cancer (SIR = 4.6; 1.5-10.7), buccal (SIR = 5.5; 1.8-12.9), and hepatic cancer (SIR = 10.0; 2.1-29.1) was increased. [96]
  • Squamous cell carcinoma (SCC) is a rare but serious consequence. Most SCCs occur in men and in the anogenital region, perhaps because these tumors are hard to detect. SCC tumors show endophytic growth along the sinus tracts once they occur. Most patients with SCC have a history of hidradenitis suppurativa for 10 years or longer; the prevalence of SCC among patients with perianal hidradenitis suppurativa lasting 20-30 years is approximately 3.2%. [97] The diagnosis of perianal SCC is often delayed owing to chronic scarring and the endophytic nature of its growth pattern. Metastases and death may result.
  • The first case of vulvar SCC as a complication of hidradenitis suppurativa was reported in the English-language literature in 1999. [31] All 5 previously reported cases of SCC with hidradenitis suppurativa in women involved the buttocks or the perianal region. Maclean and Coleman suggest that hidradenitis suppurativa arising in extra-axillary sites is a premalignant condition and that it should not be treated conservatively. [98] SCC that arises in chronically scarred and inflamed skin (Marjolin ulcer) tends to be more aggressive than that resulting from actinic damage, and it is associated with local invasion or recurrence after excision, distant metastasis, and a higher mortality rate. [99]
  • Attention should also be given to the development of anal cancer.
  • The draining sinus tract is a late complication of hidradenitis suppurativa and leads to extensive periodically inflamed lesions that are lined by a variably thickened stratified epithelium.
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