Dermatologic Manifestations of Hidradenitis Suppurativa Treatment & Management

  • Author: Marina Jovanovic, MD, PhD; Chief Editor: Dirk M Elston, MD   more...
 
Updated: Jan 14, 2011
 

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 (see Surgical Care).[28] 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
  • Medical anti-inflammatory or antiantiandrogen therapy such as tetracycline, intralesional triamcinolone, or finasteride
  • Biologic therapy

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.[57] 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.[19]

Nonablative radiofrequency therapy can be used for patients with Harley stage I and II.[58]

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.[27]

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Surgical Care

Surgery is the sine qua non treatment, especially in chronic hidradenitis suppurativa. Wide surgical excision, with margins well beyond the clinical borders of activity, remains the most definitive surgical therapy.[28, 59, 60] With this technique, sufficient resection of the lesion is the most important issue.[61] Surgery has hitherto been considered a curative treatment, but specific studies have suggested otherwise. Although recurrence rates may be lower with surgery that is more aggressive, recurrences continue.[12, 62] After radical excision, the disease recurred in 33% of the patients.[62] Surgery is most valuable in the chronic and recurrent stages of hidradenitis suppurativa.[28, 61]

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.[63]

Nonsurgical procedures are only supportive, but they are important either before or after surgery.[28, 33, 61, 64] If the disease is diagnosed and treated early, secondary systemic complications can be prevented and the extent of surgery can be limited.[61]

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.[20, 21] Patients should be warned that new lesions may develop at a site that was not apparent at the time of their initial surgery.[33]

Numerous helpful and relatively minor surgical techniques include drainage; exteriorization; 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.[53, 65, 66]

  • 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.[41] Deroofing of sinus tracts and curettage of fistulous tracts have distinct roles as preliminary treatments before more definitive intervention, particularly in the acute phase of perianal disease. 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.[66]
  • 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.[61]
  • 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. It also obviates diversion with or without proctectomy.[67]
  • 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.[68] Carbon dioxide laser treatment should be considered as a treatment option in patients with Harley stage II.[69]

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.[61] 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.[53, 70] However, in lesions that cannot be completely resected, the use of a musculocutaneous flap is recommended.[65] 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.[71] 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.[61]
  • 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.[16, 20]
  • A report on 5 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.[72]

Recurrence after surgery is likely if excision is inadequate or if the distribution of apocrine glands is unusually wide.[16, 61, 65] 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.[16] An overall recurrence rate of 2.5% has been estimated after wide surgical excision, with a median postoperative follow-up of 36 months.[61]

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Diet

Patients who are obese should be advised to lose weight.[28]

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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.[15, 28]

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Contributor Information and Disclosures
Author

Marina Jovanovic, MD, PhD  Chief of Dermatology Ward and Contact Dermatitis Investigative Unit, Clinic of Dermatoveneroleogic Diseases, Clinical Center, Novi Sad, Serbia; Professor in Dermatology, Medical Faculty, University of Novi Sad, Vojvodina, Serbia

Disclosure: Nothing to disclose.

Coauthor(s)

George Kihiczak, MD  Clinical Associate Professor, Department of Dermatology, New Jersey Medical School and University Hospital

George Kihiczak, MD is a member of the following medical societies: American Academy of Dermatology, American Medical Association, and Medical Society of New Jersey

Disclosure: Nothing to disclose.

Robert A Schwartz, MD, MPH  Professor and Head, Dermatology, Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health, UMDNJ-New Jersey Medical School

Robert A Schwartz, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American College of Physicians, and Sigma Xi

Disclosure: Nothing to disclose.

Specialty Editor Board

Daniel Mark Siegel, MD, MS  Director, Procedural Dermatology Fellowship Program, Clinical Professor of Dermatology, Department of Dermatology, State University of New York Downstate

Daniel Mark Siegel, MD, MS is a member of the following medical societies: American Academy of Dermatology, American College of Mohs Micrographic Surgery and Cutaneous Oncology, American College of Physician Executives, American Society for Dermatologic Surgery, American Society for MOHS Surgery, and International Society for Dermatologic Surgery

Disclosure: Nothing to disclose.

David F Butler, MD  Professor of Dermatology, Texas A&M University College of Medicine; Chair, Department of Dermatology, Director, Dermatology Residency Training Program, Scott and White Clinic, Northside Clinic

David F Butler, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, American Society for Dermatologic Surgery, American Society for MOHS Surgery, Association of Military Dermatologists, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Jeffrey J Miller, MD  Associate Professor of Dermatology, Penn State University College of Medicine; Staff Dermatologist, Penn State Milton S Hershey Medical Center

Jeffrey J Miller, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, Association of Professors of Dermatology, North American Hair Research Society, and Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Catherine M Quirk, MD  Clinical Assistant Professor, Department of Dermatology, University of Pennsylvania

Catherine M Quirk, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Dermatology

Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD  Director, Department of Dermatology, Geisinger Medical Center

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

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Vulvar hidradenitis suppurativa.
Vulvar and inguinal indurations.
Sinus tract.
Draining sinus tract.
Axillary hidradenitis suppurativa in a patient with pyoderma gangrenosum.
Close-up view of axillary hidradenitis suppurativa in a patient with pyoderma gangrenosum.
Submammary hidradenitis suppurativa in a patient with pyoderma gangrenosum.
Double-ended-comedones. Hidradenitis suppurativa in a patient with pyoderma gangrenosum.
Inguinal hidradenitis suppurativa in a patient with pyoderma gangrenosum.
Close-up view of inguinal hidradenitis suppurativa in a patient with pyoderma gangrenosum.
Pyoderma gangrenosum in a patient with hidradenitis suppurativa.
Close-up view of pyoderma gangrenosum in a patient with hidradenitis suppurativa.
Coexisting hidradenitis suppurativa and pyoderma gangrenosum.
Coexisting hidradenitis suppurativa and pyoderma gangrenosum.
Hidradenitis suppurativa in a patient with pyoderma gangrenosum.
 
 
 
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