eMedicine Specialties > Dermatology > Diseases of the Adnexa

Hidradenitis Suppurativa: Treatment & Medication

Author: Marina Jovanovic, MD, PhD, Chief of Dermatology Ward and Contact Dermatitis Investigative Unit, Clinic of Dermatoveneroleogic Diseases, Clinical Center, Novi Sad, Serbia and Montenegro; Associate Professor in Dermatology, Medical Faculty, University of Novi Sad, Vojvodina, Serbia and Montenegro
Coauthor(s): George Kihiczak, MD, Clinical Associate Professor, Department of Dermatology, New Jersey Medical School and University Hospital; 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
Contributor Information and Disclosures

Updated: Aug 17, 2009

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 (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.72 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.73
  • 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

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.28,74,75 With this technique, sufficient resection of the lesion is the most important issue.76 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.12,77 After radical excision, the disease recurred in 33% of the patients.77 Surgery is most valuable in the chronic and recurrent stages of hidradenitis suppurativa.28,76

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.78

Nonsurgical procedures are only supportive, but they are important either before or after surgery.28,33,76,79 If the disease is diagnosed and treated early, secondary systemic complications can be prevented and the extent of surgery can be limited.76

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.68,80,81

  • 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.62 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.81
  • 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.76
  • 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.82
  • 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.83 Carbon dioxide laser treatment should be considered as a treatment option in patients with Harley stage II.84

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.76 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.68,85 However, in lesions that cannot be completely resected, the use of a musculocutaneous flap is recommended.80 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.86 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.76
  • 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.87  

Recurrence after surgery is likely if excision is inadequate or if the distribution of apocrine glands is unusually wide.16,76,80 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.76

Diet

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

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

Medication

Treatment of hidradenitis suppurativa remains a considerable challenge. Therapeutic options for hidradenitis suppurativa were long restricted to the use of local disinfectants and systemic antibiotics, as well as repeated incision and drainage, which produce only short-term benefits. 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).80

Treatment should be individualized according to the state and extent of the disease. Absolute cessation of smoking is essential in the treatment of hidradenitis suppurativa. Management with antibiotics or other medications may relieve early symptoms, but radical surgery may be necessary for control and prevention of recurrence.75
 
Alikhan et al suggest a treatment algorithm based upon the Hurley classification or a tiered approach. For patients in Hurley stage I, antibiotics and intralesional injections of corticosteroids represent a good first-line therapy, while flares should be treated with short courses of systemic corticosteroids. If this regimen fails, zinc, or, in females of non-childbearing age, antiandrogen, therapy may be effective. Long-term immunosuppressive therapy or surgical therapy may be required in some patients. For patients in Hurley stage III, wide excision may prove to be the only effective treatment.28

Cryotherapy has also been used as adjunctive therapy. In draining sinuses, cryotherapy works by accelerating the resorption of the inflammation. However, patients must be warned about pain, prolonged healing time, and risk of infection after the procedure, and they must be informed that the treatment is unlikely to influence disease progression.88

Antibiotics

Acute episodes and relapses of hidradenitis suppurativa should be treated as bacterial infections. Mild topical steroid creams in combination with topical antibiotics in the aminoglycoside group, such as clindamycin 2% solution, gentamicin collagen sponge, and erythromycin 3% gel, have been favored.81,89 Some authors advocate long-term treatment with systemic antibiotics (eg, tetracycline, minocycline, clindamycin, erythromycin in combination with metronidazole), but long-term outcomes are often poor.27,28


Tetracycline (Panmycin, Sumycin, Tetracap)

Used to treat gram-positive and gram-negative organisms and mycoplasmal, chlamydial, and rickettsial infections. Inhibits bacterial protein synthesis by binding with 30S and possibly 50S ribosomal subunits.

Adult

250-500 mg PO q6h

Pediatric

<12 years: Not recommended
>12 years: Administer as in adults

Bioavailability decreases with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; can decrease effects of oral contraceptives, causing breakthrough bleeding and increasing risk of pregnancy; can increase hypoprothrombinemic effects of anticoagulants

Documented hypersensitivity; severe hepatic dysfunction; severe renal impairment; pregnancy; children <12 y; SLE

Pregnancy

X - Contraindicated; benefit does not outweigh risk

Precautions

Photosensitivity may occur with prolonged exposure to sunlight or tanning equipment; reduce dose in renal impairment; consider drug serum level determinations in prolonged therapy; use during tooth development (last half of pregnancy through age 8 y) can cause permanent discoloration of teeth; Fanconilike syndrome may occur with outdated tetracyclines


Doxycycline (Doryx, Vibramycin, Bio-Tab)

Inhibits protein synthesis and thus bacterial growth by binding to 30S and possibly 50S ribosomal subunits of susceptible bacteria.

Adult

200 mg PO initially, followed by 100 mg PO qd/bid

Pediatric

<12 years: Not recommended
>12 years: Administer as in adults

Bioavailability decreases with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; can increase hypoprothrombinemic effects of anticoagulants; can decrease effects of oral contraceptives, causing breakthrough bleeding and increasing risk of pregnancy

Documented hypersensitivity; pregnancy; children <12 y; SLE; severe hepatic dysfunction

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Photosensitivity may occur with prolonged exposure to sunlight or tanning equipment; reduce dose in renal impairment; consider drug serum level determinations in prolonged therapy; use during tooth development (last half of pregnancy through age 8 y) can cause permanent discoloration of teeth; Fanconilike syndrome may occur with outdated tetracyclines


Clindamycin (Cleocin)

Lincosamide for treatment of serious skin and soft tissue staphylococcal infections. Also effective against aerobic and anaerobic streptococci (except enterococci). Inhibits bacterial growth, possibly by blocking dissociation of peptidyl t-RNA from ribosomes, causing RNA-dependent protein synthesis to arrest.

Adult

150-300 mg PO q6h

Pediatric

3-6 mg/kg PO q6h

Increases duration of neuromuscular blockade induced by tubocurarine and pancuronium; erythromycin may antagonize effects; antidiarrheals may delay absorption

Documented hypersensitivity; regional enteritis; ulcerative colitis; hepatic impairment; antibiotic-associated colitis; diarrhea

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in severe hepatic dysfunction; no adjustment necessary in renal insufficiency; associated with severe and possibly fatal colitis by allowing overgrowth of Clostridium difficile


Erythromycin (E.E.S., E-Mycin, Eryc)

Inhibits bacterial growth, possibly by blocking dissociation of peptidyl t-RNA from ribosomes, causing RNA-dependent protein synthesis to arrest. In children, age, weight, and severity of infection determine proper dosage. When bid dosing is desired, half the total daily dose may be taken q12h. For more severe infections, double the dose.

Adult

250-500 mg PO q6h or 0.5-1 g PO q12h

Pediatric

<2 years: Not established
2-8 years: 250 mg PO q6h
>8 years: Administer as in adults

Coadministration may increase toxicity of theophylline, digoxin, carbamazepine, and cyclosporine; may potentiate anticoagulant effects of warfarin; coadministration with lovastatin and simvastatin increases risk of rhabdomyolysis; decreases metabolism of repaglinide, increasing serum levels and effects

Documented hypersensitivity; hepatic impairment; porphyria; liver disease (estolate)

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Caution in liver disease; estolate formulation may cause cholestatic jaundice; adverse GI effects are common (give doses pc); discontinue use if nausea, vomiting, malaise, abdominal colic, or fever occurs

Retinoids

Vitamin A derivatives have many roles. They encourage cellular differentiation, are antiproliferative, and serve as immunomodulators. Although some patients have dramatic responses to isotretinoin 1 mg/kg/d as monotherapy36 or combined with prednisolone (ie, when isotretinoin was introduced after 8 wk of prednisolone and erythromycin therapy),18 retinoids may be useful only as an adjunct to reduce inflammation before and after surgery.33,79

Results from a long-term follow-up study indicate that the response of hidradenitis suppurativa to isotretinoin is only moderate and is related to the severity of the disease.79 The dose of isotretinoin is unlikely to be important in treating hidradenitis suppurativa. Others propose that long-term treatment with isotretinoin is more successful than the usual 4- to 6-month regimen.18 Isotretinoin does not affect the size of the apocrine gland, and etretinate or acitretin (25 mg bid) may be more useful, at least in some cases. The fact that some conditions do not respond to isotretinoin, yet do respond to etretinate and acitretin, suggests that the suppression of hyperkeratinization is more important than glandular shrinkage. In parous women, a prolonged course of isotretinoin is probably a safer initial choice; however, severe complications, such as acute pancreatitis associated with hyperlipidemia, may occur, even in patients without an identifiable risk factor.90


Isotretinoin (Accutane)

Affects epidermal differentiation, especially at the follicular infundibulum. Also has immunomodulating effects. Has been used as chemoprophylaxis for skin cancers.
A US Food and Drug Administration–mandated registry is now in place for all individuals prescribing, dispensing, or taking isotretinoin. For more information on this registry, see iPLEDGE. This registry aims to further decrease the risk of pregnancy and other unwanted and potentially dangerous adverse effects during a course of isotretinoin therapy.

Adult

1 mg/kg PO qd or divided bid

Pediatric

Administer as in adults

Toxicity may occur with vitamin A coadministration; pseudotumor cerebri or papilledema may occur when coadministered with tetracyclines; may reduce plasma levels of carbamazepine

Documented hypersensitivity; breastfeeding; renal or hepatic impairment, pregnancy

Pregnancy

X - Contraindicated; benefit does not outweigh risk

Precautions

May decrease night vision; inflammatory bowel disease may occur; may be associated with hepatitis; occasional exaggerated healing response of acne lesions (excessive granulation with crusting) may occur; patients with diabetes may have difficulty controlling their blood glucose levels; avoid exposure to UV light or sunlight until tolerance achieved; discontinue treatment if rectal bleeding, abdominal pain, or severe diarrhea occur; mood swings or depression may occur; caution in patients with history of depression; avoid pregnancy

Sulfones

These agents have anti-inflammatory effects.91


Dapsone (Avlosulfon)

Bactericidal and bacteriostatic against mycobacteria; mechanism of action similar to that of sulfonamides, in which competitive antagonism of PABA prevents formation of folic acid, inhibiting bacterial growth.

Adult

100 mg PO qd

Pediatric

1-1.5 mg/kg PO qd

May inhibit anti-inflammatory effects of clofazimine; hematologic reactions may increase with folic acid antagonists (eg, pyrimethamine) (monitor for agranulocytosis during second and third month of therapy); probenecid increases toxicity; trimethoprim may increase toxicity of both drugs; concurrent rifampin may significantly decrease levels (increased renal clearance)

Documented hypersensitivity; severe anemia; G-6-PD deficiency

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Perform weekly blood cell counts (first month), then WBC counts monthly (for 6 mo), then semiannually; discontinue if hematopoiesis occurs or if platelet or leukocyte counts significantly decrease; caution in methemoglobin reductase deficiency, G-6-PD deficiency (>200 mg/d), or hemoglobin M because of high risk of hemolysis and Heinz body formation; caution in patients exposed to other agents or conditions (eg, infection, diabetic ketosis) capable of producing hemolysis; peripheral neuropathy can occur (rare); phototoxicity may occur with UV light exposure

Corticosteroids

These agents have anti-inflammatory properties and cause profound and varied metabolic effects. Corticosteroids modify the body's immune response to diverse stimuli. Intralesional injection with either a syringe or an automatic needleless injector usually decreases the size of draining sinuses. The injection of 0.05-0.25 mL of triamcinolone acetonide suspension (2.5-10 mg/mL) into each lesion is recommended for its anti-inflammatory effects. This treatment can be repeated every 2-3 weeks if necessary.29 The anti-inflammatory effects of systemic corticosteroids may be useful in acute exacerbations. Prednisolone 60 mg/d with lower maintenance doses provides some long-term control.53,54


Triamcinolone acetonide (Amcort, Aristospan Intra-Articular)

For inflammatory dermatosis responsive to steroids; decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing capillary permeability. Intramuscular injection may be used for widespread skin disorder. Intralesional injections may be used for localized skin disorder.

Adult

0.05-0.25 mL intralesionally q2-3wk

Pediatric

Administer as in adults

Coadministration with barbiturates, phenytoin, and rifampin decreases effects

Documented hypersensitivity; fungal, viral, and bacterial skin infections

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Multiple complications (eg, severe infections, hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression) may occur; abrupt discontinuation of may cause adrenal crisis


Prednisolone (Prelone)

Decreases autoimmune reactions, possibly by suppressing key components of immune system.

Adult

60 mg/d PO in single or divided doses until remission; thereafter, reduce dose to lowest amount that produces acceptable clinical response

Pediatric

Use lowest dose that produces acceptable clinical response

Decreases effects of salicylates and toxoids (for immunizations); phenytoin, carbamazepine, barbiturates, and rifampin decrease effects

Documented hypersensitivity; viral, fungal, or tubercular skin lesions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in hyperthyroidism, osteoporosis, cirrhosis, nonspecific ulcerative colitis, peptic ulcer, diabetes, and myasthenia gravis

Hormones

Combined treatment with the antiandrogen cyproterone acetate and ethinyl oestradiol has been shown to be of benefit to women with long-standing hidradenitis suppurativa. Treatment with the antiandrogen cyproterone acetate in combination with estrogen ethinyl estradiol and ethinyl estradiol in combination with the low-dose progestin norgestrel may significantly improve disease activity, especially in patients with mild forms of hidradenitis suppurativa, but many conditions do not respond to these treatments. Finasteride, a competitive inhibitor of 5-alpha reductase type II isoenzyme, may be beneficial in hidradenitis suppurativa.57


Cyproterone acetate (Androcur)

Inhibits androgen binding to target cells.

Adult

50 mg PO bid on days 5-14 of menstrual cycle

Pediatric

Not established

Documented hypersensitivity; <18 y (may arrest bone maturation); malignant and hepatic diseases; severe depression; history of thromboembolic disorders

Pregnancy

X - Contraindicated; benefit does not outweigh risk

Precautions

Caution in breastfeeding and liver function abnormalities


Ethinyl estradiol (Estinyl)

Reduces secretion of LH and FSH from pituitary gland by decreasing amount of gonadotropin-releasing hormones.

Adult

50 mcg PO qd on days 5-25 of each menstrual cycle; administer in combination with cyproterone acetate

Pediatric

Not established

May reduce hypoprothrombinemic effects of anticoagulants; coadministration of barbiturates, rifampin, and other agents that induce hepatic microsomal enzymes may reduce estrogen levels; may increase corticosteroid levels; use with hydantoins may cause spotting, breakthrough bleeding, and reduced contraceptive effectiveness; increased fluid retention caused by estrogen intake may reduce seizure control; antibiotics may alter GI flora and reduce absorption of oral contraceptives, reducing their effectiveness

Documented hypersensitivity; thrombophlebitis; undiagnosed vaginal bleeding

Pregnancy

X - Contraindicated; benefit does not outweigh risk

Precautions

May interfere with thyroid function test results and serum cortisol test results by increasing concentrations of hormone binding; caution in hepatic impairment, migraine, seizure disorders, cerebrovascular disorders, breast cancer, and thromboembolic disease

Immunosuppressants

Because of the concurrent presentation of hidradenitis suppurativa and Crohn disease, as well as the morphological and histological similarities, these 2 conditions may share the same pathogenesis, namely excess tumor necrosis factor-alpha (TNF-alpha) production. This was supported by several reports in the literature of patients with hidradenitis suppurativa and Crohn disease who responded to infliximab.31,92,93,94,95 Infliximab is an inhibitor of TNF-alpha. Although approved by the US Food and Drug Administration (FDA) for the treatment of Crohn disease and rheumatoid arthritis, infliximab has also been used in hidradenitis suppurativa.96 The benefits outweigh the risks associated with its use, especially when it is administrated in severe chronic cases resistant to standard therapies.82

Patients self-report that pain significantly decreased following infliximab treatment. This correlated with significant physician-observed clinical improvement (P = .0001). Patients reported a rapid response after the first infusion, and some of them noticed decreased pain after 24 hours.96,97 Although the efficacy has proven impressive and short-term adverse effects have been few and relatively benign, the long-term adverse effects have not been studied. Further trials are needed to assess effects of its prolonged use.97,98 Moreover, the existing prospective studies have described variable patient responses and significant adverse reactions, including hypersensitive reactions, lupuslike reactions, and abdominal pain secondary to colon cancer, tuberculosis, and motor neuropathy. The studies varied in their outcome assessment, population studied, and dose of infliximab used in patients with hidradenitis suppurativa.99,100,101
 
Other inhibitors, including etanercept (a human fusion protein receptor consisting of 2 human TNF-alpha receptors and Fc domain of human immunoglobulin G1) and adalimumab (a fully humanized recombinant anti-TNF-alpha monoclonal antibody) have also produced variable patient responses and significant adverse reactions. Enough information is not yet available to assess the true risks of TNF-alpha inhibitor use as therapy for  hidradenitis suppurativa. None of the studies used a control group. Thus, randomized controlled studies are necessary to determine the risk-to-benefit ratio of TNF-alpha inhibitor therapy in the treatment of hidradenitis suppurativa.102,103,104,105

Therapeutic experience with nonspecific immunosuppression in hidradenitis suppurativa using methotrexate is unlikely to offer any significant advance. Before finally determining the value (or lack of value) of methotrexate in hidradenitis suppurativa, investigation  of different dosage schedules in future patients with hidradenitis suppurativa would be worthwhile.106


Infliximab (Remicade)

Inhibits TNF-alpha activity and triggers complement-mediated lysis of TNF-alpha–expressing cells in vitro. Monoclonal chimeric antibody made from human constant and mouse variable regions of IgG, with binding specificity for human TNF-alpha. Binds to inactive TNF-alpha and can bind specifically to both membrane-bound and soluble TNF-alpha. Binds to inactive TNF-alpha monomers, preventing their association into active trimers. Used to treat severe inflammatory diseases that do not respond to systemic corticosteroids or immunosuppressants.

Adult

3-5 mg/kg per infusion q4-6wk

Pediatric

Efficacy and safety in children have not been established

Documented hypersensitivity; congestive heart failure; tuberculosis

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Perform tuberculosis skin testing prior to initiating treatment, if positive, obtain chest radiograph; check a full panel of laboratory studies, including CBC count with differential, basic metabolic panel, liver function tests, ANA, and HIV serology; search for any active infections, including cutaneous infections; consider the potential for patient's own immune system to mount an immune response to the foreign murine portion of the drug; caution regarding long-term development of antibodies to the drug, because these lead to loss of clinical efficacy; acute and delayed infusion reactions may develop; anaphylaxis and bronchospasm can occur (rarely); lupuslike syndrome may occur; congestive heart failure may develop; caution in personal and/or family history of neurological symptoms/disease (demyelinating)

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Multimedia: Hidradenitis Suppurativa
References
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Further Reading

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Keywords

hidradenitis suppurativa, HS, acne inversa, acne triad, acne tetrad, hidradenitis axillaris, apocrinitis, intertriginous acne, pyoderma fistulans sinifica, Verneuil's disease, Verneuil disease, dissecting cellulitis of scalp and neck, acne conglobata, follicular occlusion triad, follicular occlusion tetrad, pilonidal sinus, acneiform disorder, apocrine occlusion

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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 and Montenegro; Associate Professor in Dermatology, Medical Faculty, University of Novi Sad, Vojvodina, Serbia and Montenegro
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.

Medical Editor

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 Academy of Facial Plastic and Reconstructive Surgery, American College of Mohs Micrographic Surgery and Cutaneous Oncology, American College of Physician Executives, American Society for Dermatologic Surgery, American Society for Laser Medicine and Surgery, American Society for MOHS Surgery, and International Society for Dermatologic Surgery
Disclosure: Nothing to disclose.

Pharmacy Editor

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.

Managing Editor

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.

CME Editor

Catherine Quirk, MD, Clinical Assistant Professor, Department of Dermatology, Brown University
Catherine 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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