Hidradenitis Suppurativa Treatment & Management
- Author: Marina Jovanovic, MD, PhD; Chief Editor: William D James, MD more...
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). 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
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.
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. With this technique, sufficient resection of the lesion is the most important issue. 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. 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.
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.
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. Patients should be warned that new lesions may develop at a site that was not apparent at the time of their initial surgery.
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. 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. 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.
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.
Minor procedures can include exteriorization and laying open of tracts and electrocoagulation and excision and primary closure (eg, the Pollock procedure). 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. It also obviates diversion with or without proctectomy.
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. Carbon dioxide laser treatment should be considered as a treatment option in patients with Hurley stage II.
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.
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. More research is needed before Nd:YAG laser can be established as a standard treatment for hidradenitis suppurativa.
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. 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. 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, the option of choice for recurrent disease. 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.
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.
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.
The width of the excision, and not the wound closure technique, influence the therapeutic outcome. 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. An overall recurrence rate of 2.5% has been estimated after wide surgical excision, with a median postoperative follow-up of 36 months.
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. 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.
Nonablative radiofrequency therapy can be used for patients with Harley stage I and II.
Patients who are obese should be advised to lose weight.
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.
Complications of hidradenitis suppurativa include local and systemic infections resulting from the spread of microorganisms 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. 
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.  Rectal and urethral fistulas are rare. 
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. 
In male patients, severe ulcerative genital disease can cause destruction of the prepuce. 
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. 
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%.  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.  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.  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. 
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.
[Guideline] Zouboulis CC, Desai N, Emtestam L, Hunger RE, Ioannides D, Juhász I, et al. European S1 guideline for the treatment of hidradenitis suppurativa/acne inversa. J Eur Acad Dermatol Venereol. 2015 Apr. 29 (4):619-44. [Medline].
Wang SC, Wang SC, Alavi A, Alhusayen R, Bashash M, Sibbald RG. Hidradenitis Suppurativa: A Frequently Missed Diagnosis, Part 2: Treatment Options. Adv Skin Wound Care. 2015 Aug. 28 (8):372-80; quiz 381-2. [Medline].
van der Zee HH, Jemec GB. New insights into the diagnosis of hidradenitis suppurativa: Clinical presentations and phenotypes. J Am Acad Dermatol. 2015 Nov. 73 (5 Suppl 1):S23-6. [Medline].
von der Werth JM, Jemec GB. Morbidity in patients with hidradenitis suppurativa. Br J Dermatol. 2001 Apr. 144(4):809-13. [Medline].
Alikhan A, Lynch PJ, Eisen DB. Hidradenitis suppurativa: a comprehensive review. J Am Acad Dermatol. 2009 Apr. 60(4):539-61; quiz 562-3. [Medline].
Sartorius K, Lapins J, Emtestam L, Jemec GB. Suggestions form uniform outcome variables when reporting treatment effects in hidradenitis suppurativa. Br J Dermatol. 2003. 149:211-3.
Rompel R, Petres J. Long-term results of wide surgical excision in 106 patients with hidradenitis suppurativa. Dermatol Surg. 2000 Jul. 26(7):638-43. [Medline].
Kimball AB, Jemec GB, Yang M, Kageleiry A, Signorovitch JE, Okun MM, et al. Assessing the validity, responsiveness and meaningfulness of the Hidradenitis Suppurativa Clinical Response (HiSCR) as the clinical endpoint for hidradenitis suppurativa treatment. Br J Dermatol. 2014 Dec. 171 (6):1434-42. [Medline].
Blok JL, Spoo JR, Leeman FW, Jonkman MF, Horváth B. Skin-Tissue-sparing Excision with Electrosurgical Peeling (STEEP): a surgical treatment option for severe hidradenitis suppurativa Hurley stage II/III. J Eur Acad Dermatol Venereol. 2015 Feb. 29 (2):379-82. [Medline].
Jemec GB. What's new in hidradenitis suppurativa?. J Eur Acad Dermatol Venereol. 2000 Sep. 14(5):340-1. [Medline].
Bohn J, Svensson H. Surgical treatment of hidradenitis suppurativa. Scand J Plast Reconstr Surg Hand Surg. 2001 Sep. 35(3):305-9. [Medline].
Slade DE, Powell BW, Mortimer PS. Hidradenitis suppurativa: pathogenesis and management. Br J Plast Surg. 2003 Jul. 56(5):451-61. [Medline].
Tanaka A, Hatoko M, Tada H, Kuwahara M, Mashiba K, Yurugi S. Experience with surgical treatment of hidradenitis suppurativa. Ann Plast Surg. 2001 Dec. 47(6):636-42. [Medline].
Golcman R, Golcman B, Tamura BM, Nogueira MA, Zoo CM, Germano JA. Subcutaneous fistulectomy in bridging hidradenitis suppurativa. Dermatol Surg. 1999 Oct. 25(10):795-8. [Medline].
Tierney E, Mahmoud BH, Hexsel C, Ozog D, Hamzavi I. Randomized control trial for the treatment of hidradenitis suppurativa with a neodymium-doped yttrium aluminium garnet laser. Dermatol Surg. 2009 Aug. 35(8):1188-98. [Medline].
Iwasaki J, Marra DE, Fincher EF, Moy RL. Treatment of hidradenitis suppurativa with a nonablative radiofrequency device. Dermatol Surg. 2008 Jan. 34(1):114-7. [Medline].
Velpeau A. Dictionnaire de Medicine, un Repertoire des Sciences Medicales sons le Rapport, Theorique et Pratique. 2nd ed Paris. 1839. 91.
Verneuil A. Etudes sur les tumeurs de la peau et quelques maladies des glandes sudoripores. Arch Gen Med. 1854. 4:693-705.
Schiefferdecker B. Die Hautdrusen des Menschen und der Saugetierre ihre Histologishe und rassenanatomische Bedeutung Sowie die Muscularis Sexualis. Stuttgart. 1922.
Brunsting HA. Hidradenitis suppurativa: abscess of the apocrine sweat glands. Arch fur Dermatol und Syph (Berlin). 1939. 39:108-20.
Pillsbury DM, Shelley WB, Kligman AM. Bacterial infections of the skin. Dermatology. Philadelphia: WB Saunders Co; 1956. 482-9.
Plewig G, Kligman AM. Acne: Morphogenesis and Treatment. Berlin: Springer-Verlag; 1975.
Plewig G, Steger M. Acne inversa (alias acne triad, acne tetrad, or hydradenitis suppurativa). Marks R, Plewig G, eds. Acne and Related Disorders. London: Martin Dunitz Ltd; 1989. 343-57.
Yu CC, Cook MG. Hidradenitis suppurativa: a disease of follicular epithelium, rather than apocrine glands. Br J Dermatol. 1990 Jun. 122(6):763-9. [Medline].
Attanoos RL, Appleton MA, Douglas-Jones AG. The pathogenesis of hidradenitis suppurativa: a closer look at apocrine and apoeccrine glands. Br J Dermatol. 1995 Aug. 133(2):254-8. [Medline].
Sellheyer K, Krahl D. "Hidradenitis suppurativa" is acne inversa! An appeal to (finally) abandon a misnomer. Int J Dermatol. 2005 Jul. 44(7):535-40. [Medline].
Gulliver W, Zouboulis CC, Prens E, Jemec GB, Tzellos T. Evidence-based approach to the treatment of hidradenitis suppurativa/acne inversa, based on the European guidelines for hidradenitis suppurativa. Rev Endocr Metab Disord. 2016 Feb 1. 35(2 Pt 1):191-4. [Medline].
Revuz JE, Canoui-Poitrine F, Wolkenstein P, et al. Prevalence and factors associated with hidradenitis suppurativa: results from two case-control studies. J Am Acad Dermatol. 2008 Oct. 59(4):596-601. [Medline].
Jemec GB, Heidenheim M, Nielsen NH. Hidradenitis suppurativa--characteristics and consequences. Clin Exp Dermatol. 1996 Nov. 21(6):419-23. [Medline].
Manolitsas T, Biankin S, Jaworski R, Wain G. Vulval squamous cell carcinoma arising in chronic hidradenitis suppurativa. Gynecol Oncol. 1999 Nov. 75(2):285-8. [Medline].
Wang SC, Wang SC, Sibbald RG, Alhusayen R, Bashash M, Alavi A. Hidradenitis Suppurativa: A Frequently Missed Diagnosis, Part 1: A Review of Pathogenesis, Associations, and Clinical Features. Adv Skin Wound Care. 2015 Jul. 28 (7):325-32; quiz 333-4. [Medline].
Jemec GB. Hidradenitis suppurativa. J Cutan Med Surg. 2003 Jan-Feb. 7(1):47-56. [Medline].
Palmer RA, Keefe M. Early-onset hidradenitis suppurativa. Clin Exp Dermatol. 2001 Sep. 26(6):501-3. [Medline].
Mengesha YM, Holcombe TC, Hansen RC. Prepubertal hidradenitis suppurativa: two case reports and review of the literature. Pediatr Dermatol. 1999 Jul-Aug. 16(4):292-6. [Medline].
Blok JL, Boersma M, Terra JB, Spoo JR, Leeman FW, van den Heuvel ER, et al. Surgery under general anaesthesia in severe hidradenitis suppurativa: a study of 363 primary operations in 113 patients. J Eur Acad Dermatol Venereol. 2015 Aug. 29 (8):1590-7. [Medline].
Barth JH, Layton AM, Cunliffe WJ. Endocrine factors in pre- and postmenopausal women with hidradenitis suppurativa. Br J Dermatol. 1996 Jun. 134(6):1057-9. [Medline].
Mandal A, Watson J. Experience with different treatment modules in hidradenitis suppuritiva: a study of 106 cases. Surgeon. 2005 Feb. 3(1):23-6. [Medline].
Hughes R, Kelly G, Sweeny C, Lally A, Kirby B. The medical and laser management of hidradenitis suppurativa. Am J Clin Dermatol. 2015 Apr. 16 (2):111-23. [Medline].
Saunte DM, Boer J, Stratigos A, et al. Diagnostic delay in hidradenitis suppurativa is a global problem. Br J Dermatol. 2015 Dec. 173 (6):1546-9. [Medline].
Roy MK, Appleton MA, Delicata RJ, Sharma AK, Williams GT, Carey PD. Probable association between hidradenitis suppurativa and Crohn's disease: significance of epithelioid granuloma. Br J Surg. 1997 Mar. 84(3):375-6. [Medline].
Martínez F, Nos P, Benlloch S, Ponce J. Hidradenitis suppurativa and Crohn's disease: response to treatment with infliximab. Inflamm Bowel Dis. 2001 Nov. 7(4):323-6. [Medline].
Church JM, Fazio VW, Lavery IC, Oakley JR, Milsom JW. The differential diagnosis and comorbidity of hidradenitis suppurativa and perianal Crohn's disease. Int J Colorectal Dis. 1993 Sep. 8(3):117-9. [Medline].
Jansen T, Plewig G. What's new in acne inversa (alias hidradenitis suppurativa)?. J Eur Acad Dermatol Venereol. 2000 Sep. 14(5):342-3. [Medline].
Gonzalez-Lopez A, Velasco E, Pozo T, Del Villar A. HIV-associated pityriasis rubra pilaris responsive to triple antiretroviral therapy. Br J Dermatol. 1999 May. 140(5):931-4. [Medline].
Kleeman D, Trueb RM, Schmid-Grendelmeier P. [Reticular pigmented anomaly of the flexures. Dowling-Degos disease of the intertrigo type in association with acne inversa]. Hautarzt. 2001 Jul. 52(7):642-5. [Medline].
Libow LF, Friar DA. Arthropathy associated with cystic acne, hidradenitis suppurativa, and perifolliculitis capitis abscedens et suffodiens: treatment with isotretinoin. Cutis. 1999 Aug. 64(2):87-90. [Medline].
Thein M, Hogarth MB, Acland K. Seronegative arthritis associated with the follicular occlusion triad. Clin Exp Dermatol. 2004. 29:545-62.
Bhosale P, Barron B, Lamki L. The "SAPHO" syndrome: a case report of a patient with unusual bone scan findings. Clin Nucl Med. 2001 Jul. 26(7):619-21. [Medline].
Ah-Weng A, Langtry JA, Velangi S, Evans CD, Douglas WS. Pyoderma gangrenosum associated with hidradenitis suppurativa. Clin Exp Dermatol. 2005 Nov. 30(6):669-71. [Medline].
Pavlovic M. Oboljenja apokrinih znojnih zlezda. Karadaglic D, ed. Dermatologija Beograd: Vojnoizdavacki Zavod. 2000. 754-61.
Shelley WB, Cahn MM. The pathogenesis of hidradenitis suppurativa in man; experimental and histologic observations. AMA Arch Derm. 1955 Dec. 72(6):562-5. [Medline].
Lapins J, Jarstrand C, Emtestam L. Coagulase-negative staphylococci are the most common bacteria found in cultures from the deep portions of hidradenitis suppurativa lesions, as obtained by carbon dioxide laser surgery. Br J Dermatol. 1999 Jan. 140(1):90-5. [Medline].
Mowad CM, McGinley KJ, Foglia A, Leyden JJ. The role of extracellular polysaccharide substance produced by Staphylococcus epidermidis in miliaria. J Am Acad Dermatol. 1995 Nov. 33(5 Pt 1):729-33. [Medline].
Kurzen H, Kurokawa I, Jemec GB, et al. What causes hidradenitis suppurativa?. Exp Dermatol. 2008 May. 17(5):455-6; discussion 457-72. [Medline].
Fitzsimmons JS, Guilbert PR, Fitzsimmons EM. Evidence of genetic factors in hidradenitis suppurativa. Br J Dermatol. 1985 Jul. 113(1):1-8. [Medline].
Pink AE, Simpson MA, Desai N, Trembath RC, Barker JN. Gamma-Secretase mutations in hidradenitis suppurativa: new insights into disease pathogenesis. J Invest Dermatol. 2013 Mar. 133(3):601-7. [Medline].
Gao M, Wang PG, Cui Y, et al. Inversa acne (hidradenitis suppurativa): a case report and identification of the locus at chromosome 1p21.1-1q25.3. J Invest Dermatol. 2006 Jun. 126(6):1302-6. [Medline].
Lapins J, Asman B, Gustafsson A, Bergstrom K, Emtestam L. Neutrophil-related host response in hidradenitis suppurativa: a pilot study in patients with inactive disease. Acta Derm Venereol. 2001 May. 81(2):96-9. [Medline].
Giamarellos-Bourboulis EJ, Antonopoulou A, Petropoulou C, et al. Altered innate and adaptive immune responses in patients with hidradenitis suppurativa. Br J Dermatol. 2007 Jan. 156(1):51-6. [Medline].
Hunger RE, Surovy AM, Hassan AS, Braathen LR, Yawalkar N. Toll-like receptor 2 is highly expressed in lesions of acne inversa and colocalizes with C-type lectin receptor. Br J Dermatol. 2008 Apr. 158(4):691-7. [Medline].
Champion RH. Disorder of sweat glands. Rook A, Wilkinson DS, Ebling FJ, eds. Textbook of Dermatology. 6th ed. Oxford: Blackwell Science; 1998. 1985-2002.
Edlich RF, Winters KL, Britt LD, Long WB 3rd, Gubler KD, Drake DB. Difficult wounds: an update. J Long Term Eff Med Implants. 2005. 15(3):289-302. [Medline].
Wiseman MC. Hidradenitis suppurativa: a review. Dermatol Ther. 2004. 17(1):50-4. [Medline].
Lewis F, Messenger AG, Wales JK. Hidradenitis suppurativa as a presenting feature of premature adrenarche. Br J Dermatol. 1993 Oct. 129(4):447-8. [Medline].
Farrell AM, Randall VA, Vafaee T, Dawber RP. Finasteride as a therapy for hidradenitis suppurativa. Br J Dermatol. 1999 Dec. 141(6):1138-9. [Medline].
Barth JH. Cutaneous Virilism, Apocrine Glands and Hidradenitis Suppurativa [thesis]. London: University of London; 1992.
Jemec GB, Gniadecka M. Sebum excretion in hidradenitis suppurativa. Dermatology. 1997. 194(4):325-8. [Medline].
Jansen I, Altmeyer P, Piewig G. Acne inversa (alias hidradenitis suppurativa). J Eur Acad Dermatol Venereol. 2001 Nov. 15(6):532-40. [Medline].
Wasik F, Barancewicz-Losek M. Hryncewicz-Gwozdz A, Jelen M: Hidradenitis suppurativa complicated by hidradenocarcinoma. Dermatol Klin (Wroclaw). 2001. 3 (Suppl 1):64.
Jansen T, Plewig G. Acne inversa. Int J Dermatol. 1998 Feb. 37(2):96-100. [Medline].
Kurzen H, Jung EG, Hartschuh W, Moll I, Franke WW, Moll R. Forms of epithelial differentiation of draining sinus in acne inversa (hidradenitis suppurativa). Br J Dermatol. 1999 Aug. 141(2):231-9. [Medline].
Kurokawa I, Nishijima S, Kusumoto K, Senzaki H, Shikata N, Tsubura A. Immunohistochemical study of cytokeratins in hidradenitis suppurativa (acne inversa). J Int Med Res. 2002 Mar-Apr. 30(2):131-6. [Medline].
Kurokawa I, Nishijima S, Suzuki K, et al. Cytokeratin expression in pilonidal sinus. Br J Dermatol. 2002 Mar. 146(3):409-13. [Medline].
Kurokawa I, Nishimura K, Yamanaka K, Mizutani H, Tsubura A, Revuz J. Cytokeratin expression in squamous cell carcinoma arising from hidradenitis suppurativa (acne inversa). J Cutan Pathol. 2007 Sep. 34(9):675-8. [Medline].
Jemec GB, Gniadecka M. Ultrasound examination of hair follicles in hidradenitis suppurativa. Arch Dermatol. 1997 Aug. 133(8):967-70. [Medline].
Jansen T, Romiti R, Plewig G, Altmeyer P. Disfiguring draining sinus tracts in a female acne patient. Pediatr Dermatol. 2000 Mar-Apr. 17(2):123-5. [Medline].
Gniadecki R, Jemec GB. Lipid raft-enriched stem cell-like keratinocytes in the epidermis, hair follicles and sinus tracts in hidradenitis suppurativa. Exp Dermatol. 2004 Jun. 13(6):361-3. [Medline].
Matusiak L, Bieniek A, Szepietowski JC. Soluble interleukin-2 receptor serum level is a useful marker of hidradenitis suppurativa clinical staging. Biomarkers. 2009 Sep. 14(6):432-7. [Medline].
Aksakal AB, Adisen E. Hidradenitis suppurativa: importance of early treatment; efficient treatment with electrosurgery. Dermatol Surg. 2008 Feb. 34(2):228-31. [Medline].
Boer J, van Gemert MJ. Long-term results of isotretinoin in the treatment of 68 patients with hidradenitis suppurativa. J Am Acad Dermatol. 1999 Jan. 40(1):73-6. [Medline].
van Rappard DC, Mooij JE, Mekkes JR. Mild to moderate hidradenitis suppurativa treated with local excision and primary closure. J Eur Acad Dermatol Venereol. 2012 Jul. 26(7):898-902. [Medline].
Yamashita Y, Hashimoto I, Matsuo S, Abe Y, Ishida S, Nakanishi H. Two-stage surgery for hidradenitis suppurativa: staged artificial dermis and skin grafting. Dermatol Surg. 2014 Feb. 40(2):110-5. [Medline].
Jianbing T, Biao C, Qin L, Yanhong W. Topical negative pressure coupled with split-thickness skin grafting for the treatment of hidradenitis suppurativa: a case report. Int Wound J. 2013 Jul 9. [Medline].
Busnardo FF, Coltro PS, Olivan MV, Busnardo AP, Ferreira MC. The thoracodorsal artery perforator flap in the treatment of axillary hidradenitis suppurativa: effect on preservation of arm abduction. Plast Reconstr Surg. 2011 Oct. 128(4):949-53. [Medline].
Alharbi M, Perignon D, Assaf N, Qassemyar Q, Elsamad Y, Sinna R. Application of the inner arm perforator flap in the management of axillary hidradenitis suppurativa. Ann Chir Plast Esthet. 2014 Feb. 59(1):29-34. [Medline].
Bodzin JH. Laser ablation of complex perianal fistulas preserves continence and is a rectum-sparing alternative in Crohn's disease patients. Am Surg. 1998 Jul. 64(7):627-31; discussion 632. [Medline].
Lapins J, Sartorius K, Emtestam L. Scanner-assisted carbon dioxide laser surgery: a retrospective follow-up study of patients with hidradenitis suppurativa. J Am Acad Dermatol. 2002 Aug. 47(2):280-5. [Medline].
Madan V, Hindle E, Hussain W, August PJ. Outcomes of treatment of nine cases of recalcitrant severe hidradenitis suppurativa with carbon dioxide laser. Br J Dermatol. 2008 Dec. 159(6):1309-14. [Medline].
Hynes PJ, Earley MJ, Lawlor D. Split-thickness skin grafts and negative-pressure dressings in the treatment of axillary hidradenitis suppurativa. Br J Plast Surg. 2002 Sep. 55(6):507-9. [Medline].
Rehman N, Kannan RY, Hassan S, Hart NB. Thoracodorsal artery perforator (TAP) type I V-Y advancement flap in axillary hidradenitis suppurativa. Br J Plast Surg. 2005 Jun. 58(4):441-4. [Medline].
Rhode JM, Burke WM, Cederna PS, Haefner HK. Outcomes of surgical management of stage III vulvar hidradenitis suppurativa. J Reprod Med. 2008 Jun. 53(6):420-8. [Medline].
Frohlich D, Baaske D, Glatzel M. [Radiotherapy of hidradenitis suppurativa--still valid today?]. Strahlenther Onkol. 2000 Jun. 176(6):286-9. [Medline].
Russ E, Castillo M. Lumbosacral epidural abscess due to hidradenitis suppurativa. AJR Am J Roentgenol. 2002 Mar. 178(3):770-1. [Medline].
Gupta S, Kumar B. Dorsal perforation of prepuce: a common end point of severe ulcerative genital diseases?. Sex Transm Infect. 2000 Jun. 76(3):210-2. [Medline].
Lapins J, Ye W, Nyren O, Emtestam L. Incidence of cancer among patients with hidradenitis suppurativa. Arch Dermatol. 2001 Jun. 137(6):730-4. [Medline].
Malaguarnera M, Pontillo T, Pistone G, Succi L. Squamous-cell cancer in Verneuil's disease (hidradenitis suppurativa). Lancet. 1996 Nov 23. 348(9039):1449. [Medline].
Maclean GM, Coleman DJ. Three fatal cases of squamous cell carcinoma arising in chronic perineal hidradenitis suppurativa. Ann R Coll Surg Engl. 2007 Oct. 89(7):709-12. [Medline].
Crain VA, Gulati S, Bhat S, Milner SM. Marjolin's ulcer in chronic hidradenitis suppurativa. Am Fam Physician. 2005 May 1. 71(9):1652, 1657. [Medline].
Kimball AB, Sobell JM, Zouboulis CC, Gu Y, Williams DA, Sundaram M, et al. HiSCR (Hidradenitis Suppurativa Clinical Response): a novel clinical endpoint to evaluate therapeutic outcomes in patients with hidradenitis suppurativa from the placebo-controlled portion of a phase 2 adalimumab study. J Eur Acad Dermatol Venereol. 2015 Jul 22. 27(6):528-9. [Medline].
Yildiz H, Senol L, Ercan E, Bilgili ME, Karabudak Abuaf O. A prospective randomized controlled trial assessing the efficacy of adjunctive hyperbaric oxygen therapy in the treatment of hidradenitis suppurativa. Int J Dermatol. 2016 Feb. 55 (2):232-7. [Medline].
Jemec GB. Clinical practice. Hidradenitis suppurativa. N Engl J Med. 2012 Jan 12. 366(2):158-64. [Medline].
Boer J, Nazary M. Long-term results of acitretin therapy for hidradenitis suppurativa. Is acne inversa also a misnomer?. Br J Dermatol. 2011 Jan. 164(1):170-5. [Medline].
Jamshidi M, Obermeyer RJ, Govindaraj S, Garcia A, Ghani A. Acute pancreatitis secondary to isotretinoin-induced hyperlipidemia. J Okla State Med Assoc. 2002 Feb. 95(2):79-80. [Medline].
Katsanos KH, Christodoulou DK, Tsianos EV. Axillary hidradenitis suppurativa successfully treated with infliximab in a Crohn's disease patient. Am J Gastroenterol. 2002 Aug. 97(8):2155-6. [Medline].
Lebwohl B, Sapadin AN. Infliximab for the treatment of hidradenitis suppurativa. J Am Acad Dermatol. 2003 Nov. 49(5 Suppl):S275-6. [Medline].
Rosi YL, Lowe L, Kang S. Treatment of hidradenitis suppurativa with infliximab in a patient with Crohn's disease. J Dermatolog Treat. 2005 Feb. 16(1):58-61. [Medline].
Trent JT, Kerdel FA. Tumor necrosis factor alpha inhibitors for the treatment of dermatologic diseases. Dermatol Nurs. 2005 Apr. 17(2):97-107. [Medline].
Sullivan TP, Welsh E, Kerdel FA, Burdick AE, Kirsner RS. Infliximab for hidradenitis suppurativa. Br J Dermatol. 2003 Nov. 149(5):1046-9. [Medline].
Gupta AK, Skinner AR. A review of the use of infliximab to manage cutaneous dermatoses. J Cutan Med Surg. 2004 Mar-Apr. 8(2):77-89. [Medline].
Grant A, Gonzalez T, Montgomery MO, Cardenas V, Kerdfel FA. Infliximab therapy for patients with moderate to severe hidradenitis suppurativa: A randomized, double blind, placebo-control crossover trial. J Am Acad Dermatol. 2010. 62:205-17.
Mekkes JR, Bos JD. Long-term efficacy of a single course of infliximab in hidradenitis suppurativa. Br J Dermatol. 2008 Feb. 158(2):370-4. [Medline].
Ingram JR, McPhee M. Management of hidradenitis suppurativa: a U.K. survey of current practice. Br J Dermatol. 2015 Oct. 173 (4):1070-2. [Medline].
Ingram JR, Woo PN, Chua SL, Ormerod AD, Desai N, Kai AC, et al. Interventions for hidradenitis suppurativa: a Cochrane systematic review incorporating GRADE assessment of evidence quality. Br J Dermatol. 2016 Jan 23. 32(2):204-5. [Medline].
Lee RA, Dommasch E, Treat J, et al. A prospective clinical trial of open-label etanercept for the treatment of hidradenitis suppurativa. J Am Acad Dermatol. 2009 Apr. 60(4):565-73. [Medline].
Giamarellos-Bourboulis EJ, Pelekanou E, Antonopoulou A, et al. An open-label phase II study of the safety and efficacy of etanercept for the therapy of hidradenitis suppurativa. Br J Dermatol. 2008 Mar. 158(3):567-72. [Medline].
Zangrilli A, Esposito M, Mio G, Mazzotta A, Chimenti S. Long-term efficacy of etanercept in hidradenitis suppurativa. J Eur Acad Dermatol Venereol. 2008 Nov. 22(10):1260-2. [Medline].
Yamauchi PS, Mau N. Hidradenitis suppurativa managed with adalimumab. J Drugs Dermatol. 2009 Feb. 8(2):181-3. [Medline].
Boer J, Jemec GB. Resorcinol peels as a possible self-treatment of painful nodules in hidradenitis suppurativa. Clin Exp Dermatol. 2010 Jan. 35(1):36-40. [Medline].