Approaching the patient with hidradenitis suppurativa (HS) can be a challenging, time-consuming task. I find it helpful to break down the encounter into critical divisions. Initially, one must evaluate all facets of their disease: the relevant history, the patient’s severity of symptoms, the patient’s functional abilities to cope with their disease, the comorbidities that might be present, and the physical findings (Hurley Stage I, II or III). The composite of each of these divisions will influence the clinician’s decisions in selecting the ideal treatment. Visit-to-visit comparisons will allow the physician to determine responses to therapy.
Determine when the condition was first noted, the manifestation and duration of a current flare, past treatments, other medical problems, family history, and association with other follicular diseases such as acne, folliculitis decalvans, or pilonidal cyst (including if found in family members).
Pain, itching, drainage, and odor represent the most common symptoms. Each may worsen with “flares.” It is helpful to note how frequently flares occur for each patient. We ask patients to globally grade (0-10) each of their symptoms (thereby creating a pain-drainage-odor score) for the period to include the previous 2 weeks.
How does each patient cope with their disease? Some patients with marked physical findings are functionally capable, whereas other patients with milder disease may be severely compromised. We have found the DLQI Questionnaire to yield a consistent measure of intensity, and a valid measure of the impact of the disease on the patient’s ability to function in day-to-day activities.
HS is unlike many other dermatologic conditions, largely because of the permanent injury which may occur, and because of its multiple associations. Each association must be considered as part of the elements of the condition. They include acne, folliculitis decalvans, pilonidal sinus, family history, inflammatory bowel disease (Crohn’s disease, ulcerative colitis, irritable bowel disease), endocrinopathy (diabetes, thyroid disease, polycystic ovary syndrome), arthralgias, cardiovascular disease (including heart attacks or stroke), associated inflammatory conditions (including pyoderma gangrenosum, erythema nodosum, familial fevers, and arthritis), obesity, smoking, depression (including suicidal ideation), and pain management/opiate dependence. We find that a checklist is often helpful in evaluating the full scope of impact of the disease, and for selecting experts for co-management where needed.
Because of the high risk of comorbidities, we initially evaluate CBC with diff, metabolic panel, serum fasting glucose, lipid status, hormones to included total and free testosterone, DHEA-S, thyroid function, and inflammatory markers, including sedimentation rate, C-reactive protein, and high-sensitivity CRP.
Nodules, abscesses, sinus tracts, scars, and drainage are most frequently found in intertriginous areas, but may occur in almost any skin surface. We evaluate each anatomic site of involvement, and assign an acne-like score (0-4) for each location.
Pharmacologic management: The principal concept for medical management is that HS is an inflammatory, rather than infectious, disease. Antibiotics with anti-inflammatory properties are usually the initial agents used: doxycycline, minocycline, erythromycin, sulfamethoxazole/trimethoprim (Bactrim), or the combination of clindamycin and rifampin may be helpful. The penicillins and cephalosporins are generally not helpful. Weight loss and smoking cessation, where appropriate, are generally good goals but will usually not improve the HS. Dietary influences are controversial, but avoidance of dairy products and high glycemic index foods (sweets) may be helpful in some patients. Consideration of possible superinfection, or a flare influenced by change in biofilm, may suggest the need for specific anti-infective agents. For patients with a small abscess, consideration may be given to the use of intralesional steroids (we commonly use a combination of triamcinolone and lincomycin). For more widespread activity, a short course of systemic steroids may be considered. Avlosulfone (topical or oral) may be a helpful addition but is usually ineffective as single therapy. Biologic agents such as adalimumab or infliximab may greatly improve the inflammation-control of many patients with persistent and/or severe disease, but are generally not considered first-line therapy.
Surgical Management: Patients with a painful, solitary abscess will often benefit from any procedure releasing the abscess contents. Incision and drainage yields almost immediate relief, but is associated with very high recurrence rates, even with packing of the abscess. A more effective, and lasting, treatment is “unroofing/deroofing,” where an excision of the top of the skin overlying the abscess is performed (like “taking the top off a teapot”), with curettage of the walls of the abscess. The base of the lesion is left undisturbed.
In many patients, and especially those with persistent sinus tracts and scarring, removal of the entire affected tissue may produce the only lasting benefits. Wide-local excision has long been the standard of care, although occult extension of sinus tracts may result in substantial risk of recurrence. More sophisticated approaches, using presurgical ultrasound, or staged intrasurgical CO2 laser marsupialization may result in more lasting resolution, but are considered primarily in those patients who require more than pharmacologic or simple surgical procedures.
Suggestion: Because of the scope and complexity of HS, this is one condition that we find really helpful to have a flow sheet.