HS TREATMENT TOOLBOX:
Multi-modal
Management Approach
Managing hidradenitis suppurativa (HS) may consist of medical, procedural, and lifestyle approaches. Using these approaches as part of a multi-modal treatment plan is considered best practice for managing HS across stages.1-3
Additionally, a multidisciplinary team that includes dermatology, primary care, surgery, and other specialties may be needed to treat HS.1
Considerations for therapy include disease severity, tolerance to medications, associated comorbidities, and costs.1
More HS disease education and information on management can be found on the HS Foundation website.
Types of Treatment for HS
The North American Clinical Guidelines for HS cover a range of interventions, from procedural to medical.2,3 Review some of the key considerations to keep in mind when determining an appropriate management approach for your patients with HS.
Antibiotics
Topical1,3,4
Clinical Use:
For mild localized disease or limited flares; has anti-inflammatory effect as well as prophylactic action in preventing secondary bacterial infection.
Considerations:
Risk of antibiotic resistance.
Oral1,3
Clinical Use:
Provide acute relief of symptoms related to secondary infections—a short course is appropriate for mild HS flares; has anti-inflammatory effect as well as prophylactic action in preventing secondary bacterial infection.
Considerations:
For moderate/severe lesions, oral antibiotics may need to be prescribed for several weeks to months. Long-term use is associated with risk of antibiotic resistance and can cause comorbidities associated with altered commensal microflora.
Corticosteroids
Intralesional Injections1,3-5
Clinical Use:
Accelerate resolution of acute inflammatory painful lesions.
Considerations:
- Can cause skin atrophy, telangiectasias, and hypopigmentation
- Long-term efficacy has not been established
- Intralesional steroids were not superior to placebo (saline) injections, in a placebo-controlled trial6
Oral3,7
Clinical Use:
As rescue therapy for flares or to bridge to other long-term therapy. However, long-term systemic corticosteroids tapered to low doses can be considered for adjunct therapy in cases of severe disease and suboptimal response to standard therapy.
Considerations:
Long-term systemic steroid use is associated with a range of potential complications, including osteoporosis, hyperglycemia, and adrenal suppression.
Topical Disinfectants1,3,4
Clinical Use:
May reduce the frequency of secondary infection; some have anti-inflammatory properties.
Considerations:
Minimal clinical evidence of effectiveness in HS.
Hormonal Therapy1,3,5,8
Clinical Use:
Address possible hormonal etiology in HS; typically used in female patients.
Considerations:
- Oral contraceptives carry an increased risk of venous thromboembolism
Retinoids1,3,5
Clinical Use:
Have antiproliferative and immunomodulatory effects.
Considerations:
- Side effects of this class include xerosis, hyperlipidemia, and depression
- Retinoids are teratogenic, cannot be used in women who are pregnant or planning to become pregnant
Immunosuppressants1,3,5
Clinical Use:
Act through a variety of mechanisms to systemically inhibit the immune response.
Considerations:
Due to the potential for serious side effects, long-term management with immunosuppressants should be limited.
Biologics1,3,5,9
Clinical Use:
Biologics target specific cytokines believed to contribute to HS inflammation. Addressing inflammation may help reduce certain physical manifestations of the disease.
Considerations:
Adverse drug effects associated with biologics may be serious and can include—but are not limited to— serious infections, malignancy, allergic reactions, nervous system problems, heart failure, and lupus-like syndrome.
Light and Laser Therapy1-3,5,10
Clinical Use:
Proposed mechanism is that dermal heating results in follicular destruction and a disruption of the inflammatory infiltrate.
Considerations:
Laser treatment can result in the dermis being replaced by scarring.
Surgery
Procedural interventions may be required to cut out damaged skin tissue from sinus tracts and scarring, but they do not stop the underlying disease process. Radical excisions can be extensive and resulting scarring can be disfiguring.1,2
Incision and drainage1,2,4,5
Clinical Use:
Relieves pain of abscesses; provides acute relief for early, limited disease, where there is no scarring.
Considerations:
Relies only on passive drainage; does not clear proliferative HS lesions; high recurrence rates with no long-term benefit; costly procedures.
Deroofing and localized excision2,4,5,11
Clinical Use:
Skin-tissue saving; postsurgical morbidity and risk of scar contractures are reduced.
Considerations:
Recurrence rates are higher than for wide excision procedures: 22.0% with local excision, 27.0% with deroofing.
Wide excision2,4,5,11
Clinical Use:
Includes a lateral margin of disease-free tissue, sometimes an entire anatomical region; lower recurrence rate (13% overall, 15% primary closure, 8% using flaps, 6% grafting).
Considerations:
Greater postoperative morbidity, such as infection, bleeding, and contracture; can result in prolonged recovery and scar formation.
Antibiotics
Topical1,3,4
Clinical Use:
For mild localized disease or limited flares; has anti-inflammatory effect as well as prophylactic action in preventing secondary bacterial infection.
Considerations:
Risk of antibiotic resistance.
Oral1,3
Clinical Use:
Provide acute relief of symptoms related to secondary infections—a short course is appropriate for mild HS flares; has anti-inflammatory effect as well as prophylactic action in preventing secondary bacterial infection.
Considerations:
For moderate/severe lesions, oral antibiotics may need to be prescribed for several weeks to months. Long-term use is associated with risk of antibiotic resistance and can cause comorbidities associated with altered commensal microflora.
NOTE: The treatments, clinical uses, and considerations listed herein are not intended to be comprehensive. Management of HS should be guided by a physician and individualized to each patient. Randomized controlled trials are lacking for many of the treatments listed. Some treatment information is based on small studies and expert opinion.3
Importance of Early Diagnosis and Appropriate Management
Early diagnosis and timely medical intervention is hypothesized to reduce lasting damage of cutaneous architecture including scarring.13,14
Timely recognition with appropriate management is believed to limit the emotional and physical burden of HS for patients.13,14
This progressive disease can result in scarring, tunnel formation, severe pain, and other debilitating symptoms.13,14
Lifestyle Considerations for Symptom Relief
Although not applicable to all HS patients, these tips and lifestyle changes may help provide symptom relief.1
Wearing loose-fitting clothing
may help prevent excessive friction that can cause lesion irritation or rupture
Weight loss
may help reduce skin friction and occlusion that can exacerbate HS
Keeping the skin clean
may help decrease the potential for odor or infection. Several antiseptic cleansers are available and can be used in areas of recurrent lesions. Washcloths and brushes should be avoided9
Diet modifications
may help some patients with HS. Foods with added sugar, dairy, whey products, foods made with brewer's yeast, and high carbohydrate foods may exacerbate symptoms15,16
Smoking cessation
may benefit patients with HS, as smoking has been shown to be a potential contributing factor in disease severity
Discover a Treatment Option
Explore a treatment option that may be part of your management approach for your moderate to severe HS patients.
Co-managing HS With a Specialist
Partner with an experienced HS specialist in dermatology to co-manage your HS patients.
REFERENCES
1. Lockwood SJ, Prens LM, Porter ML, Kimball AB. Treatment of hidradenitis suppurativa. In: Kimball AB, Jemec GBE, eds. Hidradenitis Suppurativa: A Disease Primer. Switzerland: Springer International Publishing AG; 2017:39-51. 2. Alikhan A, Sayed C, Alavi A, et al. North American clinical management guidelines for hidradenitis suppurativa: a publication from the United States and Canadian Hidradenitis Suppurativa Foundations: part I: diagnosis, evaluation, and the use of complementary and procedural management. J Am Acad Dermatol. 2019;81(1):76-90. 3. Alikhan A, Sayed C, Alavi A, et al. North American clinical management guidelines for hidradenitis suppurativa: a publication from the United States and Canadian Hidradenitis Suppurativa Foundations: part II: topical, intralesional, and systemic medical management. J Am Acad Dermatol. 2019;81(1):91-101. 4. Saunte DML, Jemec GBE. Hidradenitis suppurativa: advances in diagnosis and treatment. JAMA. 2017;318(20):2019-2032. 5. Ingram JR. Treatment of hidradenitis suppurativa (acne inversa). UpToDate website. October 30, 2019. https://www.uptodate.com/contents/hidradenitis-suppurativa-treatment. Accessed March 16, 2020. 6. Frew JW, Hawkes JE, Krueger JG. Topical, systemic and biologic therapies in hidradenitis suppurativa: pathogenic insights by examining therapeutic mechanisms. Ther Adv Chronic Dis. 2019;10:1-24. 7. Liu D, Ahmet A, Ward L, et al. A practical guide to the monitoring and management of the complications of systemic corticosteroid therapy. Allergy Asthma Clin Immunol. 2013;9(1):30. 8. Shah N. Hidradenitis suppurativa: a treatment challenge. Am Fam Physician. 2005;72(8):1547-1552. 9. Margesson LJ, Danby FW. Hidradenitis suppurativa. Best Pract Res Clin Obstet Gynaecol. 2014;28(7):1013-1027. 10. Xu LY, Wright DR, Mahmoud BH, Ozog DM, Mehregan DA, Hamzavi IH. Histopathologic study of hidradenitis suppurativa following long-pulsed 1064-nm Nd:YAG laser treatment. Arch Dermatol. 2011;147(1):21-28. 11. Mehdizadeh A, Hazen PG, Bechara FG, et al. Recurrence of hidradenitis suppurativa after surgical management: a systematic review and meta-analysis. J Am Acad Dermatol. 2015;73(5)(suppl 1):S70‐S77. 12. DeFazio MV, Economides JM, King KS, et al. Outcomes after combined radical resection and targeted biologic therapy for the management of recalcitrant hidradenitis suppurativa. Ann Plast Surg. 2016;77(2):217-222. 13. Micheletti RG. Natural history, presentation, and diagnosis of hidradenitis suppurativa. Semin Cutan Med Surg. 2014;33(suppl 3):S51-S53. 14. Woodruff CM, Charlie AM, Leslie KS. Hidradenitis suppurativa: a guide for the practicing physician. Mayo Clin Proc. 2015;90(12):1679-1693. 15. Mata E, Marr K, Price K, et al. Dietary factors in hidradenitis suppurativa. Presented at: Symposium on Hidradenitis Suppurativa Advances; November 1-3, 2019; Detroit, MI. 16. Choi F, Lehmer L, Ekelem C, Mesinkovska NA. Dietary and metabolic factors in the pathogenesis of hidradenitis suppurativa: a systematic review. Int J Dermatol. 2020;59(2):143‐153.