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Hidradenitis

Brittney DeClerck, MD, Matthew DeLaney, MD, and Matthieu DeClerck, MD
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23:20

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Hidradenitis suppurativa is a chronic condition that can have a tremendous impact on a patient’s quality of life. In this segment we sit down with Dr. Brittney DeClerck and look at evidence based approaches to helping get these patients some much needed relief.

Pearls:

  • Hidradenitis suppurativa (HS) is caused by recurrent inflammation of apocrine sweat glands in the axillae and groin.
  • It is most common in overweight, young women.
  • HS is not caused by infection, however, draining abscesses can offer immediate relief.
  • All patients should be referred to dermatology for more definitive management.
  • Weight loss, smoking cessation, and looser fitting clothing can reduce disease severity.

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  • Hidradenitis suppurativa (HS) is a complex disease with two primary derangements. 
    • One is a predisposition to having occlusion of the hair follicles. 
    • The occluded hair follicles tend to rupture beneath the skin triggering a robust inflammatory response. 
  • HS can cause multiple types of lesions, however, blackheads (comedones) are most often the primary lesions, which represent occluded follicles from retained keratin. 
    • Over time, the scarring from these lesions will create sinus tracts. 
  • HS tends to occur most frequently in adolescent/young adult, African American, overweight, women. 
    • Affects females twice as much as men.
  • HS most commonly affects areas of the body with apocrine sweat glands (ie: associated with a hair follicle) such as the axillae, groin, and buttocks. 
  • Hidradenitis is an inflammatory and NOT an infectious process. 
    • The abscesses are sterile initially, but can become infected secondarily in some cases.
  • History should focus on prior treatments and what has been effective and ineffective. 
    • I&D can be offered if there is fluctuance.
      • I&D is not curative like with infectious abscesses, but offers immediate relief.
      • Packing these after drainage is generally not recommended. 
      • There is no harm in performing I&D’s in patients with HS’s long term course.
    • Antibiotics are NOT recommended after I&D unless there is surrounding cellulitis. 
  • Topical clindamycin is a safe therapy to prescribe from UC to reduce the likelihood of recurrence. 
  • Dermatologists will often prescribe an oral tetracycline for 4-6 months.
  • 1-2 week courses of low dose oral prednisone (~10mg daily) and/or intralesional injections of steroids, such as triamcinolone (5-10mg), can be helpful. 
    • Intralesional injections should target where the dermis and subcutaneous tissue meet, but should only be performed by providers with training in this procedure.
  • Longer term therapies dermatologists may prescribe for this condition include biologic therapies, such as adalimumab.
  • Surgical excision of the apocrine gland containing tissues by a plastic surgeon can be curative. 
  • Patients can reduce the likelihood of recurrence by avoiding heat, tight clothing, sweat, friction, pressure, trauma, shaving in the area, and smoking.
    • Weight loss is also helpful for reducing frequency and severity of HS flares.

 

References: 

  1. Saunte D, Jemec G. Hidradenitis Suppurativa: Advances in Diagnosis and Treatment. JAMA. 2017;318(20):2019‐2032. doi:10.1001/jama.2017.16691
  2. Lee E, Alhusayen R, et al. What is hidradenitis suppurativa?. Can Fam Physician. 2017;63(2):114‐120.
  3. Alikhan A. Hidradenitis Suppurativa. JAMA Dermatol. 2016;152(6):736. doi:10.1001/jamadermatol.2016.0185
  4. Goldburg S, Strober B, et al. Hidradenitis suppurativa: Epidemiology, clinical presentation, and pathogenesis. J Am Acad Dermatol. 2020;82:1045-58.
  5. Goldburg S, Strober B, et al. Hidradenitis suppurativa: Current and emerging therapies. J Am Acad Dermatol. 2020;82:1061-82. 

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