Hidradenitis

1. HIDRADENITIS SUPPURATIVA
Review By :
Dr. Mohammad Baghaei
Cosmetic Scientist

2. HIDRADENITIS SUPPURATIVA
 Disease of the follicle
 Deep tender nodules in the groin, axilla,
buttocks
 Difficult to treat
 May respond to Accutane
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3. What is hidradenitis suppurativa?
Hidradenitis suppurativa is a chronic, recurrent,
and painful disease in which there is inflammation
in areas of the apocrine sweat glands. These
glands are found mainly in the armpits and groins.
Within hidradenitis there is a blockage of the hair
follicles. This causes a mixture of boil-like lumps,
areas leaking pus, and scarring.
Hidradenitis tends to begin in early life, and is
more common in women, black and
Mediterranean people. It affects about 1% of the
population. Hidradenitis often starts at puberty,
and is most active between the ages of 20 and 40
years, and in women, can resolve at menopause.
It is 3 times more common in females than in
males.
hidradenitis suppurativa
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4. What are the clinical features of
hidradenitis suppurativa?
 Risk factors include:
1. Other family members with hidradenitis suppurativa
2. Obesity and insulin resistance/metabolic syndrome
3. Cigarette smoking
4. Follicular occlusion disorders: acne conglobata, dissecting cellulitis,
pilonidal sinus
5. Inflammatory bowel disease (Crohn disease)
6. Rare autoinflammatory syndromes associated with abnormalities of
PSTPIP1 gene*
* PAPA syndrome (Pyogenic Arthritis, Pyoderma gangrenosum and Acne), PASH syndrome (Pyoderma
gangrenosum, Acne, Suppurative Hidradenitis) and PAPASH syndrome (Pyogenic Arthritis, Pyoderma
gangrenosum, Acne, Suppurative Hidradenitis)
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5. What causes hidradenitis suppurativa?
Hidradenitis suppurativa is an
autoinflammatory disorder. Although the exact
cause is not yet understood, contributing
factors include:
o Friction from clothing and body folds
o Aberrant immune response to commensal
bacteria
o Follicular occlusion
o Release of pro-inflammatory cytokines
o Inflammation causing rupture of the
follicular wall and destroying apocrine
glands and ducts
o Secondary bacterial infection
o Certain drugs
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6. Signs
 Hidradenitis can affect a single or multiple
areas in the armpits, neck, submammary
area, and inner thighs. Anogenital
involvement most commonly affects the
groin, mons pubis, vulva (in females),
sides of the scrotum (in males), perineum,
buttocks and perianal folds
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7. Signs
Signs include:
 Open and closed comedones
 Painful firm papules and larger nodules
 Pustules, fluctuant pseudocysts and
abscesses
 Pyogenic granulomas
 Draining sinuses linking inflammatory
lesions
 Hypertrophic and atrophic scars
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8. Severity
The severity and extent of hidradenitis suppurativa is
recorded at assessment and when determining the impact
of a treatment. The Hurley system describes three distinct
clinical stages:
1. Solitary or multiple, isolated abscess formation without
scarring or sinus tracts
2. Recurrent abscesses, single or multiple widely
separated lesions, with sinus tract formation
3. Diffuse or broad involvement, with multiple
interconnected sinus tracts and abscesses.
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9. Severity
Severe hidradenitis (Hurley Stage 3) has been
associated with:
 Male gender
 Axillary and perianal involvement
 Obesity
 Smoking
 Disease duration
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10. What is the treatment for hidradenitis
suppurativa?
General measures:
 Weight loss; follow low-glycaemic, low-dairy diet
 Smoking cessation: this can lead to improvement within a few months
 Loose fitting clothing
 Daily unfragranced antiperspirants
 If prone to secondary infection, wash with antiseptics or take bleach baths
 Apply hydrogen peroxide solution or medical grade honey to reduce
malodour
 Apply simple dressings to draining sinuses
 Analgesics, such as paracetamol (acetaminophen), for pain control.
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11. Medical management of hidradenitis
suppurativa
 Medical management of hidradenitis
suppurativa is difficult. Treatment is
required long term. Effective options are
listed below.
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12. Antibiotics
• Topical clindamycin, with benzoyl peroxide to
reduce bacterial resistance
• Short course of oral antibiotics for acute
staphylococcal abscesses, eg flucloxacillin
• Prolonged courses (minimum 3 months) of
tetracycline, metronidazole, cotrimoxazole,
fluoroquinolones or dapsone for their anti-
inflammatory action
• Six-to-twelve week courses of the
combination of clindamycin (or doxycycline)
and rifampicin for severe disease
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13. Antiandrogens
 Long-term oral contraceptive pill; antiandrogenic
progesterones drospirenone or cyproterone
acetate may be more effective than standard
combined pills. These are more suitable than
progesterone-only pills or devices.
 Spironolactone and finasteride
 Response takes 6 months or longer.
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14. Immunomodulatory treatments for
severe disease
 Intralesional corticosteroids into nodules
 Systemic corticosteroids short-term for flares
 Methotrexate, ciclosporin, and azathioprine
 TNFα inhibitors adalimumab and infliximab,
used in higher dose than required for psoriasis,
are the most successful treatments to date. Note
that paradoxically, they may sometimes induce
new-onset hidradenitis suppurativa
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15. Other medical treatments
 Metformin in patients with insulin
resistance
 Acitretin (unsuitable for females
of childbearing potential)
 Isotretinoin – effective for acne
but appears unhelpful for most
cases of hidradenitis
 Colchicine
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16. Surgical management of hidradenitis
suppurativa
 Incision and drainage of acute abscesses
 Curettage and deroofing of nodules, abscesses and
sinuses
 Laser ablation of nodules, abscesses and sinuses
 Wide local excision of persistent nodules
 Radical excisional surgery of entire affected areaa
 Nd:YAG laser hair removal
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17. TheEnd
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