Topical clindamycin versus systemic tetracycline in the treatment of hidradenitis suppurativa

Medical and Surgical Treatment of Hidradenitis Suppurativa: A Review

Hidradenitis suppurativa (HS) is a chronic inflammatory skin disease presenting with painful nodules, abscesses, sinus tracts, and scarring primarily affecting apocrine gland-rich intertriginous areas. HS prevalence ranges from 0.05 to 1%. The central pathogenic event in HS is believed to be the occlusion of the upper part of the folliculopilosebaceous unit, leading to the rupture of the sebofollicular canal with the consequent development of perifollicular lymphohistiocytic inflammation. The HS treatment choices are influenced by disease severity and its individual subjective impact, involving both medical and surgical interventions. However, given the chronic nature of HS, its destructive impact on social, working, and daily life of patients, its management is often frustrating for both the patient and physician. Hence, prompt and effective management strategies are urgently needed and a multidisciplinary approach is advocated. Therefore, in this article, we highlighted the main features of HS (clinical aspects, epidemiology, pathogenesis, diagnostic criteria, classifications, comorbidities, and treatments), so that awareness of this disease might be heightened in primary care physicians and surgeons, who may be the first health care providers to see patients with this disease owing to its characteristic clinical presentation (inflammatory nodules, abscesses, sinus tract, etc.).

The Clinical Pattern of Axillary Hidradenitis Suppurativa among Saudi Arabians: Mode of Presentation and Treatment Challenges

Background:

Hidradenitis suppurativa is a chronic follicular occlusive disease affecting the folliculopilosebaceous unit. The clinical course is variable, ranging from mild to severe cases. Definitive evidence-based guidelines for the management are lacking. In addition, the multifaceted clinical features and the unpredictable course of the disease make a uniform approach to treatment impractical. As a result, there are multiple therapeutic approaches. Therefore, in this study, we aim to analyze the results of management of axillary hidradenitis suppurativa among the local community in Saudi Arabia.

Materials and Methods:

A retrospective cohort database analysis of 1369 patients diagnosed and treated for axillary hidradenitis suppurativa between January 2004 and December 2013 was done. Seven hundred and forty-one (54.12%) were females and 628 (45.87%) were males. All patients with Stage I disease favored the conservative method while all patients with Stage II chose the surgical approach.

Results:

The mean age was 25.5 years. Nine hundred and seventy-four (71.15%) patients were treated conservatively; the mean healing time was 5.5 weeks. Three hundred and ninety-five (28.85%) patients were treated surgically. One hundred and fourteen (28.9%) had incision and drainage, 281 (71.1%) had complete excision; all wounds eventually healed without significant scarring. The recurrence rate was 12.5% (122 patients) in the conservative method group and zero (0%) in the surgical method group.

Conclusions:

Hidradenitis suppurativa remains a challenging clinical condition for patients and physicians. Further studies need to focus not only on the etiology of this disease but also on the optimal treatment regimen. Public awareness programs are necessary to avoid late presentation and complications.

Photodynamic Therapy and Skin Appendage Disorders: A Review

Photodynamic therapy (PDT) is a noninvasive treatment that utilizes light treatment along with application of a photosensitizing agent. In dermatology, PDT is commonly used and approved for the treatment of oncological conditions such as actinic keratosis, Bowen disease and superficial basal cell carcinoma. In the last 2 decades however, PDT has also been used for the treatment of several nonneoplastic dermatological diseases. The present review summarizes published data on PDT application in skin appendage disorders. Our literature review shows that: (a) PDT may be a suitable treatment for acne, folliculitis decalvans, hidradenitis suppurativa, nail diseases, and sebaceous hyperplasia; (b) there is a lack of agreement on PDT features (type, concentrations and incubation period of used substances, number and frequency of PDT sessions, optimal parameters of light sources, and patient characteristics [e.g., failure to previous treatments, disease severity, body surface area involved, etc.] which should guide PDT use in these diseases);

Treatments for hidradenitis suppurativa

Hidradenitis suppurativa (HS) is not easily treated. Although not uncommon, HS is often misdiagnosed outside specialized clinics and inappropriately treated as a simple boil or abscess. In recent years, guidelines have been developed on the basis of expert opinion and the available literature. A multifaceted approach is necessary as HS lesions include both inflammation (amenable to medical treatment) as well as fibrosis (amenable to surgery only). The recommended antiinflammatory therapies encompass both antimicrobials and regular anti-inflammatory drugs. We have, therefore, reviewed treatments with the following agents: clindamycin, tetracycline, rifampicin, ertapenem, dapsone, triamcinolone, infliximab, adalimumab, and anakinra. The development of new medical treatments, however, is an ongoing effort, and important new data have been presented since the publication of the guideline. The current approach to the management of fibrotic lesions is surgery. It is important, as manifest fibrosis is generally not susceptible to medical treatment. Here minor excision, carbon dioxide-laser, and major surgery are discussed, and current evidence supporting their use is provided. A comprehensive three-pronged approach with adjuvant therapy, medical therapy, and surgery is recommended. The importance of adjuvant therapy, that is, pain management, wound care, and attention, is stressed. Adjuvant therapy not only plays a major role in patients' perception of a successful treatment but also is of practical importance to their coping and self-management. HS presents a significant unmet need, and this review provides a mechanistic update on the current real-world therapeutic option for the management of this distressing disease.

An Update on Medical Treatment Options for Hidradenitis Suppurativa

Hidradenitis suppurativa (HS) is a chronic inflammatory skin disease characterized by recurrent inflammatory nodules mostly located in the armpits and groin. Over the years multiple treatments for HS have been proposed; however, to date a cure is still lacking. In this update we provide an overview of most drug treatments reported on for HS, where possible with their mode of action and side effects. In mild cases, clindamycin lotion or resorcinol cream have proven effective. Tetracyclines are a first-line systemic option in more widespread or severe cases, followed by the combination of clindamycin and rifampicin. However, the recurrence rate is high after discontinuation of clindamycin plus rifampicin combination therapy. Long-term treatment with retinoids, especially acitretin is feasible, although teratogenicity has to be taken into account in females of reproductive age. Multiple anti-inflammatory drugs have been suggested for HS, such as dapsone, fumarates or cyclosporine. However, their effectiveness in HS is based on small case series with varying results. If most common treatments have failed, biologics (e.g., infliximab or adalimumab) are the next step. Although not addressed in this review, surgical interventions are often needed to achieve remission.

Intralesional triamcinolone for flares of hidradenitis suppurativa (HS): A case series

BACKGROUND

Hidradenitis suppurativa (HS) is a chronic inflammatory disease of the hair follicle. Standard practice of managing acute flares with corticosteroid injection lacks scientific evidence.

OBJECTIVE

We sought to assess the outcomes of routine treatment using intralesional triamcinolone (triamcinolone acetonide 10 mg/mL) in the management of acute flares in HS.

METHODS

This was a prospective case series evaluating the effect of intralesional corticosteroids for alleviation of acute flares in HS. Physician- and patient-reported outcomes were noted.

RESULTS

Significant reductions in physician-assessed erythema (median score from 2-1, P < .0001), edema (median score from 2-1, P < .0001), suppuration (median score from 2-1, P < .0001), and size (median score from 3-1, P < .0001) was demonstrated at follow-up. A significant difference in patient-reported pain visual analog scale scores occurred after 1 day (from 5.5-2.3, P < .005) and from day 1 to day 2 (from 2.3-1.4, P < .002).

LIMITATIONS

Small study size, open single-arm design, and short follow-up time are the limitations of this study.

CONCLUSION

Intralesional injection of corticosteroids is perceived as beneficial by physicians and patients in the management of HS flares by reducing pain after 1 day and signs of inflammation approximately 7 days later.

Hidradenitis Suppurativa

Background:

Hidradenitis suppurativa is a clinically defined disease that causes considerable morbidity for patients. The results of recent studies, which have increased the understanding of this disease, are reviewed.

Objective:

The epidemiology, risk factors, pathogenesis, and treatment of this disease are summarized to help clinicians with practical patient management.

Conclusion:

Hidradenitis suppurativa remains a clinical challenge to patients and physicians alike. Physicians should be familiar with the impact this disease has on the patient and with the range of treatments available. Use of simple incisions as treatment is strongly discouraged. Additional pathogenic as well as therapeutic studies are necessary.

Management of hidradenitis suppurativa

Hidradenitis suppurativa is a recurring chronic inflammatory debilitating skin disease of the hair follicle that usually presents with painful, deep-seated and inflamed lesions in the apocrine gland-bearing areas of the body. The lesions often progress to become chronic with purulent discharge, sinus formation and scarring. Hidradenitis suppurativa is associated with systemic comorbidities, including metabolic syndrome and inflammatory bowel disease.(1) Long-term treatment is often necessary and requires coordination between primary care, dermatologists and surgeons. However, there is a lack of good quality evidence and a paucity of authoritative guidance on treatment strategies. In this article, we review the diagnosis and management of hidradenitis suppurativa and discuss some new developments, including the use of cytokine modulators.

Evidence-based approach to the treatment of hidradenitis suppurativa/acne inversa, based on the European guidelines for hidradenitis suppurativa

Hidradenitis suppurativa/acne inversa (HS) is a chronic inflammatory skin disease characterized by painful, recurrent nodules and abscesses that rupture and lead to sinus tracts and scarring. To date, an evidence-based therapeutic approach has not been the standard of care and this is likely due to the lack of evidence based treatment guidelines. The purpose of this study was to promote a holistic evidence-based approach which implemented Level of Evidence and Strength of Recommendation for the treatment of HS. Based upon the European Dermatology Forumguidelines for the management of HS, evidence-based approach was explored for the treatment of HS. The diagnosis of HS should be made by a dermatologist or other healthcare professional with expert knowledge in HS. All patients should be offered adjuvant therapy as needed (pain management, weight loss, tobacco cessation, treatment of super infections, and application of appropriate dressings). The treating physician should be familiar with disease severity scores, especially Hurley staging, physician global assessment and others. The routine use of patient'reported outcomesincluding DLQI, itch and pain assessment (Visual Analogue Scale) is strongly recommended. The need for surgical intervention should be assessed in all patients depending upon type and extent of scarring, and an evidence-based surgical approach should be implemented. Evidence-based medical treatment of mild disease consists of topical Clindamycin 1 % solution/gel b.i.d. for 12 weeks or Tetracycline 500 p.o. b.i.d. for 4 months (LOE IIb, SOR B), for more widespread disease. If patient fails to exhibit response to treatment or for a PGA of moderate-to-severe disease, Clindamycin 300 p.o. b.i.d. with Rifampicin 600 p.o. o.d. for 10 weeks (LOE III, SOR C) should be considered. If patient is not improved, then Adalimumab 160 mg at week 0, 80 mg at week 2; then 40 mg subcutaneously weekly should be administered (LOE Ib, SOR A). If improvement occurs then therapy should be maintained as long as HS lesions are present. If the patient fails to exhibit response, then consideration of second or third line therapy is required. A growing body of evidence is being published to guide the treatment of HS. HS therapy should be based upon the evaluation of the inflammatory components as well as the scarring and should be directed by evidence-based guidelines. Treatment should include surgery as well as medical treatment. Future studies should include benefit risk ratio analysis and long term assessment of efficacy and safety, in order to facilitate long term evidence based treatment and rational pharmacotherapy.

Acitretin

Background:

Hidradenitis suppurativa (HS) is a chronic, recurrent inflammatory disease of the pilosebaceous follicle that severely affects patients’ quality of life and can be challenging for clinicians to manage. A few case series have reported on the efficacy of acitretin monotherapy in the treatment of intractable HS.

Objective:

To assess the efficacy of acitretin for the treatment of intractable HS.

Methods:

A retrospective review was conducted involving all patients with HS who received acitretin between January 2011 and January 2015 in a tertiary academic medical center. All patients with HS who received acitretin, either as a monotherapy or as an adjuvant to other systemic medications, were included, and clinical response was assessed using the physician global scale.

Results:

Fourteen patients with HS (mean age 48 years [range 32-64 years]; 9 [64%] were men) received acitretin. Most patients (86%) had Hurley stage II or III disease. All patients had failed other standard systemic medications prior to initiating acitretin. Six patients (43%) received acitretin monotherapy, and 8 patients (57%) received acitretin as an adjuvant to other standard systemic medications. None of the patients who received acitretin monotherapy exhibited clinical improvements. Clinical improvements were observed in 7 of the 8 (87.5%) patients who received acitretin as an adjuvant to other systemic medications, with 3 patients (37.5%) exhibiting partial response and 4 patients (50%) exhibiting good response.

Conclusions and Relevance:

Acitretin monotherapy was ineffective for the treatment of intractable HS. Acitretin may be effective when used as an adjuvant to other systemic medications.

Hidradenitis Suppurativa in 64 Female Patients: Retrospective Study Comparing Oral Antibiotics and Antiandrogen Therapy

Background:

Hidradenitis suppurativa (HS) is a recurrent disease confined to apocrine gland-bearing areas causing painful, deep-seated lesions and draining sinus tracts. Uniformly effective therapy is lacking. Improvements in current medical management strategies are needed.

Objective:

We sought to determine the success rate for a variety of treatments in our female HS patients and whether androgen-related tests can predict a response to antiandrogen therapy. As HS has been linked to a hyperandrogen state, we sought to determine if it is also associated with polycystic ovary syndrome (PCOS).

Methods:

A retrospective chart review was performed examining hormonal profiles and the response to a variety of treatments in female patients with HS.

Results:

Sixty-four female HS patients were identified (mean age 33 years). Antiandrogen therapy was superior to oral antibiotic therapy (55% vs 26%) based on a two-sample, two-sided, t-test statistic (p < .04). The prevalence of PCOS among our study patients in whom androgen markers were available was 8 of 21 (38.1%), and even if taken over all study patients, not necessarily investigated for PCOS, the prevalence was 8 of 64 (12.5%). This reflects a greater than expected prevalence among all women (10%).

Conclusion:

As a proof-of-concept study, despite limitations inherent in a retrospective chart review, there is sufficient signal to suggest that a hormonal manipulation approach to therapy should be considered in all women presenting with HS. Female patients presenting with HS should prompt investigations for underlying PCOS and insulin resistance.

Interventions for hidradenitis suppurativa: a Cochrane systematic review incorporating GRADE assessment of evidence quality

More than 50 interventions have been used to treat hidradenitis suppurativa (HS), and so therapy decisions can be challenging. Our objective was to summarize and appraise randomized controlled trial (RCT) evidence for HS interventions in adults. Searches were conducted in Medline, Embase, CENTRAL, LILACS, five trials registers and abstracts from eight dermatology conferences until 13 August 2015. Two review authors independently assessed study eligibility, extracted data and assessed methodological quality. Primary outcomes were quality of life and adverse effects of the interventions. Twelve trials, from 1983 to 2015, investigating 15 different interventions met our inclusion criteria. The median trial duration was 16 weeks and the median number of participants was 27. Adalimumab 40 mg weekly improved the Dermatology Life Quality Index (DLQI) by 4·0 points, which equates to the minimal clinically important difference for the scale, compared with placebo (95% confidence interval -6·5 to -1·5 points). Evidence quality was reduced to 'moderate' because the results are based on only a single study. Adalimumab 40 mg every other week was ineffective in a meta-analysis of two studies comprising 124 participants. Infliximab 5 mg kg(-1) improved the DLQI score by 8·4 points after 8 weeks in a moderate-quality study completed by 33 of 38 participants. Etanercept 50 mg twice weekly was ineffective. Inclusion of a gentamicin sponge prior to primary closure did not improve outcomes. Other interventions, including topical and oral antibiotics, were investigated by relatively small studies, preventing treatment recommendations due to imprecision. More, larger RCTs are required to investigate most HS interventions, particularly oral treatments and surgical therapy. Moderate-quality evidence suggests that adalimumab given weekly and infliximab are effective, whereas adalimumab every other week is ineffective.

Recalcitrant Hidradenitis Suppurativa: An Investigation of Demographics, Surgical Management, Bacterial Isolates, Pharmacologic Intervention, and Patient-reported Health Outcomes

Hidradenitis suppurativa (HS) is characterized by chronic inflammation, recurrent abscesses, and scarring. Surgery is performed when medical management and antibiotic therapy fails. This study sought to evaluate the demographics, surgical procedures, bacteriology, pharmacologic intervention, and quality of life of patients with recalcitrant HS requiring surgical intervention. A retrospective chart review was performed of 76 recalcitrant HS patients at the University of Illinois Medical Center. Patient demographics, bacterial culture, and surgery data were reviewed. Quality of life was assessed using the 36-item short-form health survey. Patients were mostly female (73.7%) and African American (81.6%) with a mean duration of symptoms of 8.6 years before surgery. Patients underwent at least one surgical procedure, most often to the axillae (57.6%) and 73.7 per cent received antibiotics. The most common culture isolates were Corynebacterium species (14.0%), Staphylococcus epidermidis (13.1%), and Staphylococcus aureus (10.4%) with varying resistance patterns. Surveyed patients had depressed 36-item short-form health survey physical functioning and social functioning scores. Recalcitrant HS patients with progressive symptomology over approximately nine years before surgical intervention were more likely to be African American women with axillary HS. Quality of life was diminished. We recommend initial treatment of HS with clindamycin and trimethoprim–sulfamethoxazole in clindamycin refractory cases.

Hidradenitis Suppurativa: A Guide for the Practicing Physician

Hidradenitis suppurativa is a chronic inflammatory disease of apocrine gland-bearing skin. Although immunologic derangements, genetic predisposition, obesity, and smoking are likely important factors, the pathogenesis of the disease and the effect of available treatments on disease course have not been fully elucidated. In the absence of proper treatment, chronic inflammation results in diffuse scarring and a wide array of complications, including the development of cutaneous squamous cell carcinoma. This severe and chronic disease can have detrimental effects on self-esteem and quality of life. No ideal treatment regimen has been defined, but several therapies have been found to reduce lesion severity and improve symptoms. We reviewed the literature through July 2014 for existing treatments. Published articles were obtained via systematic review of medical databases (PubMed, Embase, Google Scholar) and scrutiny of citation lists using the search terms "hidradenitis suppurativa" and "acne inversa". Given the scarce literature on treatment strategies, we also reviewed data from any case reports or prospective and retrospective studies that were located. On the basis of the existing literature, we provide an evidence-based algorithm for the management of this disease in the primary care setting. More research is needed to evaluate the comparative effectiveness of topical and systemic treatments and to better understand the pathogenesis, natural history, and subtypes of hidradenitis suppurativa.

Interventions for hidradenitis suppurativa

BACKGROUND

Hidradenitis suppurativa (HS) is a chronic inflammatory skin condition characterised by recurrent painful boils in flexural sites, such as the axillae and groin, that affects about 1% of the population, with onset in early adulthood.

OBJECTIVES

To assess the effects of interventions for HS in people of all ages.

SEARCH METHODS

We searched the following databases up to 13 August 2015: the Cochrane Skin Group Specialised Register, CENTRAL in the Cochrane Library (Issue 7, 2015), MEDLINE (from 1946), EMBASE (from 1974), and LILACS (from 1982). We also searched five trials registers and handsearched the conference proceedings of eight dermatology meetings. We checked the reference lists of included and excluded studies for further references to relevant trials.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of all interventions for hidradenitis suppurativa.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed study eligibility and methodological quality and performed data extraction. Our primary outcomes were quality of life, measured by a validated dermatology-specific scale, and adverse effects of the interventions.

MAIN RESULTS

Twelve trials, with 615 participants, met our inclusion criteria. The median number of participants in each trial was 27, and median trial duration was 16 weeks. The included studies were conducted over a 32-year time period, from 1983 to 2015. A single RCT that was underpowered to detect clinically meaningful differences investigated most interventions.There were four trials of anti-TNF-α (tumour necrosis factor-alpha) therapies, which included etanercept, infliximab, and adalimumab. Adalimumab 40 mg weekly improved the Dermatology Life Quality Index (DLQI) score in participants with moderate to severe HS by 4.0 points relative to placebo (95% confidence interval (CI) -6.5 to -1.5 points), an effect size approximately equal to the DLQI minimal clinically important difference. We reduced the evidence quality to 'moderate' because the effect size was based on the results of only one study. In a meta-analysis of two studies with 124 participants, standard dose adalimumab 40 mg every other week was ineffective compared with placebo (moderate quality evidence). In a smaller study of 38 participants, of whom only 33 provided efficacy data, infliximab 5 mg/kg treatment improved DLQI by 8.4 DLQI points after eight weeks. Etanercept 50 mg twice weekly was well tolerated but ineffective.In a RCT of 200 participants, no difference was found in surgical complications (week one: risk ratio (RR) 0.78, 95% CI 0.58 to 1.05, moderate quality evidence) or risk of recurrence (after three months: RR 0.96, 95% CI 0.68 to 1.34, moderate quality evidence) in those randomised to receive a gentamicin-collagen sponge prior to primary closure compared with primary closure alone.RCTs of other interventions, including topical clindamycin 1% solution; oral tetracycline; oral ethinylestradiol 50 mcg with either cyproterone acetate 50 mg or norgestrel 500 mcg; intense pulsed light; neodymium-doped yttrium aluminium garnet (Nd:YAG) laser; methylene blue gel photodynamic therapy; and staphage lysate, were relatively small studies, preventing firm conclusions due to imprecision.

AUTHORS' CONCLUSIONS

Many knowledge gaps exist in RCT evidence for HS. Moderate quality evidence exists for adalimumab, which improves DLQI score when 40 mg is given weekly, twice the standard psoriasis dose. However, the 95% confidence interval includes an effect size of only 1.5 DLQI points, which may not be clinically relevant, and the safety profile of weekly dosing has not been fully established. Infliximab also improves quality of life, based on moderate quality evidence.More RCTs are needed in most areas of HS care, particularly oral treatments and the type and timing of surgical procedures. Outcomes should be validated, ideally, including a minimal clinically important difference for HS.

Cyclosporine treatment of severe Hidradenitis suppurativa--A case series

BACKGROUND

Hidradenitis suppurativa (HS) is an overlooked but common disease severely affecting both genders. HS is generally perceived as difficult to treat and although a number of treatments are available, the need for more effective treatment is apparent.

OBJECTIVES

Cyclosporine A (CsA) has been suggested as an effective treatment in four smaller case series. It was therefore decided to review a larger series of cases, reporting all outcomes in order to provide a less biased base for evaluating the potential of CsA for use in HS.

METHODS

An exploratory retrospective review of case notes was performed at three departments of dermatology with a special interest in HS, where HS had been treated with CsA in the period 2009-2012.

RESULTS

In total, 18 HS patients treated with CsA were identified and analysed and 50% reported some benefit. All patients had previously been treated with multiple various other modalities.

LIMITATIONS

This is an exploratory retrospective review with a limited number of patients.

CONCLUSIONS

This retrospective review found some effect of CsA in the recalcitrant cases studied, mainly reported as "slight improvement". This may be due to a number of factors which may have overestimated (e.g., concommitant therapy) or underestimated (e.g., case selection of recalcitrant cases) the effect, and indicates the need for prospective evaluation of the claims. The present data provide a basis for power calculations in future studies investigating the potential for treating HS with CsA in a randomised controlled trial.

Hidradenitis Suppurativa and Wound Management

Hidradenitis suppurativa (HS) is a chronic, burdensome, debilitating disease of the hair follicle. It presents with recurrent painful inflamed and noninflamed lesions usually in specific body areas such as axillary, inguinal, perineal, and genital areas. It is associated with a large range of other diseases and conditions, such as obesity, arthropathy, inflammatory bowel diseases, and sqaumous cell carcinoma. Medical therapy may be systemic or topical, mainly based on antibiotics, retinoids, hormones and immunosuppressive drugs, including biological therapies. Surgical and laser therapies may be a valid therapeutic approach in order to treat locally recurring lesions. The aim of this article is to review the wound healing options after skin excision and laser treatments, with a focus on lesions left to heal by secondary intention, analyzing the efficacy of moist wound dressings, negative pressure wound therapy, bioactive dressings, such as platelet-rich plasma gel and hylarunoic acid scaffold, or autologous keratinocyte suspension in platelet concentrate and skin-grafting tecniques.

Hidradenitis Suppurativa: A Frequently Missed Diagnosis, Part 2: Treatment Options

Hidradenitis suppurativa (HS) is a chronic inflammatory disorder of the intertriginous area. Patients with HS have several challenges to their quality of life and activities of everyday living, including malodor, purulent discharge, and discomfort. There is often a delay in diagnosis and appropriate treatment. The need for cosmetically acceptable local treatments and dressing application makes this disease an important challenge for wound care specialists. The choice of optimal treatment varies depending on the disease severity, expert knowledge, the availability of an interprofessional team, and patient factors.

Severe hidradenitis suppurativa treatment using platelet-rich plasma gel and Hyalomatrix

Hidradenitis suppurativa (HS) can be a debilitating chronic disease. The underlying cause of the disease is still not clear. HS may be managed through numerous different medical or surgical procedures. Surgical treatment may consist of local excisions and reconstruction using a variety of methods: perforator flaps, skin grafts, local flaps, primary closure or secondary wound healing with vacuum and other devices. This report describes our experience with surgical excision and closure using platelet-rich plasma (PRP) gel and Hyalomatrix PA (HPA) in a patient with severe HS involving most of the body surface. We treated the patient with resection of severe HS of the nuchae and closure with PRP gel prepared with the RegenKit(®) to promote neovascularisation and HPA, a delivery system for hyaluronic acid, to induce a neodermis at the wound bed and to stimulate regeneration in a humid and protected environment. Complete wound healing was achieved after 2 months. The obtained result proved the efficacy of this treatment without complications. No recurrence was observed during the 1 year after the surgical procedure. Severe HS can be safely and effectively managed with wide excision, PRP gel and Hyalomatrix to achieve a successful outcome.

Recurrence rate and patient satisfaction of CO2 laser evaporation of lesions in patients with hidradenitis suppurativa: a retrospective study

BACKGROUND

Hidradenitis suppurativa (HS) is a debilitating disease and is difficult to treat. Validation of surgical techniques is therefore of great importance in the management of HS. Carbon dioxide (CO2) laser evaporation has been shown effective, but larger-scale studies are scarce.

OBJECTIVE

To determine the recurrence rate, time to recurrence, and factors influencing disease recurrence in skin treated with CO2 laser evaporation, and healing by secondary intention; and patients' satisfaction with treatment.

METHODS

Fifty-eight patients treated with CO2 laser evaporation were interviewed regarding recurrence and satisfaction after a mean of 25.7 months.

RESULTS

Seventeen of 58 (29%) reported recurrence of HS lesions within the borders of the treated areas after a mean of 12.7 months. Obesity was a risk factor for recurrence with a hazard ratio of 4.53. Fifty-five patients (95%) reported some or great improvement, and 91% would recommend the CO2 laser surgery to other HS patients.

CONCLUSION

This study supports the claim that CO2 laser treatment is an effective modality for recurrent HS lesions in a majority of patients. The authors identified obesity as a risk factor for recurrence. Self-reported satisfaction is high, and only 3 of 58 report no change in the condition. None reported a worsening.

The medical and laser management of hidradenitis suppurativa

Hidradenitis suppurativa (HS) is a chronic, debilitating skin disease characterized by painful recurrent nodules and abscesses. In advanced stages, sinus tracts form, with resulting fibrotic and cribriform scar formation, leading to dermal contractures and induration of the affected skin. The epidemiology of HS is poorly described, and few population-based studies exist. The reported incidence varies from 0.0003 to 4%. Effective treatment options for HS are limited, and randomized controlled trials addressing the safety and/or efficacy of available treatments are scarce. No medical treatment to date has been approved by the US FDA specifically for the treatment of HS. While some evidence of disease improvement exists with agents including clindamycin and rifampicin, metformin, fumarates, infliximab, and adalimumab, no single treatment has shown overwhelmingly positive outcomes. The lack of randomized controlled trials for most treatments and often disappointing treatment outcomes is disheartening. This study reviews the published evidence for treatment options for HS.

European S1 guideline for the treatment of hidradenitis suppurativa/acne inversa

Hidradenitis suppurativa/acne inversa (HS) is a chronic, inflammatory, recurrent, debilitating skin disease of the hair follicle that usually presents after puberty with painful, deep-seated, inflamed lesions in the apocrine gland-bearing areas of the body, most commonly the axillae, inguinal and anogenital regions. A mean disease incidence of 6.0 per 100,000 person-years and an average prevalence of 1% has been reported in Europe. HS has the highest impact on patients' quality of life among all assessed dermatological diseases. HS is associated with a variety of concomitant and secondary diseases, such as obesity, metabolic syndrome, inflammatory bowel disease, e.g. Crohn's disease, spondyloarthropathy, follicular occlusion syndrome and other hyperergic diseases. The central pathogenic event in HS is believed to be the occlusion of the upper part of the hair follicle leading to a perifollicular lympho-histiocytic inflammation. A highly significant association between the prevalence of HS and current smoking (Odds ratio 12.55) and overweight (Odds ratio 1.1 for each body mass index unit) has been documented. The European S1 HS guideline suggests that the disease should be treated based on its individual subjective impact and objective severity. Locally recurring lesions can be treated by classical surgery or LASER techniques, whereas medical treatment either as monotherapy or in combination with radical surgery is more appropriate for widely spread lesions. Medical therapy may include antibiotics (clindamycin plus rifampicine, tetracyclines), acitretin and biologics (adalimumab, infliximab). A Hurley severity grade-relevant treatment of HS is recommended by the expert group following a treatment algorithm. Adjuvant measurements, such as pain management, treatment of superinfections, weight loss and tobacco abstinence have to be considered.

Hidradenitis suppurativa in children and adolescents: a review of treatment options

Hidradenitis suppurativa (HS) is a burdensome disease and has the potential to affect the life course of patients. It is a rare disease in children, and the recorded literature is correspondingly scarce. This article reviews the therapeutic options for HS in children and adolescents, and highlights particular differences or challenges with treating patients in this age group compared with adults. The work-up of paediatric patients with HS should include considerations of possible endocrine co-morbidities and obesity. Medical therapy of lesions may include topical clindamycin. Systemic therapy may include analgesics, clindamycin and rifampicin, finasteride, corticosteroids or tumour necrosis factor alpha (TNFα) blockers. Superinfections should be appropriately treated. Scarring lesions generally require surgery.

Management of hidradenitis suppurativa wounds with an internal vacuum-assisted closure device

BACKGROUND

Hidradenitis suppurativa is a chronic, debilitating disease that is difficult to treat. Once medical management fails, wide local excision offers the best chance for cure. However, the resultant wound often proves too large or contaminated for immediate closure.

METHODS

The authors performed a retrospective chart review of hidradenitis cases managed surgically between 2005 and 2010. Data collected included patient characteristics, management method, and outcomes. Approximately half of the patients received internal vacuum-assisted closure therapy using the vacuum-assisted closure system and delayed closure and half of the patients received immediate primary closure at the time of their excision. Delayed closure consisted of closing the majority of the wound in a linear fashion following internal vacuum-assisted closure while accepting healing by means of secondary intention for small wound areas.

RESULTS

Patients managed with internal vacuum-assisted closure had wounds on average four times larger in area than patients managed without internal vacuum-assisted closure. In both groups, all wounds were eventually closed primarily. Healing times averaged 2.2 months with internal vacuum-assisted closure and 2.7 months without. At an average follow-up time of 2.3 months, all patients with internal vacuum-assisted closure had no recurrence of their local disease.

CONCLUSIONS

Severe hidradenitis presents a treatment challenge, as surgical excisions are often complicated by difficult closures and unsatisfactory recurrence rates. This study demonstrates that wide local excision with reasonable outcomes can be achieved using accelerated delayed primary closure. This method uses internal vacuum-assisted closure as a bridge between excision and delayed primary closure, facilitating closure without recurrence in large, heavily contaminated wounds.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

[Acne inversa (hidradenitis suppurativa). From diagnosis to therapy]

An estimated 1% of the population suffers from hidradenitis suppurativa/acne inversa, a chronic inflammatory disease that is a burden for patients and doctors alike. The progressive disease often isolates the patients socially and causes constant pain. It can take years until the diagnosis is finally made. Dermatologists are often confronted with a relapsing condition and a frustrated patient. This article summarizes our understanding of the disease and outlines therapeutic options.

Pharmacologic interventions for hidradenitis suppurativa: what does the evidence say?

BACKGROUND

Hidradenitis suppurativa is a chronic debilitating skin disease that is recalcitrant to treatment.

OBJECTIVE

The aim of this article was to conduct an evidence-based review of pharmacologic interventions for the treatment of hidradenitis suppurativa (HS).

METHODS

A systematic search of MEDLINE, EMBASE, and the Cochrane database was conducted to identify controlled trials (randomized controlled trials, cohorts, and case-control studies) published in English. The abstracts were examined using predetermined inclusion and exclusion criteria. The identified studies were used to develop the recommendations. Clinically relevant outcomes that were assessed were: clinical remission, patient global assessment, physician global assessment, number of skin lesions, and improvement in Hurley's stage, or Sartorius score.

RESULTS

Overall there was sparse evidence to support the use of any treatment modality. There is fair evidence to support the use of antibacterials in HS and they should be used as first-line therapy (level II-1/grade B). There is fair evidence to support the use of intravenous infliximab in the treatment of advanced HS (Hurley's stage II and III). Given the high cost of anti-tumor necrosis factor therapy and its adverse-effect profile, intravenous infliximab should be offered to patients with severe disease affecting their daily activities who have failed antibacterial therapy (level I/grade B). There is insufficient evidence to support the use of antiandrogens in HS; consideration could be given to their use in women with mild to moderate disease (Hurley's stage I and II) who have failed antibacterial therapy and women with an abnormal hormone profile (level II-2/grade I).

CONCLUSIONS

The existing evidence suggests that antibacterials and anti-tumor necrosis factor therapy are effective in the treatment of HS. Further research is required to confirm the efficacy of the different medications within these groups and to explore the efficacy of other treatment modalities.

Long-term efficacy of infliximab in hidradenitis suppurativa

INTRODUCTION

Hidradenitis suppurativa (HS) is a chronic disease with painful, inflamed lesions in the apocrine gland-bearing areas of the body and unsatisfactory treatment. TNFα blockers have been proposed as promising treatments, but only few randomized, short-term, small controlled trials have been conducted. The aim of this study was to evaluate long-term response of HS patients treated with infliximab (IFX).

MATERIAL AND METHODS

A long-term, prospective study of 10 patients with moderate-severe refractory HS treated with IFX was performed, including assessment of therapy safety, disease severity, and activity. Previous reports on IFX treatment for HS were reviewed.

RESULTS

Lack of response was observed in 20% and relapse in 50% of patients, after a median period of 37 weeks. The median number of doses administered was 7.5 during 49 weeks. No life-threatening adverse events were detected. Systematic review of 61 previously published cases showed lack of response was associated with previous surgery, young age at diagnosis, and long time of evolution of the disease.

CONCLUSIONS

Long-term IFX therapy might be an efficient, well-tolerated, safe option for patients with short-time evolution, severe HS. Relapse is common after 8 months of continuous treatment, especially in patients with more severe disease and in those treated with IFX in monotherapy.

Management of regional hidradenitis suppurativa with vacuum-assisted closure and split thickness skin grafts

BACKGROUND

Hidradenitis suppurativa can be a debilitating chronic illness. The underlying cause of the disease is still not clear, but effective treatment of widespread regional disease relies on resection of all the involved skin and subcutaneous tissue. Closure of the resulting large wound is dependent on either flap or skin graft coverage. Many of the resulting wounds are too large for flap closure or result in unacceptable flap donor site deficits.

METHODS

We present a series of 11 patients with 24 regional disease sites treated with a protocol of excision, followed by wound vacuum-assisted closure (VAC; KCI, San Antonio, TX) therapy to stimulate angiogenesis of exposed fat, and then skin grafting with the use of VAC to support the grafts on the recipient sites.

RESULTS

Only 3 of the patients required regrafting. One patient had a VAC failure because of poor patient compliance, and 1 patient had 4 sites that each required regrafting as the epithelium would not fill in the residual open areas as it usually did in other patients. All patients were cured of their local disease.

CONCLUSIONS

Massive regional hidradenitis suppurativa can be successfully managed with wide excision, VAC therapy, and skin grafting to allow these patients to live normal and productive lives.

Depression in patients with hidradenitis suppurativa

BACKGROUND

Hidradenitis suppurativa (HS) is a chronic recurrent inflammatory skin disease with abscess formation and scarring predominantly in the inverse areas. The disease is often difficult to treat and patients experience a decreased quality of life (QoL). It is hypothesized that depression is more common in HS patients than among other dermatological patients.

OBJECTIVES

To evaluate the prevalence of depression in patients with HS.

METHODS

In total 211 HS patients were included in the study and 233 were dermatological control patients. Their QoL and depression scores were assessed using the Dermatology Life Quality Index (DLQI) and the Major Depression Inventory (MDI) questionnaires. HS severity was recorded with a questionnaire and Hurley stages were extracted from the case records.

RESULTS

The DLQI was significantly higher for HS patients than for the control patients, 8.4 ± 7.5 vs. 4.3 ± 5.6 (P < 0.0001) and correlated with Hurley stage severity scores. Mean MDI scores were significantly higher for HS patients, 11.0 vs. 7.2 (P < 0.0001). However, clinically defined depression rates according to the International Classification of Diseases, 10th edition (ICD-10) criteria were not significantly higher in HS patients compared to controls (9% vs. 6%).

CONCLUSIONS

HS is a chronic skin disease with major impact on QoL even when compared to other dermatological diseases. MDI scores in HS patients correlate with disease severity. This correlation could indicate that the MDI represents a valid measure of disease related morbidity that may serve as an outcome measure in future studies and a relevant point of intervention for individual patients.