For treating HS, Dr. Friedman’s philosophy is to “dump the bucket on it. You want to hit this disease from multiple angles because this is a condition resulting from many factors: inflammation, bacteria, hormones, genetics, diet (high glycemic and dairy-based foods), smoking and sedentary lifestyle,” he says.
Evidence supports a number of different treatment approaches, foremost antibiotics, antihormonal therapies like oral contraceptives and spironolactone, intralesional steroid injections and topical antibacterial washes.
Treatment can even involve immunosuppressants that lower the immune system. For example, in September 2015, the biologic adalimumab (Humira, Abbott Laboratories) became the first FDA approved treatment specifically for HS, according to Dr. Friedman.
“Depending on the stage of HS, treatment strategies can be successful,” says Dr. Friedman, the residency program director of dermatology at George Washington.
Dr. Friedman’s first line of therapy for moderate disease in an otherwise healthy individual is intralesional steroids, usually between 5 and 10 mg/ml into the active lesions themselves, which also helps alleviate pain.
Patients are also placed on a combination of the antibiotics clindamycin and rifampin, each 300 mg twice daily.
“I think this combination works better than a single antibiotic by itself,” Dr. Friedman relates. “You also limit the potential for drug resistance from bacteria in the body and on the skin because you are using two antibiotics with different mechanisms of action.”
However, Dr. Friedman cautions patients that rifampin will turn their body secretions (tears, sweet and even urine) into the color orange. Moreover, rifampin prevents oral contraceptives from being efficacious.
First-line therapy also consists of a topical antibacterial wash, such as chlorhexidine to be used neck down when bathing.
Advising patients to eat well and placing them on a vitamin regimen (a combination of vitamin C, zinc and V8 tomato juice) are also part of the mix.
In addition, Dr. Friedman liberally prescribes the drug gabapentin to remedy nerve-derived pain.
“This is a very safe medication and the ceiling is extremely high as to how much you can actually use,” he says.
In severe or recalcitrant cases, Dr. Friedman encompasses all first-line therapies plus adalimumab, for which the dosing regimen is the same as for Crohn’s disease, starting with four injections on the first day.
Patients with active, swollen, red draining boils who wait 20 years to begin treatment, “also have a lot of scarring or what are called sinus tracts, which are like tunnels under the skin with openings on either end,” Dr. Friedman explains. “These tunnels facilitate pus buildup and bacteria growth.”
Although the inflammation can be managed with injections and even a biologic, the sinus tracts often need eradicating, for which Dr. Friedman advocates a wide, local incision.
“You literally scoop out the whole area of scar tissue and tracts (marsupialization), letting it heal by itself, otherwise known as secondary intention,” he says.
Dr. Friedman says such an incision can be very effective, whereas patients who seek treatment much earlier, with the signs of multiple, recurrent boils, can be managed solely from an anti-inflammatory standpoint.
Disclosure: Dr. Friedman reports no relevant financial disclosures.