Evidence supports combined treatments to target the many factors tied to hidradenitis suppurativa.
The estimated pervasiveness of hidradenitis suppurativa (HS) in the United States ranges from a low of 0.006% to a high of 4.1% in the general population.
This compares to a prevalence of 2.2% for psoriasis in the United States.
Dr. Friedman“This is an extremely common condition, but a condition that is identified late,” says Adam Friedman, M.D., an associate professor and residency program director of dermatology at George Washington School of Medicine and Health Sciences in Washington, D.C. “The reality, though, is that we do not know the actual prevalence. The range is extraordinary.”
Dr. Friedman, who gave a presentation on HS at the Orlando Dermatology Aesthetic & Clinical Conference (ODAC) in Miami in January, says patients are affected physically with pain, discomfort, ongoing dysfunction and even permanent scarring.
But the impact may be even greater from a psychosocial perspective. “There is the potential social ostracism, not to mention the mental impact of having a chronic inflammatory disease” says Dr. Friedman, in a post-presentation interview with Dermatology Times.
As with psoriasis and eczema, HS is a systemic disease.
“HS is not infection,” Dr. Friedman notes. “It is a mix of inappropriate immune stimulation.”
Likewise, analogous inflammatory cascades, as seen with acne, cause the HS lesions in the groin, under the breasts, in the buttocks and in the armpits.
Recent studies show that patients with HS are at much higher risk for multiple medical problems, including diabetes and peripheral vascular disease (PVD).
“This list is similar to what we find with psoriasis,” Dr. Friedman says.
Factors that worsen HS, and may negate the effects of treatment, are drugs (lithium, androgenic medications), smoking, stress, friction (rubbing, squeezing, pinching) and obesity.
However, HS is not an easy disease to diagnose.
“Based on the data, the condition is first identified among patients in their late 20s or early 30s,” Dr. Friedman reports.
Skin phototype V female with ulcerated plaques, sinus tracts, and scarring. Photo: Adam Friedman, M.D.
But HS usually manifests much earlier in life. For instance, in the beginning, it can look like an ingrown hair, a boil, skin acne or infection.
“Patients usually do not see a dermatologist,” Dr. Friedman says.
Instead, patients are treated by emergency medicine, where HS is managed like an infection.
“The infection is cut open, which is the worst thing you can do because that injury will create more inflammation and scarring,” Dr. Friedman explains.
Short-term medication is also not a solution, as HS is a condition that needs to be monitored long term.
“By the time these patients visit a dermatologist, a lot of damage has already occurred,” Dr. Friedman says.
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.
Hurley Stage III HS in a skin phototype 2 female. Photo: Adam Friedman, M.D.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.