Management of Acute and Chronic Pain Associated With Hidradenitis Suppurativa: A Comprehensive Review of Pharmacologic and Therapeutic Considerations in Clinical Practice
Hidradenitis suppurativa (HS), a chronic, inflammatory, recurrent cutaneous disorder of the hair follicles, is debilitating and has substantial morbidity. Hidradenitis suppurativa–related pain has a profound effect on patient quality of life, yet at present, there are no established pain management algorithms. This comprehensive review provides an update on current treatment of HS-associated pain, including a summary of existing literature surrounding pharmacologic treatments of acute, perioperative, and chronic pain. Additionally, the epidemiology, pathophysiology, and clinical features of the disease are summarized.
Practice Points
- First-line therapies may not provide adequate pain control in many patients with hidradenitis suppurativa.
- Pain caused by inflamed abscesses and nodules can be treated with either intralesional corticosteroids or incision and drainage. Tissue-sparing surgical techniques may lead to shorter healing times and less postoperative pain.
- Long-term management involves lifestyle modifications and pharmacologic agents.
- The most effective pain remedies developed thus far are limited to surgery and tumor necrosis factor α inhibitors.
Clinical Presentation and Diagnosis
Establishing a diagnosis of HS necessitates recognition of disease morphology, topography, and chronicity. Hidradenitis suppurativa most commonly occurs in the axillae, inguinal and anogenital region, perineal region, and inframammary region.5,31 A typical history involves a prolonged disease course with recurrent lesions and intermittent periods of improvement or remission. Primary lesions are deep, inflamed, painful, and sterile. Ultimately, these lesions rupture and track subcutaneously.15,25 Intercommunicating sinus tracts form from multiple recurrent nodules in close proximity and may ultimately lead to fibrotic scarring and local architectural distortion.32 The Hurley staging system helps to guide treatment interventions based on disease severity. Approach to pain management is discussed below.
Pain Management in HS: General Principles
Pain management is complex for clinicians, as there are limited studies from which to draw treatment recommendations. Incomplete understanding of the etiology and pathophysiology of the disease contributes to the lack of established management guidelines.
A PubMed search of articles indexed for MEDLINE using the terms hidradenitis, suppurativa, pain, and management revealed 61 different results dating back to 1980, 52 of which had been published in the last 5 years. When the word acute was added to the search, there were only 6 results identified. These results clearly reflect a better understanding of HS-mediated pain as well as clinical unmet needs and evolving strategies in pain management therapeutics. However, many of these studies reflect therapies focused on the mediation or modulation of HS pathogenesis rather than potential pain management therapies.
In addition, the heterogenous nature of the pain experience in HS poses a challenge for clinicians. Patients may experience multiple pain types concurrently, including inflammatory, noninflammatory, nociceptive, neuropathic, and ischemic, as well as pain related to arthritis.3,33,34 Pain perception is further complicated by the observation that patients with HS have high rates of psychiatric comorbidities such as depression and anxiety, both of which profoundly alter perception of both the strength and quality of pain.7,8,22,35 A suggested algorithm for treatment of pain in HS is described in the eTable.36
Chronicity is a hallmark of HS. Patients experience a prolonged disease course involving acute painful exacerbations superimposed on chronic pain that affects all aspects of daily life. Changes in self-perception, daily living activities, mood state, physical functioning, and physical comfort frequently are reported to have a major impact on quality of life.1,3,37
