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.
Prompt discussion about the remitting course of HS will prepare patients for flares. Although the therapies discussed here aim to reduce the clinical severity and inflammation associated with HS, achieving pain-free remission can be challenging. Barriers to developing a long-term treatment regimen include intolerable side effects or simply nonresponsive disease.36,43
Management of Perioperative Pain—Medical treatment of HS often yields only transient or mild results. Hurley stage II or III lesions typically require surgical removal of affected tissues.32,44-46 Surgery may dramatically reduce the primary disease burden and provide substantial pain relief.3,4,44 Complete resection of the affected tissue by wide excision is the most common surgical procedure used.46-48 However, various tissue-sparing techniques, such as skin-tissue-sparing excision with electrosurgical peeling, also have been utilized. Tissue-sparing surgical techniques may lead to shorter healing times and less postoperative pain.48
There currently is little guidance available on the perioperative management of pain as it relates to surgical procedures for HS. The pain experienced from surgery varies based on the area and location of affected tissue; extent of disease; surgical technique used; and whether primary closure, closure by secondary intention, or skin grafting is utilized.47,49 Medical treatment aimed at reducing inflammation prior to surgical intervention may improve postoperative pain and complications.
The use of general vs local anesthesia during surgery depends on the extent of the disease and the amount of tissue being removed; however, the use of local anesthesia has been associated with a higher recurrence of disease, possibly owing to less aggressive tissue removal.50 Intraoperatively, the injection of 0.5% bupivacaine around the wound edges may lead to less postoperative pain.3,48 Postoperative pain usually is managed with acetaminophen and NSAIDs.48 In cases of severe postoperative pain, short- and long-acting opioid oxycodone preparations may be used. The combination of diclofenac and tramadol also has been used postoperatively.3 Patients who do not undergo extensive surgery often can leave the hospital the same day.
Effective strategies for mitigating HS-associated pain must address the chronic pain component of the disease. Long-term management involves lifestyle modifications and pharmacologic agents.
