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.
Various interleukin inhibitors also have emerged as potential therapies for HS, such as ustekinumab and anakinra.36,64 Both have been subject to numerous small case trials that have reported improvements in clinical severity and pain; however, both drugs were associated with a fair number of nonresponders.36,64,65
Surgical Procedures
Although HS lesions may regress on their own in a matter of weeks, surgical drainage allows an acute alleviation of the severe burning pain associated with HS flares.36,52,53 Because of improved understanding of the disease pathophysiology, recent therapies targeting the hair follicle have been developed and have shown promising results. These therapies include laser- and light-based procedures. Long-pulsed Nd:YAG laser therapy reduces the number of hair follicles and sebaceous glands and has been effective for Hurley stage I or II disease.36,43,52,53,66 Photodynamic therapy offers a less-invasive option compared to surgery and laser therapy.52,53,66 Both Nd:YAG and CO2 laser therapy offer low recurrence rates (<30%) due to destruction of the apocrine unit.43,53 Photodynamic therapy for mild disease offers a less-invasive option compared to surgery and laser therapy.53 There is a need for larger randomized controlled trials involving laser, light, and CO2 therapies.66
Conclusion
Hidradenitis suppurativa is a debilitating condition with an underestimated disease burden. Although the pathophysiology of the disease is not completely understood, it is evident that pain is a major cause of morbidity. Patients experience a multitude of acute and chronic pain types: inflammatory, noninflammatory, nociceptive, neuropathic, and ischemic. Pain perception and quality of life are further impacted by psychiatric conditions such as depression and anxiety, both of which are common comorbidities in patients with HS. Several pharmacologic agents have been used to treat HS-associated pain with mixed results. First-line treatment of acute pain episodes includes oral acetaminophen, NSAIDs, and topical analgesics. Management of chronic pain includes utilization of topical agents, systemic agents, and biologics, as well as addressing lifestyle (eg, obesity, smoking status) and psychiatric comorbidities. Although these therapies have roles in HS pain management, the most effective pain remedies developed thus far are limited to surgery and TNF-α inhibitors. Optimization of pain control in patients with HS requires multidisciplinary collaboration among dermatologists, pain specialists, psychiatrists, and other members of the health care team. Further large-scale studies are needed to create an evidence-based treatment algorithm for the management of pain in HS.
