Conference Coverage

Recognize early window of opportunity in hidradenitis suppurativa



Soft tissue ultrasound is helpful in determining whether fistulae in patients with hidradenitis suppurativa will respond to medical therapy or require surgical excision, Antonio Martorell, MD, said at the annual congress of the European Academy of Dermatology and Venereology.

Dr. Antonio Martorell, a dermatologist at the Hospital of Manises in Valencia, Spain Bruce Jancin/MDedge News

Dr. Antonio Martorell

This distinction is critical in recognizing a window of opportunity in the management of hidradenitis suppurativa (HS): The period early in the disease course when medical therapy alone can be life-changing.

“The window of opportunity is an old concept in gastroenterology, but it’s a new idea in dermatology: It’s the moment in which the patient can have the best results with medical control of inflammation, before progression to tissue scarring has occurred,” explained Dr. Martorell, a dermatologist at the Hospital of Manises in Valencia, Spain, and coauthor of recent HS treatment recommendations by an international expert panel (J Eur Acad Dermatol Venereol. 2019 Jan;33[1]:19-31).

Symptoms in patients with HS can be caused by either dynamic or static lesions. Dynamic lesions arise directly from acute inflammation that can be treated with antibiotics and immunomodulatory therapy. Static lesions are associated with tissue scarring secondary to inflammatory activity and generally benefit only from surgery.

Dynamic lesions consist of nodules, abscesses, and some but not all fistulae. Although the traditional view among dermatologists has been that fistulae simply don’t respond to medical therapy and must be treated surgically, Dr. Martorell and coinvestigators have recently demonstrated in a retrospective study of 117 fistulae in 40 patients that ultrasound was useful in distinguishing four fistular subtypes, two of which responded reasonably well to medical management.

What the investigators call Type A or dermal fistulae are by definition not connected to tunnels. In Dr. Martorell’s study, they had a 95% complete resolution rate after 6 months of various medications. Dermoepidermal fistulae tunnel through the dermis to the epidermis; they had a 65% complete resolution rate. In contrast, Type C or complex fistulae, identified by the ultrasound finding of multiple tunnels extending through the dermis into underlying fat tissue, had no significant response to medical management. Neither did Type D fistulae, which are essentially Type C lesions with scarring (Dermatol Surg. 2019 Oct;45[10]:1237-44).

Thus, ultrasound can have an important impact on patient management and the decision to opt for a combined medical/surgical approach.

“It’s important to apply the HS severity scores and complete the clinical exam, but it’s also important to use ultrasound or another imaging technique,” Dr. Martorell concluded.

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