MIAMI – Clinicians have many options to treat and help people manage hidradenitis suppurativa, but for most patients, an early and accurate diagnosis remains elusive.
“The problem here is because it has so many mimickers, the diagnosis is often delayed, patients can be [treated for an incorrect diagnosis] and in many ways that treatment can be harmful,” said Adam Friedman, MD, of the George Washington University in Washington. Missed or ignored diagnoses can lead to more pain, impaired function, and wasted time and money.
“There are – no question – gaps in clinical care. Patients seek care outside of dermatology and go to urgent care centers, emergency rooms, [and other settings]. That’s why it’s not only important for us to recognize this, but to teach everyone else as well,” Dr. Friedman said at the Orlando Dermatology Aesthetic and Clinical Conference.
Tips for early detection
Look for chronicity in the disease’s presentation, Dr. Friedman said. “Chronicity is key, but the morphology will change, and lesions will look different over time.” Therefore, “the clinical presentation can be challenging, depending on when you catch the patient.”
Hidradenitis suppurativa is characterized by very purulent, indurated, abscesslike structures often on the underarms and groin. Ask patients where and how often they see lesions. Lesions in certain locations can be very disabling for patients not only because of pain, but also from a psychosocial impact. The groin and chest are prime examples. Also, there is a genetic predisposition so it is important to ask patients about family history as well.
Use combination therapy to hit disease ‘from all angles’
It is imperative to treat patients even when they present at a time of mild disease, Dr. Friedman said. “This is a chronic, snowballing disease that will get worse over time, because inflammation begets inflammation. Even if it’s mild disease, you still want to treat. Combinations are king, and we dermatologists are the synergy masters.”
Effective treatment strategies include medications that curtail inflammation and block hormonal influences; dietary changes (a minimal-dairy, low-carbohydrate diet helps some patients, for example); environmental changes and/or eliminating the invasive proliferative gelatinous mass (IPGM). “This is not step therapy,” Dr. Friedman emphasized. “You want to hit all these angles at once.”
In terms of nutritional support, “I usually put my patients on a combination of zinc and vitamin C, both anti-inflammatories, but also good for wound healing,” Dr. Friedman said. “I also get them on board with V-8, which can be a tough sell sometimes.” He recommends patients drink three small cans per week, adding that he has no financial disclosure related to the vegetable juice.
Patient education, smoking cessation, and keeping affected areas dry and cool are other important management strategies. Instruct patients that stress, friction, and obesity can each worsen the condition “I think obesity is an independent risk factor here, like it is in psoriasis, where obesity alone has been shown to increase the risk of psoriasis later on,” he said.
Ease the inflammation
Hidradenitis suppurativa is a disease of “inappropriate inflammation,” Dr. Friedman said, which explains why anti-inflammatory agents remain the mainstay of treatment. These include antibiotics, classic corticosteroids, and biologics, which all can have a role in therapy. He highlighted the potential role of the cutaneous microbiota and possible dysbiosis associated with disease activity. “I also use a lot chlorhexidine washes to wipe the microbial slate clean in high-risk areas; just be careful to avoid the face.”
Intralesional Kenalog (triamcinolone acetonide), in particular, is useful for its rapid results. “This is such a great and easy trick, and it really works quickly,” Dr. Friedman said. He added that a recent case series provides evidence for its efficacy as well ().
Three take-home treatment pointers
Dr. Friedman shared these three take-aways for treatment of hidradenitis suppurativa with antibiotics:
- The combination of oral clindamycin 300 mg twice daily and oral rifampin 300 mg twice daily carries the most evidence for efficacy and safety, with no evidence of resistance.
- Rifampin also acts against Clostridium difficile infections, which decreases the risk of associated colitis.
- Do not give a tetracycline antibiotic as monotherapy.
In terms of retinoids, “I’ve been pretty disappointed. I find them effective [in other conditions], but for hidradenitis suppurativa, I’m just not impressed, unfortunately,” Dr. Friedman said. “Antihormonal therapies such as oral contraceptives and spironolactone for women and finasteride for men have been a useful adjuncts in my practice, with evidence supporting their use in the literature, he added. Biologics are among the new treatment options, but there are cost and insurance coverage issues, Dr. Friedman said. There are small case series evaluating biologics such as infliximab, which are very supportive – and he himself has had good responses – although the Food and Drug Administration indication has been the hurdle.
One exception is the recent FDA approval of adalimumab (Humira) for hidradenitis suppurativa. “Make sure you realize that the dosing is different, more like a ‘whopping’ Crohn’s disease dose. This is a very important medication in our armamentarium – the issue is when you start it,” Dr. Friedman said. He also cautioned, “if a patient has sinus tracts and scarring, it’s not going to be enough. You still need to address that. Adalimumab is only going to get rid of the inflammation. This is why early diagnosis is so important!”
When it comes to surgery, “my philosophy is it’s all or none. If you’re going to do surgery, do surgery. You better cut these things out. Do a wide global excision,” Dr. Friedman emphasized.
Dr. Friedman is a member of the Dermatology News editorial advisory board.
Dr. Friedman had no relevant financial disclosures.