HIDRADENITIS

Hidradenitis suppurativa causes you to get painful bumps under your arms, in the groin, and between the buttocks. There is no cure but lifestyle changes can bring significant relief.

How is hidradenitis diagnosed?
Three criteria must be met: (1) typical lesions, (2) typical locations, and (3) recurrences. Hidradenitis usually presents after puberty. Roughly, a third of the patients report a positive family history in a first-degree relative. Hidradenitis is underdiagnosed and frequently misdiagnosed.

Is hidradenitis contagious?
No, it cannot be passed on to another person by contact. Microbiological swabs are negative.

What causes hidradenitis?
Triggers include genetics, psychological stress, smoking, overweight, sedentary lifestyle, diet (high glycemic and dairy based foods), friction, and certain medications. Hormones likely contribute, given the female predominance (3:1), the frequent onset at the time of the first menstrual cycle, and frequent fluctuations with the menstrual cycle.

Are there associated conditions?
Patients are at increased risk for anxiety, depression, inflammatory bowel disease, arthritis, diabetes, low HDL cholesterol level, hypertriglyceridemia, peripheral vascular disease, anemia of chronic inflammation and iron-deficiency anemia.
Squamous cell carcinoma may occur as a late complication of hidradenitis that is refractory for at least 15 years but has been reported as early as 3 years after diagnosis. The presentation may be a nonhealing or slowly enlarging ulcer.

What can I do?
Do not smoke
Keep your body mass index below 25
Manage stress
Use antiseptic soaps or bath additives
Avoid tight clothing

How else is Hidradenitis treated?

There is no cure and no therapy is working for all patients. The current algorithm is in the European guidelines, published online in 2015 in a supplement of the Journal of the European Academy of Dermatology and Venereology.

The mainstay of mild hidradenitis involves antibacterial washes and topical antibiotics.
Clindamycin 0.1% twice daily is the only topical antibiotic that has been tested in randomized trials.
Resorcinol 15% cream is an exfoliating agent with anti-inflammatory properties. It decreases pain and reduces the number of days boils are present. It is used twice daily for flares but should be avoided for maintenance due to the risk of systemic absorption. Acute flares may require intralesional steroid injections, usually between 5 and 10 mg/ml. This also helps alleviate pain.

Oral antibiotics work by suppressing inflammation but may prevent oral contraceptives from being efficacious. Options include clindamycin, erythromycin, rifampin, clarithromycin, doxycycline, tetracycline, minocycline, and metronidazole. Combinations tend to work better than a single antibiotic by itself. Two antibiotics with different mechanism of action also limit the potential for drug resistance from bacteria in the body and on the skin. Clindamycin and rifampin are frequently used together, each 300 mg or 500 mg twice daily. A 3-month course is required for best results.

Spironolactone 100 – 150 mg daily can be considered as an additional therapy in women who report flares with the menstrual cycle.

The only FDA-approved treatment is the immunosuppressant adalimumab (Humira), an antibody against TNF-alpha.

Light and laser therapies are a promising new option for hidradenitis.
Intense Pulsed Light (IPL) damages hair follicles, is noninvasive and, unlike surgery, does not require hospitalization. Highton et al. treated 18 patients twice weekly for 4 weeks and found 33% improvement after 1 year.

Topical analgesics such as diclofenac sodium gel 1% or ice packs are not always sufficient. The next step is frequently acetaminophen (Tylenol). Intralesional injection of the corticosteroid triamcinolone at a dose of 10 mg/ml can reduce the pain of an acute flare within 1 day. Topical compound anesthetics combine different mechanisms but are not insurance covered. A frequently used combination includes ketamine 10%, bupivacaine 1%, diclofenac 5%, doxepin 3% and gabapentin 6%.

If all of the above is inadequate, a pain specialist needs to be involved.


Additional information:

http://www.hs-foundation.org/

European S1 guideline for the treatment of hidradenitis suppurativa/acne inversa. J Eur Acad Dermatol Venereol 2015 Apr 29(4): 619-44

Rambhatla PV, Lim HW, Hamzavi I: A systematic review of treatments for hidradenitis suppurativa. Arch Dermatol 148(4):439-46