Hidradenitis suppurativa is a chronic, scarring, acnelike inflammatory process that occurs in the axillae, groin, and around the nipples and anus. Diagnosis is by examination. Treatment depends on stage.
Hidradenitis suppurativa is currently thought to be a chronic inflammatory condition of the hair follicle and associated structures. Follicular inflammation and subsequent occlusion leads to rupture of the follicle and development of abscesses, sinus tracts, and scarring.
Swollen, tender masses resembling cutaneous abscesses develop. These lesions are often sterile. Pain, fluctuance, discharge, and sinus tract formation are characteristic in chronic cases. In chronic cases, bacterial infection may occur in deep abscesses and sinus tracts. In chronic axillary cases, coalescence of inflamed nodules causes palpable cordlike fibrotic bands. The condition may become disabling because of pain and foul odor.
Diagnosis of Hidradenitis Suppurativa
Clinical evaluation
In this photo, multiple sinus tracts (shown as cordlike linear structures) suggest moderate hidradenitis suppurativa.
Photo courtesy of Karen McKoy, MD.
This patient has both scarring (with hyperpigmentation) and abscesses resulting from hydradenitis suppurativa.
© Springer Science+Business Media
This patient has multiple chronically draining abscesses (blue arrow) and sinus tracts (black arrows).
© Springer Science+Business Media
In this photo, multiple sinus tracts (shown as cordlike linear structures) suggest moderate hidradenitis suppurativa.
Photo courtesy of Karen McKoy, MD.
This patient has both scarring (with hyperpigmentation) and abscesses resulting from hydradenitis suppurativa.
© Springer Science+Business Media
This patient has multiple chronically draining abscesses (blue arrow) and sinus tracts (black arrows).
© Springer Science+Business Media
Diagnosis of hidradenitis suppurativa is by examination. Cultures should be taken from deep abscesses and sinus tracts in patients who have chronic disease, but often no pathogens will be found. The Hurley staging system describes the severity of disease:
Stage I: Abscess formation, single or multiple, without sinus tracts or scarring
Stage II: Single or multiple, widely separated, recurrent abscesses with sinus tract formation or scarring
Stage III: Diffuse or near diffuse involvement or multiple interconnected sinus tracts and abscesses across the entire area
Treatment of Hidradenitis Suppurativa
Stage I: Topical clindamycin, intralesional corticosteroids, and oral antibiotics
Stage II: Longer courses of oral antibiotics, antiandrogenic agents, and sometimes drainage, de-roofing, or punch debridement
Stage III: Infliximab, adalimumab, or secukinumab and often wide surgical excision and repair or grafting
Hidradenitis suppurative treatment goals are to prevent new lesions, reduce inflammation, and remove sinus tracts (1).
For Hurley stage I disease,typical treatment includes topical 1% clindamycin solution 2 times a day, topical resorcinol 15% cream once a day, oral zinc gluconate (90 mg once a day), intralesional corticosteroids (eg, 0.1 to 0.5 mL of a 5- to 10-mg/mL solution of triamcinolone acetonide once a month), and short (eg, 7- to 10-day) courses of oral antibiotics. Tetracycline, doxycycline, minocycline, or erythromycin are used until the lesions resolve. A typical regimen could include one topical treatment (eg, based on the patient's skin sensitivity) and an oral antibiotic; however, all treatments can be used in combination or alone. The skin is washed with benzoyl peroxide.
For Hurley stage II disease,treatment is with a longer (eg, 2- to 3-month) course of the same oral antibiotics used to treat stage I disease; if response is incomplete, clindamycin and/or rifampin may be added to the regimen. Adding antiandrogen therapy (eg, with oral estrogen or combination oral contraceptives, spironolactone, cyproterone acetate [not available in the United States], finasteride, or combinations) may be helpful in women. Incision and drainage may reduce the pain of an abscess but are insufficient for disease control (unlike in common cutaneous abscesses). For acute inflammatory lesions that are not excessively deep, punch debridement (ie, excision with a 5- to 7-mm punch instrument followed by digital debridement and curettage or scrubbing) is preferable. Sinus tracts should be unroofed and debrided. Patients whose lesions are deeper should be evaluated by a plastic surgeon for consideration of excision and grafting.
For Hurley Stage III disease,medical and surgical therapy should be more aggressive. Evidence of efficacy in reducing inflammation is strongest for infliximab (2). Alternatively, adalimumab may be given (3). Secukinumab is also now available and efficacious (4). Oral retinoids (isotretinoin for 4 to 6 months or acitretin for 9 to 12 months) have been effective in some patients (5). Wide surgical excision and repair or grafting of the affected areas is often necessary if the disease persists. Ablative laser therapy (CO2 or erbium:YAG) is an alternate surgical treatment (6). Laser hair removal has also been used with some success (7).
Recommended adjunctive measures for all patients with hidradenitis suppurativa include maintaining good skin hygiene, minimizing trauma, providing psychological support, and possibly avoiding high glycemic–load foods.
Treatment references
1. Alikhan A, Sayed C, Alavi A, et al: North American clinical management guidelines for hidradenitis suppurativa: A publication from the United States and Canadian Hidradenitis Suppurativa Foundations: Part II: Topical, intralesional, and systemic medical management. J Am Acad Dermatol 81(1):91-101, 2019. doi: 10.1016/j.jaad.2019.02.068
2. Shih T, Lee K, Grogan T, Deet al: Infliximab in hidradenitis suppurativa: A systematic review and meta-analysis.Dermatol Ther 35(9):e15691, 2022. doi: 10.1111/dth.15691
3. Kimball AB, Okun MM, Williams DA, et al: Two Phase 3 Trials of Adalimumab for Hidradenitis Suppurativa.N Engl J Med 375(5):422-434, 2016. doi: 10.1056/NEJMoa1504370
4. Kimball AB, Jemec GBE, Alavi A, et al: Secukinumab in moderate-to-severe hidradenitis suppurativa (SUNSHINE and SUNRISE): week 16 and week 52 results of two identical, multicentre, randomised, placebo-controlled, double-blind phase 3 trials.Lancet 401(10378):747-761, 2023. doi: 10.1016/S0140-6736(23)00022-3
5. Matusiak L, Bieniek A, Szepietowski JC: Acitretin treatment for hidradenitis suppurativa: a prospective series of 17 patients.Br J Dermatol 171(1):170-174, 2014. doi: 10.1111/bjd.12884
6. Tierney E, Mahmoud BH, Hexsel C, et al: Randomized control trial for the treatment of hidradenitis suppurativa with a neodymium-doped yttrium aluminium garnet laser. Dermatologic Surgery 35(8):1188-1198, 2009. doi: 10.1111/j.1524-4725.2009.01214.x
7. Xu LY, Wright DR, Mahmoud BH, et al: Histopathologic study of hidradenitis suppurativa following long-pulsed 1064-nm Nd:YAG laser treatment. Arch Dermatol 147(1):21-28, 2011. doi: 10.1001/archdermatol.2010.245
Key Points
Lesions are usually sterile except for deep abscesses and sinus tracts in chronic disease.
Hidradenitis suppurativa can be disabling.
Treat hidradenitis suppurativa based on the Hurley staging system.
Adjunctive measures include maintaining good skin hygiene, minimizing trauma, providing psychological support, and possibly avoiding a high glycemic load diet.
