hidradenitis suppurativa,by dr mohammad baghaei
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HIDRADENITIS SUPPURATIVA
Review By :
Dr. Mohammad Baghaei
Cosmetic Scientist
HIDRADENITIS SUPPURATIVA
Disease of the follicle
Deep tender nodules in the groin, axilla,
buttocks
Difficult to treat
May respond to Accutane
2
What is hidradenitis suppurativa?
Hidradenitis suppurativa is a chronic, recurrent,
and painful disease in which there is inflammation
in areas of the apocrine sweat glands. These
glands are found mainly in the armpits and groins.
Within hidradenitis there is a blockage of the hair
follicles. This causes a mixture of boil-like lumps,
areas leaking pus, and scarring.
Hidradenitis tends to begin in early life, and is
more common in women, black and
Mediterranean people. It affects about 1% of the
population. Hidradenitis often starts at puberty,
and is most active between the ages of 20 and 40
years, and in women, can resolve at menopause.
It is 3 times more common in females than in
males.
hidradenitis suppurativa
3
What are the clinical features of
hidradenitis suppurativa? Risk factors include:
1. Other family members with hidradenitis suppurativa
2. Obesity and insulin resistance/metabolic syndrome
3. Cigarette smoking
4. Follicular occlusion disorders: acne conglobata, dissecting cellulitis,
pilonidal sinus
5. Inflammatory bowel disease (Crohn disease)
6. Rare autoinflammatory syndromes associated with abnormalities of
PSTPIP1 gene*
* PAPA syndrome (Pyogenic Arthritis, Pyoderma gangrenosum and Acne), PASH syndrome (Pyoderma
gangrenosum, Acne, Suppurative Hidradenitis) and PAPASH syndrome (Pyogenic Arthritis, Pyoderma
gangrenosum, Acne, Suppurative Hidradenitis)
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What causes hidradenitis suppurativa?
Hidradenitis suppurativa is an
autoinflammatory disorder. Although the exact
cause is not yet understood, contributing
factors include:
o Friction from clothing and body folds
o Aberrant immune response to commensal
bacteria
o Follicular occlusion
o Release of pro-inflammatory cytokines
o Inflammation causing rupture of the
follicular wall and destroying apocrine
glands and ducts
o Secondary bacterial infection
o Certain drugs
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Signs
Hidradenitis can affect a single or multiple
areas in the armpits, neck, submammary
area, and inner thighs. Anogenital
involvement most commonly affects the
groin, mons pubis, vulva (in females),
sides of the scrotum (in males), perineum,
buttocks and perianal folds
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Signs
Signs include:
Open and closed comedones
Painful firm papules and larger nodules
Pustules, fluctuant pseudocysts and
abscesses
Pyogenic granulomas
Draining sinuses linking inflammatory
lesions
Hypertrophic and atrophic scars
7
Severity
The severity and extent of hidradenitis suppurativa is
recorded at assessment and when determining the impact
of a treatment. The Hurley system describes three distinct
clinical stages:
1. Solitary or multiple, isolated abscess formation without
scarring or sinus tracts
2. Recurrent abscesses, single or multiple widely
separated lesions, with sinus tract formation
3. Diffuse or broad involvement, with multiple
interconnected sinus tracts and abscesses.
8
Severity
Severe hidradenitis (Hurley Stage 3) has been
associated with:
Male gender
Axillary and perianal involvement
Obesity
Smoking
Disease duration
9
What is the treatment for hidradenitis
suppurativa?
General measures:
Weight loss; follow low-glycaemic, low-dairy diet
Smoking cessation: this can lead to improvement within a few months
Loose fitting clothing
Daily unfragranced antiperspirants
If prone to secondary infection, wash with antiseptics or take bleach baths
Apply hydrogen peroxide solution or medical grade honey to reduce
malodour
Apply simple dressings to draining sinuses
Analgesics, such as paracetamol (acetaminophen), for pain control.
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Medical management of hidradenitis
suppurativa
Medical management of hidradenitis
suppurativa is difficult. Treatment is
required long term. Effective options are
listed below.
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Antibiotics
• Topical clindamycin, with benzoyl peroxide to
reduce bacterial resistance
• Short course of oral antibiotics for acute
staphylococcal abscesses, eg flucloxacillin
• Prolonged courses (minimum 3 months) of
tetracycline, metronidazole, cotrimoxazole,
fluoroquinolones or dapsone for their anti-
inflammatory action
• Six-to-twelve week courses of the
combination of clindamycin (or doxycycline)
and rifampicin for severe disease
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Antiandrogens
Long-term oral contraceptive pill; antiandrogenic
progesterones drospirenone or cyproterone
acetate may be more effective than standard
combined pills. These are more suitable than
progesterone-only pills or devices.
Spironolactone and finasteride
Response takes 6 months or longer.
13
Immunomodulatory treatments for
severe disease
Intralesional corticosteroids into nodules
Systemic corticosteroids short-term for flares
Methotrexate, ciclosporin, and azathioprine
TNFα inhibitors adalimumab and infliximab,
used in higher dose than required for psoriasis,
are the most successful treatments to date. Note
that paradoxically, they may sometimes induce
new-onset hidradenitis suppurativa
14
Other medical treatments
Metformin in patients with insulin
resistance
Acitretin (unsuitable for females
of childbearing potential)
Isotretinoin – effective for acne
but appears unhelpful for most
cases of hidradenitis
Colchicine
15
Surgical management of hidradenitis
suppurativa
Incision and drainage of acute abscesses
Curettage and deroofing of nodules, abscesses and
sinuses
Laser ablation of nodules, abscesses and sinuses
Wide local excision of persistent nodules
Radical excisional surgery of entire affected areaa
Nd:YAG laser hair removal
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The End
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