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 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
Hidradenitis suppurative treatment goals are to prevent new lesions, reduce inflammation, and remove sinus tracts.
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 (500 mg 2 times a day), doxycycline (100 to 200 mg once a day), minocycline (100 mg once a day), or erythromycin (250 to 500 mg 4 times a day) are used until the lesions resolve. A typical regimen could include one topical treatment (eg, based on the patient's skin sensitivity) and an 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 300 mg orally 2 times a day and/or rifampin 600 mg orally once a day may be added to the regimen. Adding antiandrogen therapy (eg, with oral estrogen or combination oral contraceptives, spironolactone, cyproterone acetate [not available in the US], 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 (5 mg/kg IV at weeks 0, 2, and 6). Alternatively, adalimumab may be given (initial dose of 160 mg subcutaneously given in 1 day or split over 2 consecutive days, followed by 1 dose of 80 mg subcutaneously on day 15 and maintenance doses of 40 mg subcutaneously once a week beginning on day 29). Oral retinoids (isotretinoin 0.25 to 0.4 mg/kg 2 times a day for 4 to 6 months or acitretin 0.6 mg/kg once a day for 9 to 12 months) have been effective in some patients. 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. Laser hair removal has also been used with some success.
Recommended adjunctive measures for all patients with hidradenitis suppurativa include maintaining good skin hygiene, minimizing trauma, providing psychologic support, and possibly avoiding high glycemic load diets.