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Hidradenitis Suppurativa

By

Jonette E. Keri

, MD, PhD, University of Miami, Miller School of Medicine

Reviewed/Revised Mar 2024
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Topic Resources

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

Manifestations of Hidradenitis Suppurativa

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

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 Treatment references 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... read more Treatment references ). Alternatively, adalimumab may be given (3 Treatment references 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... read more Treatment references ). Secukinumab is also now available and efficacious (4 Treatment references 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... read more Treatment references ). Oral retinoids (isotretinoin for 4 to 6 months or acitretin for 9 to 12 months) have been effective in some patients (5 Treatment references 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... read more Treatment references ). 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 Treatment references 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... read more Treatment references ). Laser hair removal has also been used with some success (7 Treatment references 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... read more Treatment references ).

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.

Drugs Mentioned In This Article

Drug Name Select Trade
Cleocin, Cleocin Ovules, Cleocin Pediatric, Cleocin T, CLIN, Clindacin ETZ, Clindacin PAC, Clindacin-P, Clinda-Derm , Clindagel, ClindaMax, ClindaReach, Clindesse, Clindets, Evoclin, PledgaClin, XACIATO
AVSOLA, INFLECTRA, Remicade, RENFLEXIS, Zymfentra
ABRILADA, AMJEVITA , CYLTEZO, HADLIMA, Hulio, Hulio PEN, Humira, HUMIRA PEN, Hyrimoz, Idacio, YUFLYMA, YUSIMRY
Cosentyx
Aristocort, Aristocort A, Aristocort Forte, Aristocort HP, Aristo-Pak, Aristospan, Arze-Ject-A, Azmacort, Children's Nasacort Allergy 24HR Nasal Spray, Cinalog, Cinolar, Flutex, Hexatrione, Kenalog, Kenalog in Orabase, Kenalog-10, Kenalog-40, Kenalog-80, Nasacort, Nasacort Allergy, Nasacort AQ, Oralone, SP Rx 228 , Tac-3 , Triacet , Triamonide , Trianex , Triderm , Triesence, XIPERE, Zilretta
Emtet-500, Panmycin, Sumycin
Acticlate, Adoxa, Adoxa Pak, Avidoxy, Doryx, Doxal, Doxy 100, LYMEPAK, Mondoxyne NL, Monodox, Morgidox 1x, Morgidox 1x Kit, Morgidox 2x , Morgidox 2x Kit, Okebo, Oracea, Oraxyl, Periostat, TARGADOX, Vibramycin, Vibra-Tabs
Amzeeq, Arestin, Cleeravue-M, Dynacin, Minocin, minolira, Myrac, Solodyn, Ximino, Zilxi
A/T/S, Akne-mycin, E.E.S., Emcin Clear , EMGEL, E-Mycin, ERYC, Erycette, Eryderm , Erygel, Erymax, EryPed, Ery-Tab, Erythra Derm , Erythrocin, Erythrocin Lactobionate, Erythrocin Stearate, Ilosone, Ilotycin, My-E, PCE, PCE Dispertab , Romycin, Staticin, T-Stat
Acne Medication, Acne-10, Acneclear, Benprox , Benzac AC, Benzac W, Benzac-10, Benzac-5, Benzagel, Benzagel-10 , Benzagel-5, BenzaShave, BenzEFoam, BenzEFoam Ultra , BenzePrO, Benziq, Benziq LS, BP Cleanser, BP Cleansing Lotion, BP Foaming Wash, BP Gel, BP Topical , BP Wash, BP Wash Kit, BPO, BPO Creamy Wash, BPO Foaming Cloth, Brevoxyl-4, Brevoxyl-8, Clean&Clear Persa-Gel, Clearplex , Clearplex X, Clearskin, Clinac BPO, Del Aqua, Delos, Desquam-E, Desquam-X, EFFACLAR, Enzoclear, EPSOLAY, Ethexderm BPW, Inova, Inova Easy Pad, Lavoclen-4 , Lavoclen-8, NeoBenz Micro, NeoBenz Micro Cream Plus Pack, NeoBenz Micro SD, NeoBenz Micro Wash Plus Pack, Neutrogena Acne Cream, OC8, Oscion, Pacnex, Pacnex HP, Pacnex LP, Pacnex MX, PanOxyl, PanOxyl 10 Maximum Strength, PanOxyl 5, PanOxyl AQ, PanOxyl Aqua, PanOxyl-10, PanOxyl-5, PanOxyl-8, Peroderm, RE Benzoyl Peroxide , Riax, SE BPO, Seba, Seba-Gel, Soluclenz Rx , Theroxide, TL BPO MX, Triaz, True Marker Lintera, Zaclir, Zoderm Cleanser , Zoderm Cream, Zoderm Gel, Zoderm Redi-Pads , Zoderm Wash
Rifadin, Rifadin IV, Rimactane
Aldactone, CAROSPIR
Propecia, Proscar
Absorica, Absorica LD, Accutane, Amnesteem , Claravis , MYORISAN, Sotret, ZENATANE
Soriatane
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