Sebastian Faro, MD, PhD

Question

Since the average interval from onset of symptoms of Hidradenitis suppurativa to diagnosis is 7.2 years, what, based on your experience, should raise suspicion of Hidradenitis suppurativa among clinicians so that patients may receive the most appropriate treatment?

Answer

One of the most common diseases that is confused with Hidradenitis suppurativa is the “boils.” This leads to erroneous treatment. The initial characteristic lesion of Hidradenitis suppurativa is a nodule that enlarges. The skin over the nodule becomes erythematous, is painful, but typically does not develop a central pustule. The nodule may regress or rupture spontaneously, leaving an open sinus. The drainage is purulent, may become mixed with blood, and frequently has a foul odor. Physicians are not typically acquainted and knowledgeable about Hidradenitis suppurativa. Therefore, the disease is misdiagnosed as an infectious process because of abscess formation and purulent draining sinuses. Approximately 50% of lesions have been found to be bacterial culture negative. Therefore, nodule lesions that increase in size—which may or may not be associated with erythema, and may recede in size and recur—should lead to a tentative diagnosis of Hidradenitis suppurativa.

Question

How do you treat Hidradenitis suppurativa? Does this differ for patients with severe, recalcitrant Hidradenitis suppurativa?

Answer

Treatment is based on the Hurley stage. Stage I disease (90%) is treated medically; clindamycin plus rifampin is administered orally for 14 days. Typically, patients are administered oral antibiotics for up to 3 months before this therapy is considered a failure. In addition, topical clindamycin 2% may be applied, and triamcinolone acetonide can be injected into the lesion. I have started recommending adalimumab. Stage II disease is divided into early and late disease. Early disease is treated as Stage I disease. Late disease is treated initially with clindamycin + rifampin orally to reduce the inflammatory response associated with disease. Surgical intervention is initiated early. The surgical approach is wide excision of all involved tissue. Careful inspection of the surgical bed is conducted to ensure that all macroscopic, involved tissue is removed. All surgical sites are closed if there is not significant tension on the surgical site. If the surgical site cannot be closed primarily, the surgical site is covered with a biological graft to enhance re-epithelization. Surgical sites that were closed primarily and subsequently undergo dehiscence are managed by autologous epithelial grafting. Stage III disease is managed in the same manner as late Stage II.

Question

What do you believe are the most challenging aspects of treating patients with Hidradenitis suppurativa?

Answer

• Educating physicians during their residency to recognize Hidradenitis suppurativa.
• Disseminating information to the public to educate them about the early manifestations of Hidradenitis suppurativa. This will bring them to the physician early and allow less drastic treatments.
• Making the diagnosis as early as possible.
• Preventing disease progression.
• Ensuring the patient is educated about their disease, so that they become more adherent with treatment and office visits.
• Affordability of medications.
• Postoperative care.

Background: Hidradenitis Suppurativa (HS)

Hidradenitis suppurativa (HS), also known as acne inversa, is a painful chronic inflammatory, recurrent, and debilitating disorder of the hair follicles. The condition is most prevalent between the ages of 20 and 40 years, occurs 2 to 5 times more frequently in women, and is more common in blacks. Etiology of the disease, which ranges in severity from mild to severe, is unknown, and there is no cure. Quality of life can be decreased due to pain, drainage of pus, and limitations of range of motion due to scarring.¹