Hidradenitis suppurativa therapy successful with medical, surgical approach

Key Points

San Diego - Successful treatment of hidradenitis suppurativa (HS) often combines medical and surgical treatments, guided by increasingly sensitive symptom severity scales, according to one expert.

In medical literature, "People would talk about surgically treating this condition," says Robert A. Lee, M.D., assistant professor of medicine (dermatology), University of California, San Diego. "I always found that interesting - here you have a condition that is primarily inflammatory. But how many other rashes are treated by surgical excision? Not many."

The surgery recommendation reflects the severity of HS's impact on patients, many of whom are desperate for relief, Dr. Lee says. This recommendation also reflects how little is really known about the condition, he adds.

Confusion around HS probably began with its name, which suggests that sweat glands are causing draining, purulent inflammation, Dr. Lee says. However, he says the discoverers of HS chose the name largely because lesions generally appear where sweat glands occur most densely.

Early research appeared to confirm the idea that sweat glands play a role in HS pathology, but most experts have come to believe HS arises mainly from the impact of hair follicles, Dr. Lee says.

As with other diseases of follicular occlusion, such as nodulocystic acne, "The central idea is that the hair follicle is probably the starting point. And sweat glands probably play a secondary role" by contributing the characteristic scarring pattern of HS, he says.

Other hallmarks of HS include delays in diagnosis and treatment.

"This disease impacts private areas, often in young people, especially women. Sometimes patients are in denial or reluctant to discuss their symptoms. Even when the patient goes to the doctor, if he or she can, the patient may not present to the right physician, who might not recognize HS quickly," Dr. Lee says. The lack of a dynamic scoring system for HS symptoms has made clinical research challenging, he says. "It's hard to compare one trial versus another, sometimes even with the same medicine, when researchers use different scales to measure improvement."

HS scales

The Hurley scale, which researchers historically used, is useful for evaluating patients and planning treatments, but it is less useful for monitoring progress, Dr. Lee says. In particular, it reflects the presence of scarring caused by inflammatory abscesses and nodules (stage 3) but cannot address the patient's condition once the inflammation results. Because extensive scars may remain, the patient technically remains in Hurley stage 3, he says.

The Sartorius scale partially addresses this shortcoming (Sartorius K, Lapins J, Emtestam L, Jemec GB. Br J Dermatol. 2003;149(1):211-213), Dr. Lee says. "It's very useful for research, but like the psoriasis area and severity index (PASI), not always practical for routine clinical care." Conversely, he says, the HS Scale/Modified Sartorius Scale reflects changes in symptoms, including decreases in the number of lesions and the longest distance between lesions (Revuz J. Ann Dermatol Venereol. 2007;134(2):173-174).

"Now that we have a validated tool, we're going to be seeing better, more reliable clinical trials," Dr. Lee says.

Treatment options

"My overall philosophy is that there's a place for medical therapy and for considering surgical therapy," Dr. Lee says. Practitioners often favor medical treatments such as topical or oral antibiotics. "This appears to make sense because patients have this open, wet, warm wound." But in many cases, he says, antimicrobial treatments offer limited success.

In a 27-patient randomized, controlled trial, clindamycin improved abscesses and pustules but not inflammatory nodules at 12 weeks (Clemmensen OJ. Int J Dermatol. 1983;22(5):325-328). However, Dr. Lee says newer combination regimens, such as clindamycin and rifampin, offer some hope (Gener G, Canoui-Poitrine F, Revuz JE, et al. Dermatology. 2009;219:148-154). Other medical therapies for HS include anti-inflammatory medications, hormonal treatments and retinoids, he says.

"For clinical trials, everyone wants a medicine to be the silver bullet. I would want that, too. But the reality is that certain subsets of medicines probably will be applied better to some patients, as in acne," Dr. Lee says.

For other medications, he says, combining treatments will be the key. "Rather than just saying one particular medicine didn't work, maybe it didn't work by itself. But if you combine it with something else, the patient might get significantly better."