Hidradenitis Suppurativa
from – AFP > 2017 > August > Hidradenitis suppurativa Management comorbidities and monitoring Volume 46, Issue 8, August 2017
Definition & Pathophysiology
- Chronic, relapsing inflammatory skin disease affecting apocrine gland–bearing intertriginous areas.
- Characterised by:
- Painful, deep-seated inflammatory nodules
- Abscesses
- Sinus tracts
- Fistulae
- Scarring
- Previously thought to be apocrine gland disease; now recognised as a follicular occlusion disorder.
- Pathogenesis:
- Follicular occlusion → rupture → secondary dermal inflammation
- Involves dysregulated immune response (IL-1, TNF-α)
- Influenced by:
- Obesity and adipokines
- Smoking
- Insulin resistance and glucose dysregulation
- Androgen excess (especially in females)
- Dysbiosis of cutaneous microbiota
- Genetic predisposition (~1/3 have positive family history)
Epidemiology
- Global prevalence: ~1%
- Australian prevalence: 0.67%
- F:M ratio ≈ 3:1 (women more affected)
- Onset typically in late adolescence to early adulthood
- Commonly underdiagnosed and misdiagnosed (e.g. recurrent “boils”)
- Diagnostic delay contributes to disease progression and patient distress
Diagnostic Criteria
Diagnosis requires all three:
- Typical lesions: deep, painful nodules ± abscesses, sinus tracts, scarring
- Typical sites: axillae, groin, perineal/perianal, inframammary, intergluteal folds
- Chronicity & recurrence: ≥2 flares within 6 months
Additional workup:
- Full skin examination (Hurley staging)
- Inflammatory markers (CRP, ESR)
- Screen for comorbidities: metabolic, endocrine, psychological
- Consider pelvic/transabdominal US if PCOS suspected in women
Hurley Staging System
| Stage | Findings |
|---|---|
| I | Single/multiple abscesses, no sinus tracts or scarring |
| II | Recurrent abscesses with sinus tracts/scarring, widely separated lesions |
| III | Diffuse involvement, interconnected tracts and abscesses |
Common Comorbidities (data from Liverpool Dermatology Clinic)
| Comorbidity | Prevalence |
|---|---|
| Obesity | 61% |
| Acne | 52% |
| Hyperlipidaemia | 45% |
| Depression | 42% |
| Insulin resistance | 39% |
| Pilonidal sinus | 27% |
| Polycystic ovary syndrome | 16% |
| Diabetes mellitus | 16% |
| Hypertension | 14% |
| Keratosis pilaris | 12% |
Clinical Course
- Initial: comedones → nodules → abscesses
- Later: sinus tracts → fistulae → hypertrophic and retractile scars
- Lymphoedema can result from scarring of lymphatic drainage
- Progressive without treatment
- Complication: Squamous cell carcinoma (rare but serious)
Psychosocial Impact
- Malodorous discharge, pain, and scarring cause:
- Stigma
- Social withdrawal
- Reduced sexual function
- Anxiety, depression, suicidal ideation
- HS patients report significantly higher depression scores than controls
- Psychological support is integral:
- GP counselling
- Psychology/psychiatry referral
- Peer support groups
Pain
- Central, under-recognised feature
- Contributes to reduced quality of life
- Pain types: nociceptive, neuropathic, inflammatory
- Management:
- Paracetamol, NSAIDs
- SNRIs (duloxetine, venlafaxine)
- Pregabalin, gabapentin
- Intralesional corticosteroids ± lignocaine for acute flares
- Short courses of systemic corticosteroids for severe inflammation
- Referral to pain specialist for chronic cases
Mechanical Factors
- Friction, tight clothing, sweating → aggravation
- Advice:
- Loose, breathable clothing
- Minimise mechanical stress on affected areas
Associated Conditions
- Follicular occlusion tetrad:
- HS
- Acne conglobata
- Pilonidal sinus
- Dissecting cellulitis of the scalp
- Associated systemic diseases:
- Crohn’s disease
- Pyoderma gangrenosum
- Spondyloarthropathies
- Down syndrome (earlier onset, severe course)
Medical Management Overview
- Treat underlying comorbidities (e.g. weight loss, smoking cessation)
- Use staging (Hurley) to guide therapy
- Refer moderate/severe cases to dermatology
- Monitor inflammatory markers
1. Mild disease (Hurley I)
| Intervention |
|---|
| Topical clindamycin 1 lotion % BD × 3 months |
| Antiseptic washes (chlorhexidine 4 % or benzoyl peroxide 5 %) Use daily or every second day consider 0.05 % bleach baths for widespread disease |
| Hormonal therapy in females Indications broader than PCOS: – perimenstrual flares – acne – hirsutism – irregular cycles. Options: – low-dose COCP (ethinyloestradiol 20–30 µg + anti-androgenic progestin) – spironolactone 50–100 mg daily – cyproterone acetate ± metformin in insulin resistance |
2. Moderate disease (Hurley II)
| Intervention |
|---|
| Oral tetracyclines – Doxy 100 mg BD (or 50 mg BD in lighter patients) for 8–12 weeks – then taper to daily for maintenance – Course ≤ 16 weeks to minimise resistance |
| Clindamycin 300 mg BD + rifampicin 300 mg BD (total 600 mg/day) for 10–12 weeks. |
| Short oral prednisolone for flares Rescue only: 0.3–0.5 mg/kg/day for 7–14 days, taper promptly to avoid rebound |
| Intralesional triamcinolone 10 mg/mL, 0.1–0.5 mL per nodule; repeat ≥ 4 weeks apart |
Other options often used at this stage
- Dapsone 50–150 mg daily (anti-neutrophil effect).
- Triple antibiotic (rifampicin + moxifloxacin + metronidazole) 6-week course for rifampicin failures.
- Acitretin 0.25–0.5 mg/kg if concomitant acne conglobata or keratinisation disorders.
3. Severe disease (Hurley III or Hurley II refractory)
3.1 Biologic/advanced systemic therapy
| Agent | Status & dosing | Key points |
|---|---|---|
| Adalimumab | TGA & PBS listed for moderate-to-severe HS. Induction 160 mg SC week 0, 80 mg week 2, then 40 mg weekly (or 80 mg Q2 weeks once stable) | Assess at 12–16 weeks (HiSCR); PBS continuation requires ≥ 50 % lesion reduction. |
| Secukinumab 300 mg SC | TGA-approved Sept 2023; PBS-subsidised since 1 Jun 2024. Give weekly × 5 then monthly | Use after failure/intolerance to adalimumab or when anti-TNF contraindicated. |
| Infliximab 5 mg/kg IV | Off-label; 0, 2, 6 weeks then Q6–8 weeks | Useful in very extensive disease or rapid deterioration. Cost barriers outside clinical trials. |
| Emerging (not PBS) | Upadacitinib (JAK1), bimekizumab (IL-17F/A), anakinra (IL-1) in phase 2–3 trials |
Screen before all biologics
- Quantiferon-TB Gold, CXR if indicated
- HBsAg, anti-HBc, anti-HCV, HIV serology
- Baseline FBC, LFTs, U&E; repeat q3–6 months
- Avoid live vaccines; give influenza ± recombinant zoster before starting therapy.
3.2 Surgery & laser (adjuncts)
Consider in patients with persistent or localised disease despite optimal medical therapy
- Procedures:
- Incision and drainage (for acute abscesses; not curative)
- Deroofing of sinus tracts
- Wide excision ± grafting (high morbidity, recurrence risk)
- Dermatology referral prior to surgery is recommended
3.3 Laser Therapy
- Targets hair follicle unit
- Nd:YAG laser and IPL used in small studies
- Variable results and availability
- May be used as adjunct in axillary/groin disease
Non-Pharmacological Management
1. Management Goals
- minimise pain, drainage and odour
- prevent new lesions and scarring
- optimise quality of life and psychosocial wellbeing
- address modifiable comorbidities (obesity, smoking, metabolic syndrome) r
2. Lifestyle & Behavioural Measures
| Measure | Practical advice | Evidence/Comment |
|---|---|---|
| Smoking cessation | Offer brief intervention, nicotine replacement, varenicline or bupropion; refer to Quitline | Smoking prevalence in HS ≈ 70 %; cessation is associated with milder disease |
| Weight optimisation | Encourage Mediterranean-style diet, calorie deficit, bariatric referral if BMI > 35 kg/m² | Observational data show weight loss reduces lesion count and pain |
| Friction/sweat reduction | Loose, breathable cotton clothing; seamless sports bras/boxer briefs; remove wet clothes promptly | Reduces mechanical trauma and moisture that trigger flares |
| Hair removal | Avoid shaving/waxing; consider long-pulse Nd:YAG laser (MBS item 14106) every 6–8 weeks | Laser decreases hair density and flares in small RCTs |
| Stress management | CBT, mindfulness-based stress reduction, exercise within comfort limits | Stress is a common patient-reported trigger |
| Dietary triggers | Trial ≥ 12 week dairy- and high-GI-reduced diet if patient reports correlation | Small uncontrolled studies suggest benefit; reinforce balanced nutrition |
3. Skin & Hygiene Measures
- Daily antiseptic wash – chlorhexidine 4 % or benzoyl-peroxide 5 % once daily; leave on 2–3 min then rinse. Add moisturiser to prevent irritant dermatitis.
- Warm compresses (10 min up to 4×/day) during early inflammatory nodules to assist spontaneous drainage.
- Bleach baths (2 mL 4 % sodium hypochlorite per L water, 10 min twice weekly) in widespread disease or concomitant folliculitis.
- Avoid deodorants with alcohol/fragrance, talc, tight dressings, and squeezing lesions (risk of sinus formation)
4. Wound & Dressing Care
| Exudate level | First-line dressing | Alternatives / notes |
|---|---|---|
| Minimal | Non-adherent silicone contact layer ± gauze | Hydrogel for painful acute nodules |
| Mild–moderate | Foam or hydrofiber; sanitary/abdominal pads for daytime wear | Hydrofiber-silver or alginate-silver if malodour/infection risk |
| Moderate–heavy | Super-absorbent polyacrylate or calcium alginate | Negative Pressure Wound Therapy (VAC) for deep tunnels or post-excision wounds |
| Post-operative | Hydrofiber or foam + VAC 5–7 days then switch to foam/alginates | Monitor weekly until epithelialised |
Change dressings once saturation reaches ~75 % or at least daily to prevent maceration. Cleanse gently with saline or dilute chlorhexidine; pat dry; protect perilesional skin with zinc oxide barrier paste. Teach patients (or carers) self-dressing technique and disposal of contaminated dressings. plasticsurgerykey.comhsfoundation.ca
5. Patient Education & Self-Care
- HS is auto-inflammatory, not contagious or due to poor hygiene.
- Track flares in a diary (timing, menstruation, foods, stress, weather).
- Keep spare dressings, analgesia, and dark loose clothing in a “flare kit”.
- Join support networks (e.g. HS Australia & NZ Facebook group, IFHSF).
- Discuss intimacy concerns; recommend water-based lubricants and gentle positioning to reduce friction. self.com
6. Monitoring & Comorbidities (Annual Minimum)
| Screen for | Tool/tests |
|---|---|
| Obesity & metabolic syndrome | BMI, waist, fasting lipids, HbA1c |
| Depression & anxiety | K10, PHQ-9 / GAD-7 |
| PCOS in women | Ferriman-Gallwey, cycles, testosterone |
| Inflammatory bowel disease | History of diarrhoea/bleeding; refer if positive |
| Squamous-cell carcinoma of chronic HS scars | Full skin check; biopsy non-healing ulcers |
7. Role of the General Practitioner
- Early recognition – consider HS in any recurrent “boils” in intertriginous areas; document Hurley stage and IHS4 score for baseline. www1.racgp.org.au
- Initial management – implement lifestyle and wound measures above; start topical clindamycin 1 % if mild; provide PBS Chronic Disease Management Plan (item 721) and wound-care consumable prescriptions.
- Coordination – refer Hurley II–III or treatment-refractory cases to a dermatologist +/- plastic surgeon; arrange dietitian, wound-care nurse, psychologist/psychiatrist; facilitate access to biologics under PBS Section 100 where indicated.
- Preventive care – weight, smoking, vaccinations (influenza, pneumococcal, HPV), analgesia optimisation, contraception discussion before retinoids/biologics.
- Follow-up – 3-monthly review (earlier during flares) to reassess severity, dressing needs, mental health, and treatment adherence.
8. Indications for Specialist Referral
- Uncertain diagnosis, rapid progression, sinus/tunnel formation.
- Hurley stage II–III or IHS4 ≥ 11.
- Suspected secondary infection not settling with oral antibiotics.
- Non-healing ulcers or suspicion of squamous-cell carcinoma.
- Significant psychological morbidity or chronic pain requiring specialised input.
Key Take-Home Points for Patients
- Stop smoking and work towards a healthy weight – they are the two strongest modifiable factors.
- Use daily antiseptic wash + absorbent dressings; change dressings before they leak.
- Wear loose cotton clothing and avoid skin friction and overheating.
- Never squeeze lesions; see your GP early when new painful lumps arise.
- Engage with support groups and mental-health services; HS can affect mood as much as skin.