Hidradenitis Suppurativa: A Frequently Missed Diagnosis ... · Hidradenitis Suppurativa: A Frequently Missed Diagnosis, ... (Dermatology), University of Toronto & Ontario, Canada
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Hidradenitis Suppurativa: A FrequentlyMissed Diagnosis, Part 2: Treatment Options
C M E1 AMA PRA
Category 1 CreditTMANCC
3.0 Contact Hours
Shirley C. Wang, MD & Clinical Research Coordinator & University Health Network & Toronto, Ontario, Canada
Sheila C. Wang, PhD & Resident & Department of Dermatology, McGill University & Montreal, Quebec, Canada
Afsaneh Alavi, MD, MSc, FRCPC & Assistant Professor & Department of Medicine (Dermatology), University of Toronto &Ontario, Canada
Raed Alhusayen, MD, MSc (Clin Epi), FRCPC & Assistant Professor & Sunnybrook Health Sciences Centre & University ofToronto & Ontario, Canada
Morteza Bashash, PhD & Research Fellow & Dalla Lana Faculty of Public Health & University of Toronto, Ontario, Canada
R. Gary Sibbald, BSc, MD,MEd, FRCPC (MedDerm), MACP, FAAD,MAPWCA & Professor of Public Health andMedicine &University of Toronto & Toronto, Ontario, Canada & Director & International Interprofessional Wound Care Course & Masters ofScience in Community Health (Prevention & Wound Care) & Dalla Lana School of Public Health & University of Toronto & PastPresident, World Union of Wound Healing Societies & Clinical Editor & Advances in Skin &Wound Care & Philadelphia, Pennsylvania
Dr Alavi has disclosed that she was a consultant to AbbVie and Janssen; her institution is a recipient of grant funding from AbbVie; her institution was a recipient of payment for lecturesincluding speakers’ bureau from AbbVie and Janssen; and her spouse/partner (if any), has disclosed that he/she has no financial relationships with, or financial interests in, any commercialcompanies pertaining to this educational activity. Dr Sibbald has disclosed that he is a recipient of grant funding, consulting fee/honorarium, travel support, and participation fees fromAbbVie; and his spouse/partner (if any), has disclosed that he/she has no financial relationships with, or financial interests in, any commercial companies pertaining to this educationalactivity. Dr Alhusayen has disclosed that he is a consultant to Abbott and Janssen; and his spouse/partner (if any), has disclosed that he/she has no financial relationships with, or financialinterests in, any commercial companies pertaining to this educational activity. The remaining coauthors and their spouses/partners (if any), have disclosed that they have no financialrelationships with, or financial interests in, any commercial companies pertaining to this educational activity.
All staff and planners, including spouses/partners (if any), in any position to control the content of this CME activity have disclosed that they have no financial relationships with, or financialinterests in, any commercial companies pertaining to this educational activity.
The authors have disclosed that none of the treatments of hidradenitis suppurativa are approved by the US Food and Drug Administration as discussed in this article.
Lippincott CME Institute has identified and resolved all conflicts of interest concerning this educational activity.
To earn CME credit, you must read the CME article and complete the quiz and evaluation on the enclosed answer form, answering at least 13 of the 18 questions correctly.
This continuing educational activity will expire for physicians on August 31, 2016, and for nurses on August 31, 2017.
If you need CME or CE STAT, take the test online at: http://cme.lww.com for physicians and www.nursingcenter.com for nurses. Complete CE/CME information is on the last page of this article.
Editor’s note: This is the second part of this continuing education topic. ‘‘Hidradenitis Suppurativa: A Frequently Missed Diagnosis, Part 2: A Review of Pathogenesis, Associations, andClinical Features’’ was published in the July 2015 issue.
PURPOSE:
To provide an overview of treatment recommendations for hidradenitis suppurativa (HS).
TARGET AUDIENCE:
This continuing education activity is intended for physicians and nurses with an interest in skin and wound care.
OBJECTIVES:
After participating in this educational activity, the participant should be better able to:
1. Describe current recommendations for treatment of HS.
2. Identify warnings, adverse effects, and implications for patient education.
AUGUST 2015
ADVANCES IN SKIN & WOUND CARE & VOL. 28 NO. 8 372 WWW.WOUNDCAREJOURNAL.COM
Hidradenitis suppurativa (HS) is a chronic inflammatorydisorder of the intertriginous area. Patients with HS have severalchallenges to their quality of life and activities of everyday living,including malodor, purulent discharge, and discomfort. There isoften a delay in diagnosis and appropriate treatment. The needfor cosmetically acceptable local treatments and dressingapplication makes this disease an important challenge for woundcare specialists. The choice of optimal treatment varies dependingon the disease severity, expert knowledge, the availability of aninterprofessional team, and patient factors.KEYWORDS: hidradenitis suppurativa, inflammatory folliculardisorder, wound care
ADV SKIN WOUND CARE 2015;28:372–80; quiz 381-2.
INTRODUCTIONHidradenitis suppurativa (HS) is a chronic debilitating disease
that significantly affects the quality of life of an active, young
adult population. The large burden of HS and its comorbidities
highlight the need for an interprofessional team approach.
Typically, HS is more common in females mainly involving the
axilla and groin (Figure 1), whereas the perineum and buttocks
are commonly involved in males (Figure 2). Despite multiple
studies, a diversity of expert opinion remains on the optimal stepwise management of HS. The US Food and Drug Admin-
istration (FDA) has not approved any treatments for HS. The
recommendations in this article are based on the scientific
literature, expert knowledge of the authors, published consensus
documents, and patient experience.
GENERAL MEASURESEpidemiological data suggest an association of HS with systemic
diseases, including metabolic syndrome, psychiatric disorders,
and hyperandrogenism.1 The Mayo Clinic (http://mayocl.in/
1hZDzm2) defines metabolic syndrome as a cluster of conditions
that can be remembered by A-increased blood sugar (hemoglo-
bin A1c), B-increased blood pressure, C-abnormal cholesterol,
and D-diet with excess body fat around the waist, all of which
increase an individual’s risk of heart disease, stroke, and diabetes.
The patient’s body weight and lifestyle choices may contribute to
HS. For example, the association of HS and a high body mass
index, along with smoking, warrants weight loss counseling and
smoking cessation. Current adult obesity guidelines include a
lifestyle modification program that ideally involves:
& reduced caloric intake by 500 to 1000 kcal/d,
& 30 minutes of moderate-intensity physical activity 3 to 5 times
per week and an eventual increase to 60 minutes or more on
most days,
& cognitive-behavior therapy.2
Figure 1.
THEAXILLA,GROIN,AND INFRAMMARYAREPREDOMINANTLY
INVOLVED IN FEMALE PATIENTS
Figure 2.
THEGLUTEAL, INGUINAL INVOLVEMENTISPREDOMINATELY
SEEN IN MALE PATIENTS
ADVANCES IN SKIN & WOUND CARE & AUGUST 2015373WWW.WOUNDCAREJOURNAL.COM
when reporting treatment effects in hidradenitis suppurativa. Br J Dermatol 2003;149:211-3.
6. Chen YE, Gerstle T, Verma K, Treiser MD, Kimball AB, Orgill DP. Management of hidradenitis
suppurativa wounds with an internal vacuum-assisted closure device. Plast Reconstr Surg
2014;133:370e-377e.
7. Kerdel FA. Current and emerging nonsurgical treatment options for hidradenitis suppurativa.
Semin Cutan Med Surg 2014;33(3 Suppl):S57-9.
8. Alikhan A, Lynch PJ, Eisen DB. Hidradenitis suppurativa: a comprehensive review. J Am
Acad Dermatol 2009;60:539-61.
9. Alhusayen R, Shear NH. Pharmacologic interventions for hidradenitis suppurativa: what
does the evidence say? Am J Clin Dermatol 2012;13:283-91.
10. Jemec GB, Wendelboe P. Topical clindamycin versus systemic tetracycline in the treatment
of hidradenitis suppurativa. J Am Acad Dermatol 1998;39:971-4.
11. Gener G, Canoui-Poitrine F, Revuz JE, et al. Combination therapy with clindamycin and rifampicin
for hidradenitis suppurativa: a series of 116 consecutive patients. Dermatology 2009;219:148-54.
12. van der Zee HH, Boer J, Prens EP, Jemec GB. The effect of combined treatment with oral clindamycin
and oral rifampicin in patients with hidradenitis suppurativa. Dermatology 2009;219:143-7.
13. Bettoli V, Zauli S, Borghi A, et al. Oral clindamycin and rifampicin in the treatment of
hidradenitis suppurativa-acne inversa: a prospective study on 23 patients. J Eur Acad
Dermatol Venereol 2014;2:125-6.14. Mendonca CO, Griffiths CE. Clindamycin and rifampicin combination therapy for hidradenitis
suppurativa. Br J Dermatol 2006;154:977-8.15. Matusiak L/ , Bieniek A, Szepietowski JC. Bacteriology of hidradenitis suppurativaVwhich
antibiotics are the treatment of choice? Acta Derm Venereol 2014;94:699-702.16. Clemmensen OJ. Topical treatment of hidradenitis suppurativa with clindamycin. Int J
Dermatol 1983;22:325-8.17. Boer J, Jemec GB. Resorcinol peels as a possible self-treatment of painful nodules in
hidradenitis suppurativa. Clin Exp Dermatol 2010;35:36-40.18. Cassano N, Alessandrini G, Mastrolonardo M, Vena GA. Peeling agents: toxicological and
hidradenitis suppurativa: a series of 24 patients. Dermatology 2011;222:342-6.20. Zouboulis CC, Korge B, Akamatsu H, et al. Effects of 13-cis-retinoic acid, all-trans-retinoic
acid, and acitretin on the proliferation, lipid synthesis and keratin expression of cultured
human sebocytes in vitro. J Invest Dermatol 1991;96:792-7.21. Blok JL, van Hattem S, Jonkman MF, Horvath B. Systemic therapy with immunosuppressive agents
and retinoids in hidradenitis suppurativa: a systematic review. Br J Dermatol 2013;168:243-52.22. Puri N, Talwar A. A study on the management of hidradenitis suppurativa with retinoids
and surgical excision. Indian J Dermatol 2011;56:650-1.23. dos Santos CH, Netto PO, Kawaguchi KY, Parriera Alves JA, de Alencar Souza VP, Reverdito S.
Association and management of Crohn’s disease plus hidradenitis suppurativa. Inflamm
56. Pagliarello C, Fabrizi G, Feliciani C, Di Nuzzo S. Cryoinsufflation for Hurley Stage II hidrade-
nitis suppurativa: a useful treatment option when systemic therapies should be avoided. JAMA
Dermatol 2014;150:765-6.
57. Kagan RJ, Yakuboff KP, Warner P, Warden GD. Surgical treatment of hidradenitis suppurativa:
a 10-year experience. Surgery 2005;138:734-41.58. Hongcharu W, Taylor CR, Chang Y, Aghassi D, Suthamjariya K, Anderson RR. Topical ALA-
photodynamic therapy for the treatment of acne vulgaris. J Invest Dermatol 2000;115:183-92.59. Rose RF, Stables GI. Topical photodynamic therapy in the treatment of hidradenitis
suppurativa. Photodiagn Photodyn Ther 2008;5:171-5.60. Wollina U KA, Heinig B, Kittner T, Nowak A. Acne inversa (hidradenitis suppurativa): a
review with a focus on pathogenesis and treatment. Indian J Dermatol 2013;4:2-11.61. Divaris DX, Kennedy JC, Pottier RH. Phototoxic damage to sebaceous glands and hair
follicles of mice after systemic administration of 5-aminolevulinic acid correlates with
localized protoporphyrin IX fluorescence. Am J Pathol 1990;136:891-7.62. Passeron T, Khemis A, Ortonne JP. Pulsed dye laser-mediated photodynamic therapy for
acne inversa is not successful: a pilot study on four cases. J Dermatol Treat 2009;20:297-8.63. Strauss RM, Pollock B, Stables GI, Goulden V, Cunliffe WJ. Photodynamic therapy using
aminolevulinic acid does not lead to clinical improvement in hidradenitis suppurativa.
study of hidradenitis suppurativa following long-pulsed 1064-nm Nd:YAG laser treatment.
Arch Dermatol. 2011;147(1):21-8.
For more than 127 additional continuing education articles related to skin and wound care topics, go to NursingCenter.com/CE.
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ADVANCES IN SKIN & WOUND CARE & VOL. 28 NO. 8 380 WWW.WOUNDCAREJOURNAL.COM