Hidradenitis Suppurativa

Question 1

Hidradenitis Suppurativa:

Pathophysiology?

Answer 1

• Unclear but the primary event is follicular occlusion resulting in accumulation of inflammatory mediators
• there is developing evidence of microbiome importance
• lesional skin has poor microbial diversity relative to normal skin

Question 2

Hidradenitis Suppurativa:

Risk factors for severity of disease?

Answer 2

• genetics (1/3rd have a FHx)
• smoking
• obesity
• adipokine dysregulation
• insulin/glucose disturbance

Question 3

Hidradenitis Suppurativa:

Comorbidities?

Answer 3

Obesity 61%
Acne 52%
Hyperlipidaemia 45%
Depression 42%
Insulin resistance 39%
Pilonidal sinus 27%
PCOS 16%
Diabetes 16%
HTN 14%
Keratosis pillaris 12%

*there is an association with pyoderma gangranulosum, spondylarthropathies, crohns, downs syndrome (prepubertal onset and often treatment resistant)

Question 4

Hidradenitis Suppurativa:

How to stage disease?

Answer 4

Use the Hurley Grading stages
1 = abscess but no sinus tracts or scarring
2 = recurrent single or multiple abscesses with tracts and scarring, widely separated lesions
3 = diffuse or near diffuse involvement/interconnected tracts and abscesses

Question 5

Hidradenitis Suppurativa:

Complications?

Answer 5

• Progression
• Scarring
• malodor, painful flares
• Lymphoedema (due to scarring of lymphatic drainage)
• possible SCC development from recurrent inflammation

Question 6

Hidradenitis Suppurativa:

Management?

Answer 6

Minimise comorbidities and risk factors

• **smoking cessation
• *weight loss/dietary optimisation/physical activity
• psychological distress management

Avoid tight fitting clothing

Monitor

1) disease stage
2) CRP

Mild
Topical clindamycin solution 0.1% BD 3 months
Benzoyl peroxide 10%

Moderate to severe

1) Systemic antibiotics
- doxycycline 100mg daily for 3 months
- Combination Clindamycin 300mg BD and Rifampicin 600mg daily for 10 weeks
* C. difficile risk is high

2) Steroids (can have withdrawal or rebound flares)

3) Biologic agents
- TNFa inhibitors (adalimumab and infliximab) weekly subcutaneous or regular infusions

4) Surgical intervention with experienced HS dermatologist
5) Laser - some evidence

Pain

1) Psychological support for comorbid anxiety/depression (reduced distressed = greater pain control and tolerance)
2) topical therapies
3) simple analgesia
4) intralesional and oral steroids
* neuropathic agents (may assist in comorbid mental health - SSNRIs, gabapentanoids)
* opioids (be wary of dependence - short term flare use ideally)

Question 7

Hidradenitis Suppurativa:

Phenotypes?

Answer 7

Paediatric

• any area
• likely to progress without aggressive managment
• weight loss and laser helpful

Female

• axillary predominant
• PCOS, metobolic syndrom associated
• high burden of psychological impact

Male

• gluteal predominant
• smokers
• hyperlipidaemia associated
• can sometimes “burn out”

Genetic

• variable and severe
• strong family history
• need genetic counselling and specialist managment