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Hidradenitis suppurativa

Definition
Hidradenitis suppurativa is a chronic inflammatory skin condition characterized by painful, suppurative lesions in apocrine gland-bearing areas.
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Pathophysiology
Hidradenitis suppurativa is caused by immune dysregulation in the terminal follicular epithelium and is thought to occur due to a combination of genetic predisposition and environmental factors.
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Epidemiology
Estimates of the prevalence of hidradenitis suppurativa globally range from 0.03% to 4%. The incidence of hidradenitis suppurativa in the US is 8.6 per 100,000 population/year.
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Disease course
The dysregulated innate and adaptive immune response leads to perifollicular inflammation, hyperkeratosis, and occlusion of hair follicles in apocrine gland-bearing areas. Spillage of sebum and debris occurs due to rupture of dilated hair follicles, triggering an inflammatory response and the development of painful, inflamed nodules, abscesses, fistulas, and sinus tracts.
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Prognosis and risk of recurrence
Hidradenitis suppurativa is associated with increased all-cause mortality (incidence rate ratio 1.35, 95% CI, 1.15-1.59). Recurrence rates vary according to treatment, with rates of 13%, 22%, and 27% reported following wide excision, local excision, and deroofing, respectively.
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Key sources
The following summarized guidelines for the evaluation and management of hidradenitis suppurativa are prepared by our editorial team based on guidelines from the United States Hidradenitis Suppurativa Foundation (USHSF/CHSF 2019) and the British Association of Dermatologists (BAD 2019).
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Guidelines

1.Classification and risk stratification

Severity grading: as per BAD 2019 guidelines, document theHurley stage at baseline for the worst-affected region in all patients with hidradenitis suppurativa:
Situation
Guidance
Stage I
Abscess formation, single or multiple, without sinus tracts and cicatrization
Stage II
Recurrent abscesses with tract formation and cicatrization, single or multiple, widely separated lesions
Stage III
Diffuse or near-diffuse involvement, or multiple interconnected tracts and abscesses across the entire area
E
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2.Diagnostic investigations

Laboratory tests
Do not obtain routine microbiologic testing unless signs of secondary infection such as surrounding cellulitis or fever are present. Recognize that a negative culture may support a diagnosis of hidradenitis suppurativa based on consensus-derived diagnostic criteria.
D
Do not obtain biomarker or genetic testing in patients with hidradenitis suppurativa.
D

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  • Screening for comorbidities

3.Medical management

General principles
Manage patients with hidradenitis suppurativa via a multidisciplinary team approach, particularly when considering surgical interventions.
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Consider referring patients with Hurley stage III (severe) disease immediately to dermatology secondary care.
E

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  • Antibiotics (systemic)

  • Antibiotics (topical)

  • Antiandrogen therapy

  • Retinoids

  • Corticosteroids

  • Other immunosuppressants

  • Biologic agents

  • Agents with no evidence for benefit

  • Pain management

4.Nonpharmacologic interventions

Lifestyle modifications: as per BAD 2019 guidelines, refer patients with hidradenitis suppurativa to smoking cessation and weight management services, if relevant.
E

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  • Supplements

5.Therapeutic procedures

Intralesional corticosteroids: as per BAD 2019 guidelines, consider administering intralesional corticosteroid injections in carefully selected hidradenitis suppurativa lesions during the acute phase.
C

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  • Laser and light therapies

  • Therapies with no evidence for benefit

6.Perioperative care

Perioperative medical therapy: continue medical therapy in the perioperative period as it is likely to be beneficial and poses minimal risk of increased postoperative complications.
B

7.Surgical interventions

Surgery: perform deroofing or excision for recurrent nodules and tunnels.
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  • Wound care

8.Specific circumstances

Pregnant patients
Offer topical treatments, procedures, and safe systemic agents in pregnant patients with hidradenitis suppuratova.
Avoid using retinoids, hormonal agents, most systemic antibiotics, and most immunosuppressive medications in pregnant patients with hidradenitis suppuratova.

9.Patient education

Patient education: provide a patient information leaflet in all patients with hidradenitis suppurativa.
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10.Follow-up and surveillance

Assessment of treatment response: measure treatment response using recognized instruments for pain and QoL, including an inflammatory lesion count for patients on adalimumab therapy.
E