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Oral Antibiotics For Hidradenitis Suppurativa

How Hidradenitis Suppurativa Is Treated

Hidradenitis Suppurativa (HS) | Pathophysiology, Triggers, Signs & Symptoms, Diagnosis, Treatment

Casey Gallagher, MD, is board-certified in dermatology and works as a practicing dermatologist and clinical professor.

Treating Hidradenitis suppurativa , a chronic skin condition often requires managing both the physical symptoms and the emotional ones.

Without treatment, it can lead to serious complications such as squamous cell carcinoma , a bacterial skin infection called cellulitis. There is an association between Crohn’s disease and HS, but HS does not lead to Crohn’s disease.

What’s more, because the skin lesions caused by HS are so visible, many people with the disease isolate themselves from other people, leading to loneliness, anxiety, and depression.

DermNet / CC BY-NC-ND

This article details treatment options, including self-care measures, medications for relieving pain and inflammation and preventing infection, and alternative therapies which, although unproven, you might find worth trying. It also explains how doctors determine what to prescribe.

Risk Factors And Comorbidities

Among all risk factors for HS studied to date, the strongest correlation among biological factors is obesity, while the strongest environmental association is with smoking. Revuz et al. found an odds ratio of 4.42 for obesity and 12.55 for smoking compared to healthy controls. Another study by Miller et al. found an OR of 6.38 for obesity. In line with this, individuals with diabetes mellitus and metabolic syndrome also have a strong positive association with HS . Individuals with HS also suffer from a significantly higher rate of cardiovascular risk factors compared to healthy controls .

With respect to disease progression, 5 risk factors were associated with an increased risk of progression from Hurley stage I to stage II or III in a retrospective study of 846 Dutch individuals with HS. These included male gender, disease duration, BMI, smoking pack-years, and lesion location .

In addition, mechanical irritation and friction may also trigger HS , and the co-occurrence of HS with polycystic ovary syndrome, Crohn disease , and depression is statistically significant .

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Course And Burden Of Disease

HS is a chronic relapsing disease. If not treated adequately it may lead to serious complications such as bacterial infections, fistula formation, contractures and limb mobility limitations, squamous cell carcinoma, depression, anemia, malaise, and social impairment . Indeed, it has been reported to prevent patients from working during disease flares , and the purulent discharge can produce an odor and stain clothing, resulting in social stigma . Scarring can also cause considerable disability . A recent study showed that the effect of HS on the Dermatology Life Quality Index was 5.77 ± 4.59 for patients with Hurley stage I disease, 13.1 ± 6.41 for patients with Hurley II, and 20.4 ± 6.67 for patients with Hurley III. This is very high compared to a wide spectrum of other dermatological diseases . For example, moderate to severe psoriasis has a mean DLQI reported at 12-13 .

Among patient-reported signs and symptoms, pain was reported by 85% of individuals with HS to be the most bothersome, followed by swelling/inflammation and sensitivity/tenderness .

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Role Of Bacterial Dysbiosis In The Pathophysiology Of Hidradenitis Suppurativa

The pathogenesis of HS has not been fully elucidated, but is associated with genetic, immunological, hormonal, environmental, and microbiological factors. The recently unraveled microbiology of HS suggests abnormal host-microbiome cross-talks, bacterial pathogenicity, and dysbiotic variations according to the clinical severity of the disease . The persistence of bacteria within highly inflammatory lesions probably results from both an immune skin defect in HS and bacterial pathogenic properties.

Considering the results of pathological studies, the initial pathologic process results from hair follicle plugging, which, in case of rupture, leads to the release of keratin debris and bacteria within the dermis. Extensive bacteriological studies of HS lesions have shown that mild HS lesions are associated with low virulent skin colonizers such as Cutibacterium avidum , and coagulase negative staphylococci, including the virulent Staphylococcus lugdunensis and Corynebacterium spp. Anaerobes are associated with 50% of Hurley stage I lesions. Some patients develop more severe and chronic lesions with scarring . The microbiology of these lesions, as assessed before antibiotic treatments, is constituted of anaerobes, with a predominance of Prevotella and Porphyromonas , two gram-negative anaerobic rods. Parvimonas and Fusobacterium are associated with Hurley stage III lesions.

How Do Antibiotics Work

Hidradenitis Suppurativa 101: A Comprehensive Guide With Video

Antibiotics kill bacteria or stop them from growing and multiplying. Antibiotics only work to treat certain types of bacterial infections, like strep throat, bronchitis, and urinary tract infections. Different antibiotics work against different kinds of bacteria. Antibiotics do not work on viral infections.3

Some antibiotics are taken by mouth . Others are given through an IV or an injection.

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Clindamycin Combined With Rifampin For Hs

Clindamycin and rifampin are often used to treat inflammation. They are oral antibiotics that are used together to treat severe HS symptoms. They are also used when a tetracycline antibiotic does not work in people with mild to moderate HS.2,7,8

Researchers have studied treatment with this combination more than most other antibiotics. Using this treatment for 10 weeks, studies have shown that the combination reduces disease. Some people with HS had complete remission.2,7,8

How Do Dermatologists Treat Hs

Although HS cannot be cured, your dermatologist can create a treatment plan to control the disease and lessen your symptoms. Treatment can:

  • Reduce flare-ups

  • Prevent HS from worsening

When creating a treatment plan, your dermatologist will consider the types of lesions you have, whether you have pain or an infection, and how HS is affecting your life. This allows your dermatologist to customize a treatment plan for you.

A treatment plan for HS can have many parts and may include one or more of the following:

  • A skin care plan

Heres what each involves:

Skin care: Some soaps and other skin care products may irritate skin with HS. To reduce this irritation, your dermatologist can create a skin care plan for you. This plan may include using a wash with benzoyl peroxide and switching to a gentle antiperspirant.

Medication to treat HS: Many medications are used to treat HS. Some you apply to the HS. If you have advanced HS, you may need a medication that works throughout the body, such as a pill.

Medications that you apply to the HS include:

  • An antibiotic, such as clindamycin or dapsone, to reduce pus-filled lumps and treat infection

  • Resorcinol, a peel that opens up clogged hair follicles and reduces inflammation

When stronger medication is necessary, your dermatologist may prescribe:

While many medications are used to treat HS, the U.S. Food and Drug Administration has approved only one. Its a biologic called adalimumab .

Procedures that dermatologists use to treat HS include:

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What Are The Symptoms Of Hidradenitis Suppurativa

The characteristic symptoms of these skin conditions are as follows

  • Blackheads: It starts with small pitted areas of the skin containing blackheads. It may appear in several body locations such as the groin, pubic region, buttocks, armpits and under the breast and may return often.
  • Painful lumps: It always starts with a single, painful small lump under the skin that persists for weeks or months. Later, you may have more bumps. They usually appear in body areas with hair follicles that are more prone to sweating such as the groin and armpits. It may also appear in areas where the skin rubs together, such as skin folds under the breast, buttocks and inner thighs.
  • Tunnels: Over time, tunnels connecting the two lumps may form under the skin. They dont improve in a few weeks, but heal very slowly and often flare. They can leak very smelly pus.

Some may experience only mild symptoms. The severity of this skin condition will be assessed by your doctor in three stages

  • Stage I: Solitary or multiple isolated abscess without the formation of any tunnel or scarring.
  • Stage II: Recurrence of pus-filled lump, single or multiple widely spaced lesions with the formation of tunneling in the wound.
  • Stage III: A wide and large spread of pus-filled lumps with multiple tunnels in the wound.

Hidradenitis Suppurativa: A Review With An Emphasis On Treatment

Hidradenitis Suppuritiva

Brooke Rothstein, BA Noah Scheinfeld, MD William W. Huang, MD, MPH and Steven R. Feldman, MD, PhD

CITATION:Rothstein B, Scheinfeld N, Huang WW, Feldman SR. Hidradenitis suppurativa: a review with an emphasis on treatment. Consultant. 2016 56:693-700.

ABSTRACT: This article gives an overview of the etiology, diagnosis, staging, and treatment of hidradenitis suppurativa , a chronic skin disorder characterized by the presence of recurrent inflammatory nodules resulting in sinuses, fistulas, and scarring, commonly in the intertriginous areas. Treatment comprises topical and oral antibiotics, hormonal therapy, immunosuppressants, zinc gluconate, biologic therapy, phototherapy, laser therapy, and surgical therapy. Despite these therapies, few randomized, controlled trials have been performed, and no standard of care exists. As our understanding of HS improves, better methods of diagnosis and more effective treatments have emerged, including the recent US approval of adalimumab for HS. However, more research is needed.

KEYWORDS: Hidradenitis suppurativa, follicular occlusion, adalimumab, retinoids, antibiotics, hormone blockers, immunosuppressants, biologics, laser therapy, light therapy, or surgical therapy

Hidradenitis suppurativa , also known as acne inversa, is a chronic, inflammatory skin disorder with a worldwide prevalence of approximately 1% to 4%,1,2 although it may be a rare disease affecting fewer than 200,000 persons in the United States.3,4

METHODS

ETIOLOGY

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Hidradenitis Suppurativa: A Systematic Review And Meta

Correspondence Address

How to cite this article: Tchero H, Herlin C, Bekara F, Fluieraru S, Teot L. Hidradenitis Suppurativa: A Systematic Review and Meta-analysis of Therapeutic Interventions. Indian J Dermatol Venereol Leprol 2019 85:248-257

Abstract

Keywords:

Introduction

Hidradenitis suppurativa, also known as acne inversa or Verneuil’s disease, is a chronic inflammatory condition affecting skin regions bearing apocrine glands. The deep-seated, inflamed and painful lesions develop as sinus tracts, nodules or abscesses, most commonly after puberty. The flares that may subside untreated within two weeks occur at varying intervals with painful and suppurative manifestations.

Though it was believed to be a rare disease, the findings of several studies contradicted this view. A survey showed a point prevalence of 1% of the French population. In another study, the prevalence was found to be 4% in young adults undergoing screening for sexually transmitted diseases. This condition shows a significant gender bias with three times more occurrence in women. Although the condition is recorded routinely in postmenopausal women and children, the early 20s is the most common age of affection.

We performed this systematic review and meta-analysis to investigate the safety and efficacy of available treatment options for hidradenitis suppurativa with published data in the literature.

Methods

Literature search

Eligibility criteria

Quality assessment

Data extraction and synthesis

Results

Common Hidradenitis Suppurativa Medication Prescriptions

Within each class, your doctor has choices to make. Finding the right choice for you may involve some trial and error. Ten drugs doctors commonly prescribe for HS include:

  • Adalimumab is a biologic injection. It is the first FDA-approved treatment for HS. Doctors use it to treat moderate to severe HS.
  • Clindamycin topical is an antibiotic you apply to the skin. The advantage is you can avoid side effects that may occur when you take the medicine by mouth.
  • Cyclosporine is an oral immunosuppressant. Its main use is preventing transplant rejection.
  • Finasteride is a form of hormone therapy. It blocks production of male sex hormones. It also treats BPH and male pattern baldness.
  • Isotretinoin is an oral retinoid. It is a mainstay of nodular acne treatment. Women must avoid pregnancy while taking this drug.
  • Metformin is an oral medication for type 2 diabetes. Experts believe it helps HS by decreasing the influence of androgen hormones.
  • Methotrexate is an oral immunosuppressant. It is also a treatment for certain cancers and other autoimmune diseases.
  • Norethindrone/mestranol is an oral contraceptive. In HS, it works as a hormone therapy to balance sex hormones in females.
  • Prednisone is a corticosteroid. Generally, corticosteroids are for short-term use during outbreaks. Long-term use can cause side effects.
  • Spironolactone is a form of hormone therapy. It is a potassium-sparing diuretic that also blocks the effects of androgens.
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    Hidradenitis Suppurativa: Diagnosis And Treatment

    A dermatologist is often the doctor who diagnoses a patient with hidradenitis suppurativa

    Getting an accurate diagnosis and an individualized treatment plan can prevent HS from worsening.

    Hidradenitis suppurativa can look like another skin condition, such as worsening acne, boils, or herpes. Dermatologists have the training needed to spot the differences between HS and other conditions. This unique training allows them to diagnose HS more quickly.

    Heres what you can expect when you see a dermatologist.

    Hormonal Therapies For Hs

    Pin on HS

    Research shows that androgens affect HS in women, as shown by changes related to pregnancy and menstrual cycles. Hormonal therapies include:4,16,17

    • Estrogen-containing birth control pills Showed improvement in a rigorous test
    • Anti-androgen therapies Showed improvement block effects of androgen
    • Metformin Drug that treats type 2 diabetes notable improvement mostly in women with polycystic ovarian syndrome
    • Finasteride Drug that treats enlargement of the prostate gland in men helpful in limited research
    • Spironolactone Drug that treats high blood pressure helpful in limited research

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    Arguments For A Rational Use Of Antibiotics In Hidradenitis Suppurativa

    HS is a chronic dermatological disease with a significant negative impact on quality of life due to unmet needs. Continuous or repeated intermittent antibiotic courses are regularly employed in 70% of HS patients by general practitioners as well as specialists, with few validated alternative and satisfactory treatment options.

    • Systemic nonsteroidal antiinflammatory drugs and corticosteroids are typically used as supportive care to decrease symptoms such as pain, but no controlled studies have proved their efficacy and harmlessness.

    • Antitumor necrosis factor -alpha agents are only approved for moderate and severe HS, but not for mild cases. Moreover, anti-TNF-alpha agents such as adalimumab provide significant improvement in only 50% of the patients and, although rarely, they can cause worrisome/significant side effects.

    • Surgery, although a cornerstone treatment of HS, cannot always be performed due to the multiplicity, size, and/or localization of lesions, as well as lack of access to surgical experts specialized in HS procedures. Recurrences in the surgical margins can occur in up to 50% of cases.

    Although antibiotics may be useful in the management of HS, their long-term risks include Clostridioides difficile infections and the emergence of resistance.

    Administration Of Biologics In Hs

    Immunomodulation is becoming popular for moderate-to-severe form of the disease. Targeting the tumor necrosis factor , interleukin 1 , IL-12, and IL-23 has been considered as potential therapies .

    Adalimumab is recommended as the first-line biologic therapy for moderate-to-severe HS , followed by Infliximab and anakinra as second- and third-line options, respectively . The recommended dose of adalimumab in HS is 160 mg on Week 0, 80 mg on Week 2 and then 40 mg weekly . Recent studies suggest that those patients who do not respond to therapy within 12 weeks should discontinue the drug . However, the patients with partial or good should continue the therapy with ongoing assessment .

    Evidence is lacking for other biologic therapies, and any clinical decisions should be based on close monitoring and risk: benefit assessments . Recent studies showed administration of other biologics such as other TNF-alpha blockers , ustekinumab, secukinumab, bimekizumab, canakinumab, apremilast, anakinra, guselkumab , and rituximab in management of HS.

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    Description Of The Disease And Epidemiology

    Hidradenitis suppurativa , also called acne inversa or maladie de Verneuil, is a painful, inflammatory, debilitating skin disease with a chronic intermittent course. It typically presents after puberty with painful, deep-seated, inflamed lesions in the apocrine gland-bearing areas of the body: most commonly the axillae, inguinal and anogenital regions . Population-based studies in European countries suggest a 1-year prevalence of HS of about 1% in the general population, with estimates ranging from 0.1 to 4% globally. HS commonly presents after puberty, with the average age of onset between 21 and 23 years of age, and is more common in women, with a female to male ratio between 2:1 and 5:1 . Associations have also been reported with other inflammatory diseases, such as inflammatory bowel disease , pyoderma gangrenosum , and polycystic ovary syndrome .

    Suggested Therapy Approach Based On The Current Knowledge

    Hidradenitis Suppurativa – Mayo Clinic

    There is no single efficient therapy for the skin disorder. As a result, clinicians typically should choose from different treatment modalities and often have to combine them to achieve disease control. The choice of treatment depends on the distribution and overall severity of disease, the anatomic location and inflammatory activity of the lesions, the patients comorbidities, as well as treatment cost and availability . In order to assess the severity and extent of hidradenitis suppurativa various scoring systems are in common use: hurley stages, sartorius hidradenitis suppurativa score, hidradenitis suppurativa physician global assessment and hidradenitis suppurativa clinical response .

    HS management is often complex. The standard of care management requires an individualized approach in a multifaceted approach, ranging from self-management to local therapies, systemic antibiotics, and a wide range of immunomodulating agents, as well as surgical interventions such as excisional and laser surgeries . Additionally, the diagnosis and management of medical comorbidities and referral to psychiatrist might be taken into consideration . An overview of a suggested multidimensional approach is summarized in Figure 1.

    Figure 1. Clinical practice recommendations for the treatment of HS, modified from Hunger et al. and Saunte and Jemec .

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    Objectives Of Medical Treatment

    Control the inflammation and intercurrent infections

    Avoid progression to advanced stages with fibrosis and scarring and involvement of extensive and/or multiple areas

    Improve quality of life, particularly in regards to pain and discharge

    Prepare for surgical procedure, reducing inflammation and delimitating the lesion

    Approach extensive, disseminated, ulcerated and/or surgically difficult-to-treat clinical forms

    Treat syndromic cases, in which HS is associated to other conditions such as auto-inflammatory diseases and inflammatory bowel disease.

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