How do you treat a 35-year-old male with extensive hidradenitis suppurativa (HS) of the perianal skin?

Treatment of Extensive Perianal Hidradenitis Suppurativa

For a 35-year-old male with extensive hidradenitis suppurativa of the perianal region covering a 15x15cm area, surgical excision with healing by secondary intention is the most appropriate treatment approach. 1, 2

Disease Assessment

• This case represents Hurley stage III (severe) disease based on the extensive involvement and likely presence of interconnected sinus tracts and scarring 1
• Immediate referral to dermatology secondary care is indicated for Hurley stage III disease 1
• Pain assessment using Visual Analog Scale (VAS) and quality of life measurement using Dermatology Life Quality Index (DLQI) should be performed 3

Initial Management

• For perianal hidradenitis of this extent, immediate treatment with combination antibiotics is recommended:
  • Clindamycin 300 mg twice daily with rifampicin 300 mg twice daily for 10-12 weeks 1, 4
• Pain management with NSAIDs should be initiated 1
• Provide appropriate dressings for pus-producing lesions 1
• Screen for depression/anxiety, which is common in HS patients 1
• Screen for cardiovascular risk factors (BP, lipids, HbA1c) 1
• Address modifiable risk factors:
  • Offer smoking cessation if applicable 1
  • Offer weight management if applicable 1, 4

Definitive Treatment

• For extensive perianal hidradenitis (15x15cm), surgical referral to a hidradenitis suppurativa surgical multidisciplinary team is the definitive treatment 1
• Wide surgical excision is the treatment of choice for extensive perianal disease 2, 5
• Healing by secondary intention using tap water-moistened plain gauze dressings changed 2-3 times daily is a practical approach with good results 2
• Expected healing time for large wounds left open for secondary intention is approximately 10-12 weeks 5, 6
• Alternative wound management options include:
  • Partial closure of the wound 2
  • Delayed skin grafting, which may reduce healing time to approximately 6-8 weeks 5

Special Considerations for Perianal Disease

• Diverting colostomy may be necessary in some cases (41% of patients in one study) to facilitate wound healing 5
• Careful evaluation for malignancy is essential, as squamous cell carcinoma can develop in long-standing hidradenitis suppurativa 5, 6
• Multidisciplinary team approach involving dermatology, colorectal surgery, and wound care specialists is crucial 6

Follow-up and Monitoring

• Regular follow-up is essential to monitor wound healing and detect recurrence 2
• Recurrence is common and should be anticipated as a feature of the disease rather than a failure of treatment 2
• Long-term follow-up is necessary as some patients require multiple procedures over years to maintain control of symptoms 2, 6

Biologic Therapy Considerations

• If surgery is contraindicated or patient declines, adalimumab (Humira) is FDA-approved for moderate to severe hidradenitis suppurativa 7
• Dosing: 160 mg initially (Day 1), 80 mg two weeks later (Day 15), then 40 mg weekly starting at week 4 7
• However, for extensive perianal disease of this magnitude, surgical intervention remains the definitive treatment 1, 2, 5

Pitfalls to Avoid

• Inadequate excision is a common cause of recurrence; wide margins are essential 2, 5
• Delayed surgical intervention can lead to complications including fistula formation, scarring, and rarely malignant transformation 5, 6
• Antibiotics alone are unlikely to provide definitive treatment for extensive disease 6, 8
• Patients must be followed until definitive healing, as inadequate follow-up can lead to recurrence 6