From the Guidelines
Hidradenitis suppurativa treatment should be based on a holistic, evidence-based approach that includes lifestyle modifications, medications, and surgical options, with the goal of reducing morbidity, mortality, and improving quality of life, as recommended by the European Dermatology Forum guidelines 1.
Introduction to Hidradenitis Suppurativa
Hidradenitis suppurativa (HS) is a chronic inflammatory skin disease characterized by painful, recurrent nodules and abscesses that rupture and lead to the formation of sinus tracts and scarring, affecting approximately 1% of the population 1.
Diagnosis and Treatment
The diagnosis of HS should be made by a dermatologist or other healthcare professional with expert knowledge in HS, and treatment should be based on the severity of the disease, with mild cases managed with topical treatments such as clindamycin 1% solution applied twice daily to affected areas, and moderate to severe cases requiring oral antibiotics or biologics such as adalimumab (Humira) 40mg injected subcutaneously every other week 1.
Lifestyle Modifications and Adjuvant Therapy
All patients should be offered adjuvant therapy as needed, including pain management, weight loss, tobacco cessation, treatment of super infections, and application of appropriate dressings, and the treating physician should be familiar with disease severity scores, especially Hurley staging and Physician Global Assessment 1.
Surgical Options
Surgical intervention should be assessed in each individual patient, depending on the type and extent of scarring, and may include procedures such as deroofing, laser, local excision, or wide excision 1.
Benefit-Risk Ratio Assessment
A benefit-risk ratio structured assessment is needed to evaluate treatments, both short and long term, and real-life data from registries along with long-term efficacy and safety data from clinical trial extension phases should be evaluated further to assess long-term benefit-risk ratio and maintenance of treatment effect 1.
Key considerations in the treatment of HS include:
- Early treatment to prevent progression and complications
- A holistic, evidence-based approach that includes lifestyle modifications, medications, and surgical options
- Assessment of comorbidities and management of associated conditions
- Use of disease severity scores and patient-reported outcomes to evaluate treatment effectiveness
- Benefit-risk ratio assessment to evaluate treatments and make informed decisions.
From the FDA Drug Label
Hidradenitis Suppurativa (HS) (1.8): treatment of moderate to severe hidradenitis suppurativa in patients 12 years of age and older. Hidradenitis Suppurativa (2. 6): Adults:◦ Day 1: 160 mg (given in one day or split over two consecutive days)◦ Day 15: 80 mg ◦ Day 29 and subsequent doses: 40 mg every week or 80 mg every other week Adolescents 12 years of age and older: Adolescent WeightRecommended Dosage 30 kg (66 lbs) to less than 60 kg (132 lbs)Day 1: 80 mg Day 8 and subsequent doses: 40 mg every other week 60 kg (132 lbs) and greaterDay 1: 160 mg (given in one day or split over two consecutive days)Day 15: 80 mg Day 29 and subsequent doses: 40 mg every week or 80 mg every other week
Adalimumab (HUMIRA) is indicated for the treatment of moderate to severe hidradenitis suppurativa (HS) in patients 12 years of age and older. The recommended dosage for adults is 160 mg on Day 1,80 mg on Day 15, and 40 mg every week or 80 mg every other week starting on Day 29. For adolescents 12 years of age and older, the recommended dosage is based on weight, with 80 mg on Day 1 and 40 mg every other week for those weighing 30 kg to less than 60 kg, and 160 mg on Day 1,80 mg on Day 15, and 40 mg every week or 80 mg every other week for those weighing 60 kg or more 2.
From the Research
Definition and Characteristics of Hidradenitis Suppurativa
- Hidradenitis suppurativa (HS) is a chronic inflammatory disease characterized by painful, deep-seated nodules, abscesses, and draining tunnels in the skin of axillary, inguinal, genitoanal, or inframammary areas 3.
- The average worldwide prevalence of HS is 1%, but it varies geographically 3.
- HS has a profound negative effect on patients' quality of life and on the gross value added to society 3.
Pathogenesis and Comorbidities
- The pathogenesis of HS is complex and includes innate immune mechanisms, T-cell mechanisms, and B-cell mechanisms 3.
- Comorbidities, such as metabolic syndrome, inflammatory arthritis, and inflammatory bowel disease, frequently accompany skin alterations due to systemic inflammation 3.
- Chronic inflammation leads to irreversible skin damage with tunnel formation and morbid scarring 3.
Treatment and Management
- Management of HS can be challenging and often requires a multimodal approach with the use of on- and off-label medications 4.
- The multimodal approach to HS treatment typically involves treatment stacking of topical therapies, systemic and topical antibiotics, retinoids, hormonal and metabolic therapies, biologics and small molecule inhibitors, systemic immunosuppressants, surgical treatment, pain management, lifestyle modifications, adjunctive treatment, wound care, and flare therapy 4.
- Current treatment includes drug therapy, combined drug and surgical therapy, or surgery alone, depending on the phase of the disease 3.
- Antibacterial and anti-tumour necrosis factor therapies are effective in the treatment of HS 5.
- Clindamycin as a unique antibiotic choice has shown efficacy in HS treatment, with significant reduction in disease severity parameters and pain 6, 7.
Diagnosis and Assessment
- Evaluation and diagnosis of HS disease involve assessment of severity, extent of disease, and impact on patient quality of life 4.
- Initial diagnosis of HS should be shortly followed by comorbidity screening 4.
- Aims of management should include early intervention to prevent irreversible skin damage, adequate control of symptoms including pain, and mitigation of extra-cutaneous comorbidities, all requiring early diagnosis and an interdisciplinary, holistic, and personalized approach 3.